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in the care of women with extremely preterm pre‐labour rupture of membranes and a full explanation of the risks and benefits of continuing the pregnancy.

      Sepsis is often insidious in onset and can progress very quickly. If it is suspected, urgent referral to hospital is necessary. In hospital, high‐dose broad‐spectrum antibiotics should be started immediately, without waiting for the results of investigations. In 2012, in response to the rise in deaths, the RCOG published new guidelines on bacterial sepsis during and after pregnancy.

      Sepsis due to respiratory causes remains a leading cause of death during or after pregnancy, as was evident in the 2009 AH1N1 influenza pandemic, and the covid‐19 pandemic has highlighted this once again. Over the first wave of the covid‐19 pandemic in the UK, 10 women died with SARS‐CoV‐2 infection, of whom eight died from complications of covid‐19. A rapid report from MBRRACE‐UK (Saving Lifes, Improving Mothers’ Care Rapid Report: Learning from SARS‐CoV‐2‐related and associated maternal deaths in the UK March–May 2020) noted that the severity of women’s illnesses was often not recognised until they were in extremis, and emphasised the importance of multidisciplinary team care and obstetric leadership with daily review. This is essential in order to ensure timely recognition of deterioration, early assessment of the need for iatrogenic birth to help respiratory function and identification of postnatal complications.

      It is also important to remember that deaths from influenza continue to occur despite widespread availability of vaccination. With immunisation rates in pregnancy at less than 50%, influenza remains a threat and influenza swabs should still be taken in women presenting with severe upper respiratory tract infections, with antiviral treatments commenced until results exclude it.

      Anaesthesia

      Deaths from anaesthesia fell steadily during the 1970s due to a move to regional anaesthesia and better training of anaesthetists. Since 1985, the number has been in single figures in each triennium and in view of the rising CS rate this represents an improvement. Failed tracheal intubation has been highlighted in recent years, together with anaphylaxis and aspiration causing difficult ventilation. The most recent report emphasised the crucial role of the anaesthetist in the resuscitation, management and postoperative care of women who have obstetric haemorrhage. Particular messages included: (i) the importance of ensuring adequate intravenous access to facilitate fluid resuscitation; (ii) the need to use appropriate rapid fluid warming devices during fluid resuscitation and transfusion; and (iii) the importance of ensuring that there is evidence that there has been adequate resuscitation of a woman who has had an obstetric haemorrhage and that the haemorrhage has ceased prior to extubation.

2.6 Indirect deaths

Indirect deaths have outnumbered direct deaths in the UK since 1994–1996 (Table 2.4). In that triennium, birth and death registrations were linked by the ONS, leading to better ascertainment.

Table 2.4 The rise in indirect deaths: maternal deaths notified to the CEMD, 1991–2018

	1991–1993	1994–1996	1997–1999	2000–2002	2003–2005	2006–2008	2009–2011	2010–2012	2016–2018
Direct	129	134	106	106	132	107	83	78	92*
Indirect	100	134	136	155	163	154	170	165	125
Total	229	268	242	261	295	261	253	243	217

      ^* Suicides are included in the classification of direct maternal deaths after a change in World Health Organization guidance.

      From 2000–2002 onwards, CEMACH regional managers were involved in collecting data and this improved ascertainment further. Better identification of cases, however, is only one reason for the rise in indirect deaths, the other being a rise in risk factors such as smoking, obesity and older age at childbearing.

      Cardiac disease

      Deaths from cardiac disease have been rising and this is now the leading cause of maternal death in the UK, with approximately 50 deaths in each triennium. In 2015–2017 only four were due to congenital heart disease. The leading causes were sudden adult death syndrome, myocardial infarction, dissection of the thoracic aorta and myocardial disease (including cardiomyopathies). Only a quarter of women who died from heart disease were known to have cardiac problems prior to pregnancy, and symptoms such as breathlessness were frequently misattributed to pregnancy. A third of the women who died from cardiac disease had a BMI of 30 or more. The main learning point from all these cases was that there must be a low threshold for investigation of pregnant or recently delivered women who complain of chest pain or breathlessness, especially if they have risk factors such as hypertension. Women with cardiac disease should be cared for by obstetricians, cardiologists and obstetric anaesthetists in a coordinated fashion, with combined clinics being the gold standard.

      Mental health conditions

      Mental health disorders are common in pregnancy and after delivery. However suicide, which causes the most deaths overall, most commonly occurs between 6 weeks and 1 year after delivery and because they occur more than 42 days after delivery are missed by the standard definition of maternal death. Suicide is usually by violent means. Most women who die by suicide have a history of an affective disorder, which has a high risk of recurrence after delivery. Previous psychiatric history must be identified in early pregnancy and the risk managed proactively. Psychiatric deaths were last analysed in the 2018 MBRRACE‐UK report. This highlighted the huge variations in provision of mental health services around the UK and Ireland and the importance of ‘red flag’ symptoms such as new thoughts or acts of violent self‐harm.

      Other indirect deaths

      Of the many other causes of indirect death, the leading category is central nervous system disease, including epilepsy, where women may stop taking their medication when they become pregnant. All medical diseases in pregnancy need careful supervision because of the effects of the disease on the pregnant woman and the effects of the pregnancy on the disease. This responsibility tends to be shared between the GP, midwife, obstetrician and physician, and they often work in isolation without appreciation of the full clinical picture and risks. Good communication among carers is essential, and if it cannot be done in joint clinics, there should at least be telephone discussions with a documented outcome. Communication should not be left to the patient or her handheld notes.

2.7

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