Are most maternal deaths from pre-eclampsia avoidable?

In the latest UK Report of the Confi dential Enquiries into Maternal Deaths (the CMACE report), 20 out of 22 deaths related to pre-eclampsia involved substandard care—a disturbing statistic that is higher than for any other cause of maternal death. The substandard care in 63% of these deaths was categorised as major and they were described as “undoubtedly avoidable”. Hyper tensive diseases accounted for 17·8% of all direct maternal deaths, an increase in frequency since the last triennial report, while overall death rates have reduced. Pre-eclampsia complicates 2–8% of pregnancies, although the proportion is probably less than 5% in western nations, representing up to 30 000 women a year in the UK. Although maternal deaths are relatively rare, pre-eclampsia causes a third of severe obstetric morbidity. Fetal morbidity and mortality increase substantially in women with pre-eclampsia; hyper tension is a major cause of stillbirths, as recently highlighted in The Lancet. However, fetal compromise can be identifi ed and adverse events can be prevented by delivery. The CMACE report describes basic failings, such as poor diagnosis and failure to act on obvious serious disease. In the UK, rates of maternal death from pre-eclampsia associated with substandard care have fallen below 80% only twice since 1985. In Holland, 96% of 26 maternal deaths from pre-eclampsia between 2000 and 2004 were associated with substandard care, and of all maternal deaths in Holland during 1993–2005, the highest rate was observed for pre-eclampsia deaths (91%). Similar data are not easily available for other countries because few have access to such a powerful audit system as the British Confi dential Enquiries. Pre-eclampsia care includes the pregnant woman herself, community carers and hospital staff , and organisation of health services. The most common cause of death in this latest report (involving cases from 2006 to 2008) was intracerebral haemorrhage (9 of 22 cases), which is likely to be preventable by antihypertensive medication. Severe hypertension was neither identifi ed nor treated in several of these cases despite previous evidence showing the need to treat systolic blood pressure over 160 mm Hg in pregnant women. These reports also highlight that in pre-eclampsia oscillometric devices can under-record blood pressure. However, recent evidence from the UK showed that 33% of women with pre-eclampsia and a blood pressure over 160 mm Hg received no antihypertensives. The pre-eclamptic cerebral circulation has a specifi c vulnerability, so pre-eclampsia represents an acutely dangerous situation and needs urgent eff ective treatment. The identifi cation of pre-eclampsia relies fundamentally on the frequency of antenatal care. Globally, absence of antenatal care is strongly associated with eclampsia and death. Fewer antenatal appointments might not be cost eff ective; a UK study showed that a reduction shifts costs to neonatal care, which increases overall costs. Health-care profes sionals, including general practitioners, who are unskilled in maternity care overlook the relevance and seriousness of newonset hypertension or proteinuria. Severe pre-eclampsia is often asymptomatic, whereas individual symptoms (eg, epigastric pain and headache) are common in normal pregnancy. In the CMACE report, proteinuria was shown to have been misinterpreted as a urinary tract infection, and epigastric pain as gastritis or indigestion. Basic recognition of signs and symptoms of preeclampsia is essential for all health-care professionals involved in antenatal care. Other changes in maternity care, such as reduced continuity caused by new shift systems and diffi culties with staff retention, have only compounded the problem. In the UK, protocols now exist for screening, detection, and management of pre-eclampsia. Recom mendations from previous CMACE inquiries Published Online December 15, 2011 DOI:10.1016/S01406736(11)60785-X