Highlights from Perinatal and Maternal Mortality and Morbidity

Review

Drs Sue Belgrave (PMMRC Chair) and Lynn Sadler (PMMRC Epidemiologist)

Conflict of interest

• Neither speaker has any financial conflict of interest to declare

What do you know about the

PMMRC?

Why is the PMMRC a precious

resource?

What has it achieved?

How have these been

achieved?

Should we preserve the

PMMRC?

VOTING TIME!

Answer: No

2015 UK perinatal mortality rate 5.09/1000 births

2015 NZ perinatal mortality rate 4.84/1000 births

Question 1: New Zealand’s perinatal mortality rate is higher than the UK perinatal mortality rate?

13 women from 2006-2015 died from AFE

Answer: Suicide 6 women from 2006-2015 died from VTE

27 women from 2006-2015 died by suicide

3 women from 2006-2015 died from PPH

Question 2: The most common cause of maternal mortality in New Zealand is:

Current members: Sue Belgrave (Chair, obstetrician)

Alison Eddy (Deputy chair, midwife) Robin Cronin (Midwife)

Sue Crengle (Māori caucus) Rose Elder (Obstetrician)

Lisa Paraku (Consumer) John Tait (Obstetrician)

Max Berry (Neonatologist)

Answer: A) 8

Question 3: How many members currently sit on the PMMRC?

• Answer: Yes

A perinatal death is death of a fetus at or beyond 20 weeks gestation AT ISSUE OR weighing at least 400g IF gestation is unknown or a neonatal death up to midnight of the 27th day of life

Question 4: If a twin dies at 18 weeks but is born at 37 weeks weighing 70g, is it a perinatal death?

• Answer:

Answer:

A) Within 5 minutes of onset of CPR

Link to practice point

Question 6: When should perimortem Caesarean be performed for maternal collapse requiring CPR?

JOURNAL PUBLICATIONS

• Practice points • Recommendations

Perinatal

Mortality

Neonatal

Encephalopathy

Maternal

Mortality

Maternal

Morbidity

ANNUAL CONFERENCES

11x ANNUAL REPORTS

COMPLETE DATA ASCERTAINMENT

RESEARCHERS

National Coordination

service

Otago Mortality data

group

11x Cardiac SUDI Stillbirth Congenital anomalies Fertility AMOSS

DHB reports: 2007-2010 2011-2014

NATIONAL PERINATAL PATHOLOGY SERVICE

BETTER HEALTH FOR PREGNANT MOTHERS AND BABIES

NATIONAL MATERNITY MONITORING GROUP (NMMG)

MATERNAL AND PERINATAL MENTAL HEALTH

Child and Family Unit

Maternal and Infant Mental Health Network

NEONATAL ENCEPHALOPATHY Local and DHB specific reviews of NE Observation of mother and baby in the immediate postnatal period NE Taskforce

Maternity survey of bereaved

women

SUPPORT FOR FAMILIES

Panui for

post-mortem

MoH funding of SANDS

information

MATERNITY QUALITY & SAFETY PROGRAMME (MQSP)

PROFESSIONAL COLLEGES

HQSC

ACC

PSANZ classification

changes

Peer reviewed publications

• Farquhar C, Sadler L, Masson V, et al. Beyond the numbers: classifying contributory factors and potentially avoidable maternal deaths in New Zealand, 2006 –2009. Am J Obstet Gynecol 2011;205:331.e1-8.

• Farquhar C, Arroll N, Sadler L, Stone P & Masson V. Improving quality and safety in maternity services: can we improve prevention, detection and management of congenital abnormalities in pregnancy? The Quality and Safety Challenge 2012 August 2012

• Arroll N, Sadler L, Stone P, Masson V, Farquhar C. Can we improve the prevention and detection of congenital abnormalities? An audit of early pregnancy care in New Zealand Journal of the New Zealand Medical Association, 16-August-2013, Vol 126 No 1380

• York D, Farquhar C, Sadler L, Masson V and Belgrave S. Improving outcomes. O & G Magazine Volume 15 Number 4 Summer 2013. ISSN 1442-5319

• Sadler LC, Farquhar CM, Masson VL, et al. Contributory factors and potentially avoidable neonatal encephalopathy associated with perinatal asphyxia. Am J Obstet Gynecol 2016

• Battin M, Sadler L, Masson V, et al on behalf of the Neonatal Encephalopathy Working Group of the PMMRC Neonatal encephalopathy in New Zealand: Demographics and clinical outcome Journal of Paediatrics and Child Health (2016)

• Masson V, Farquhar C, Sadler L, Validation of local review for the identification of contributory factors and potentially avoidable perinatal deaths Australian and New Zealand Journal of Obstetrics and Gynaecology 2016; 56: 282–288

• Bartlett K, Zuccollo J, Sadler L, Masson V. Rethinking placental pathology in the PSANZ classification of unexplained stillbirth at term Australian and New Zealand Journal of Obstetrics and Gynaecology 2016 DOI: 10.1111/ajo.12492

• Farquhar C, Armstrong S, Kim B, et al. Under-reporting of maternal and perinatal adverse events in New Zealand. BMJ Open 2015;5:e007970. doi:10.1136/bmjopen-2015-007970

Peer reviewed publications (contd)

• Timing of diagnosis affects mortality in critical congenital heart disease Eckersley L, Sadler L, Parry E, et al. Arch Dis Child Published Online First: doi:10.1136/archdischild-2014-307691

• Knight M, Pierce M, Seppelt I, Kurinczuk J, Spark P, Brocklehurst P, McLintock C, Sullivan E, on behalf of the UK’s Obstetric Surveillance System, the ANZIC Influenza Investigators, and the Australasian Maternity Outcomes Surveillance System, Critical illness with AH1N1v influenza in pregnancy: a comparison of two population-based cohorts. BJOG, 2011 Jan; 118(2): 232–239. doi: 10.1111/j.1471-0528.2010.02736.x

• Vaughan G, Pollock W, Peek MJ, Knight M, Ellwood D, Homer CS, Pulver LJ, McLintock C, Ho MT, Sullivan EA., Ethical issues: The multi-centre low-risk ethics/governance review process and AMOSS. Aust NZ J Obstet Gynaecol, 2012 Apr; 52(2):195-203. doi: 10.1111/j.1479-828X.2011.01390.x

• Halliday L, Peek M, Ellwood D, Homer CSE, Knight M, McLintock C, Jackson-Pulver L, Sullivan E. The Australasian Maternity Outcomes Surveillance System (AMOSS): An evaluation of stakeholder engagement, usefulness, simplicity, acceptability, data quality and stability. Aust NZ J Obstet Gynaecol, 2012 Dec 6. doi: 10.1111/ajo.12020.

• Farquhar CM, Li Z, Lensen S, et al. Incidence, risk factors and perinatal outcomes for placenta accreta in Australia and New Zealand: a case–control study. BMJ Open 2017;7:e017713. doi: 10.1136/bmjopen-2017-017713

• McDonnell N, Knight M, Peek MJ, Ellwood D, Homer CSE, McLintock C, Vaughan G, Pollock W, Li Z, Javid N, Sullivan E and on behalf of the Australasian Maternity Outcomes Surveillance System (AMOSS). Amniotic fluid embolism: an Australian-New Zealand population-based study. BMC Pregnancy and Childbirth, 2015(15:352). DOI: 10.1186/s12884-015-0792-9

Practice points: (PMMRC website)

• Alcohol in pregnancy

• Family violence

• Perimortem caesarean section

• Postpartum sepsis

• Influenza in pregnancy

• Epilepsy in pregnancy

• Recognising the baby at risk of neonatal encephalopathy

• Care for pregnant women at risk of delivering at the lower extremes of

• Antenatal screening for down syndrome and other conditions

• Amniotic Fluid Embolism

• Maternal Suicide

Data quality

PMMRC process: Ascertainment of data NZ MMR by mortality data source 1973-2015

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Year

MMR: MDAC MMR: routine sources MMR: PMMRC

PMMRC process: Ascertainment of data NZ MMR by mortality data source 1973-2015

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5

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MMR: MDAC MMR: routine sources MMR: PMMRC Australia

Highlights from Perinatal and Maternal Mortality

Review

Amniotic fluid embolism

• 38yr old P3G4, IOL at term for mild hypertension.

• Non specific “acting strangely” just prior to delivery

• PPH despite ecbolic and fundal pressure

• Bloods, transfer to theatre

• Bakri balloon, blood transfusion commenced

• Ongoing bleeding

• Cardiac arrest: successful resuscitation, further arrest, died

• Post mortem: fetal squames in maternal lungs

Vignette

Cause specific MMR NZ and UK

0

1

2

3

4

5

6

7

AFE PPH/

haemorrhage

VTE Preeclampsia Obstetric

sepsis

Early

pregnancy

Other

direct

Pre-existing

medical

Psychiatric Other

indirect

Mate

rnal

mo

rtali

ty r

ati

o/1

00

,00

0

mate

rnit

ies

NZ2006-2015 UK2006-2014

Case review all AFE deaths and NZ AMOSS morbidity

2 PATHWAYS:

Suggests room for

improvement of care

Risk factors not more common in NZ

Cases not more severe in NZ

AFE not over-diagnosed in deaths.

Survival related to early recognition

and aggressive resuscitation

Review Findings Sudden:

collapse/arrest and

coagulopathy

Delayed:

haemorrhage and

coagulopathy

DEATHS

(2006–2014) 13 5 SURVIVORS

(2010–2013)

PRACTICE POINTS

Amniotic Fluid Embolism

Perimortem Caesarean

Section

Continue data collection

through AMOSS

RECOMMENDATION for

multidisciplinary training in

obstetric emergencies for all

practitioners involved in

intrapartum care

SURVEY of multidisciplinary

training in obstetric emergencies

across NZ DHBs

PRESENTATIONS at

PMMRC conferences

2016 and 2017

PMMRC Actions

Suicide

• 25, depression under care of mental health

• Treated and stable

• Unexpected pregnancy

• Review by locum GP and referred for TOP

• No mental health screening and no communication with mental

health team or usual GP

• Rings mental health team feeling down and asked to see GP

• Found dead 3 weeks following TOP

Vignette

PMMRC actions on maternal mental health

Early Recommendations

Progress

• Maternal mental health services should be integrated into maternity

services.

• Clinicians should perform antenatal screening, including those seeking TOP,

to identify women at increased risk of mental illness

• Women with previous psychiatric conditions require specialist review even if

well

• Preconception counselling re condition and medications

• Support the establishment of a mother and baby unit in the North Island

• Compulsory education topic midwifery recertification

• Healthy beginnings report 2012

• MOH “Rising to the Challenge”

• 3 bed child and family unit in Starship opened 2014

• Key work program of National Maternity Monitoring Group

But…

… 2017 (2015 data) reported the highest number of suicides in a single year since 2006

• Important issue for New Zealand society as a whole

• Practice points on maternal suicide and Māori

Maternal Suicide

FUTURE DIRECTION

• Recommendation (2016) and now working with

the Ministry of Health to set up a perinatal and

infant mental health network

• HQSC: Establishment of a permanent suicide

mortality review committee

Perinatal death: APH and growth restriction

• G3P2 – previous APH and PTL 32/40. BMI 40.

• Intermittent PV loss – 7 -11/40, review by GP, viability scan 9/40. No cause for bleed

seen

• 11/40 booked LMC – 11/40 scan and MSS1 – NAD

• Further PV bleed 16-18/40 – Anatomy Scan 19/40. Normal anatomy – growth on 25th

centile. No cause for bleed seen.

• Regular visits – to 32/40 – FHHR Fundal height = dates (no CGC generated)

• 33/40 APH – PTL . Arrived – Fully dilated, breech – fetal heart 80 bpm on USS. Crash

LSCS – Apgar 0 - full resus.

• Transferred to NICU – care withdrawn at 3 hours of age. Birth weight 1750g –

customised birth weight – 2nd centile.

Vignette

Placental histology

1. Features of retroplacental haemorrhage

— Large blood clot; 255 grams

— Indentation of maternal surface

— Partially empty chorionic vessels

2. Features of maternal malperfusion

— Villous infarction

— Accelerated villous maturation

3. Focal low grade chronic villitis

INVESTIGATION OF PERINATAL DEATH

Review barriers to uptake of investigations

Review of unexplained perinatal

death and review of placental

histology to inform PSANZ

classification review

PERINATAL

DEATHS INVESTIGATED

Perinatal deaths over time

Total births (international definition)

2007—2008 2009—2010 2011—2012 2013—2014 2015 Chi-squared test for

trend (p) n=129,725 n=129,530 n=125,423 n=119,134 n=59,344 n Rate n Rate n Rate n Rate n Rate

Perinatal death classification (PSANZ-PDC)

Congenital abnormality 127 0.98 141 1.09 149 1.19 114 0.96 61 1.03 0.90

Perinatal infection 32 0.25 28 0.22 21 0.17 21 0.18 12 0.20 0.22

Hypertension 14 0.11 25 0.19 12 0.10 11 0.09 10 0.17 0.63

Antepartum haemorrhage 48 0.37 47 0.36 30 0.24 29 0.24 17 0.29 0.031

Maternal conditions 23 0.18 38 0.29 24 0.19 36 0.30 15 0.25 0.24

Specific perinatal conditions 52 0.40 62 0.48 53 0.42 49 0.41 32 0.54 0.71

Hypoxic peripartum death 67 0.52 48 0.37 40 0.32 28 0.24 17 0.29 0.00030

Fetal growth restriction 61 0.47 62 0.48 50 0.40 41 0.34 14 0.24 0.015

Spontaneous preterm 16 0.12 29 0.22 19 0.15 14 0.12 14 0.24 0.54

Unexplained antepartum death 141 1.09 120 0.93 107 0.85 112 0.94 50 0.84 0.063

No obstetric antecedent 25 0.19 17 0.13 13 0.10 13 0.11 7 0.12 0.13

Perinatal death classification specific perinatal related mortality rates using international definition (>=1000g or >=28 weeks if birthweight unknown) 2007-2015

Initiatives to reduce perinatal death

Recommendations

Access to care

Screening

(diabetes, smoking,

family violence)

Smoking

cessation

Weight gain

in pregnancy

Detection of

growth restriction

APH

Early booking

Framework for assessing

contributory factors and

potentially avoidable death,

Supporting local review.

Accurate NZ data

Inform risk factors of

perinatal death (BMI,

smoking, socioeconomic

deprivation, ethnicity)

Highlight DHB

disparities

Individual DHB

reports for local

areas of focus

MOH: smoking, early booking, guidelines

MQSP/NMMG

DHB: initiatives

GROW/GAP

• STILLBIRTHS

• HYPOXIC

PERIPARTUM

DEATHS

REDUCE PERINATAL

DEATH

• INTRAPARTUM

DEATHS

Investigate

neonatal death rate

Investigate

disparities in

perinatal death

e.g. Indian

Highlights from Neonatal Encephalopathy

Review

That all DHBs review local

incident cases of NE

All babies with NE should undergo

investigation to inform prognosis

Widespread multidisciplinary

education is required on the recognition of NE

Cord gases performed on all

babies with an Apgar <7 @ 1

NEWG

That multi-disciplinary fetal surveillance

training be mandatory

That multi-disciplinary fetal surveillance

training be mandatory

Significant increase in NE

babies who had an MRI

In 2016, all L3 NICUs used a

formal tool for pre-

discharge examination

Significant

increase in NE

babies with cord

gases taken at

birth

Practice point: recognising the baby at risk of NE

INSERT HYPERLINK HERE

In 2016 72% of NE babies

were reviewed at DHB of

birth (62% MDM)

All babies with NE should undergo

investigation to predict prognosis

Widespread multidisciplinary

education is required on the recognition of NE

NE Taskforce

NEWG

Cord gases performed on all

babies with an Apgar <7 @ 1

That all DHBs review local

incident cases of NE

NE case review

2014*

*Sadler et al Am J Obst Gyn 2016

NEWG

ACC

HQSC

MOH

NE case review

2014*

*Sadler et al Am J Obst Gyn 2016

NE TASKFORCE

NEWG

ACC

HQSC

MOH

NE case review

2014*

*Sadler et al Am J Obst Gyn 2016

NE case review :

acute peripartum

events

2016-2017

NE TASKFORCE

NEWG

ACC

HQSC

MOH

Evaluate universal lactate testing

Newborn EWS

Improved maternal and fetal intrapartum

monitoring

Human factors

training

NE TASKFORCE

GAP and training

Highlights from Maternal Morbidity

Review

How to navigate the PMMRC website

Should we preserve the

PMMRC?

Should we preserve the

PMMRC?

Acknowledgements: • Families • LMCs • DHB local coordinators • DHB staff • Otago Mortality Data Group • PMMRC and its working groups • National coordination service • HQSC board and staff • MOH • ACC • Professional colleges