CEMACH

Chapter 2: Thrombosis and thromboembolism

James Drife

Summary of key findings for 2003-05

The deaths of 41 women who died from thrombosis and/or thromboembolism are counted in this Chapter. Of these, 33 deaths were attributed to pulmonary embolism and eight to cerebral vein thrombosis. Additionally, three Late deaths attributed to pulmonary embolism are counted in Chapter 15 but the lessons to be learnt from these cases are discussed here.

Pulmonary embolism still remains the leading Direct cause of maternal death in the United Kingdom with a mortality rate of 1.56 per 100,000 maternities. Although the numbers of deaths attributed to pulmonary embolism appear to be higher than the 25 cases identified in the previous Report for 2000-2002, the difference is not statistically significant as Table 2.1 shows.

Table 2.1 Direct deaths from thrombosis and thromboembolism and rates per 100,000 maternities; United Kingdom: 1985-2005.

Pulmonary embolism Cerebral vein thrombosis Thrombosis and thromboembolism
  Number Rate 95 per cent CI Number Rate 95 per cent CI Number Rate 95 per cent CI
1985-87 30 1.32 0.83 1.89 2 0.09 0.02 0.32 32 1.41 1.00 1.99
1988-90 24 1.02 0.68 1.51 9 0.38 0.20 0.72 33 1.40 1.00 1.96
1991-93 30 1.30 0.91 1.85 5 0.22 0.09 0.51 35 1.51 1.09 2.10
1994-96 46 2.09 1.57 2.79 2 0.09 0.02 0.33 48 2.18 1.65 2.90
1997-99 31 1.46 1.03 2.07 4 0.19 0.07 0.48 35 1.65 1.19 2.29
2000-02 25 1.25 0.85 1.85 5 0.25 0.11 0.59 30 1.50 1.05 2.14
2003-05 33 1.56 1.11 2.19 8 0.38 0.19 0.75 41 1.94 1.43 2.63

The apparent difference arose mainly from fluctuations in numbers of antepartum deaths, as Table 2.2 shows. Despite the rising caesarean section rate, the numbers of women dying from postpartum pulmonary embolism after caesarean section remains lower than in the early 1990s as thromboprophylaxis becomes routine.

Table 2.2 Timing of deaths from pulmonary embolism; United Kingdom: 1985-2005.

  Deaths after
miscarriage/
ectopic
Antepartum
deaths
Collapse before
delivery followed by
perimortem
caesarean section
Deaths
in labour
Death
after
caesarean
section
Deaths
after
vaginal
delivery
Not
known
Total
Direct

deaths
Late
deaths
1985-87 1 16 0 0 7 6 0 30 *
1988-90 3 10 0 0 8 3 0 24 4
1991-93 0 12 0 1 13 4 0 30 5
1994-96 3 15 0 0 15 10 3 46 2
1997-99 1 13 3 0 4 10 0 31 9
2000-02 3 4 1 1 9 7 0 25 1
2003-05 3 11 4 0 7 8 0 33 3

* Most Late deaths were not reported to Enquiry in this triennium.

Cases counted in other Chapters

Pulmonary embolism also contributed to a few deaths from other causes which are counted and discussed in other chapters. These include a case where it was the terminal event for a woman with advanced cancer, discussed in Chapter 11, and two women who died of Indirect causes including Budd-Chiari syndrome due to thrombosis obstructing the hepatic vein whose cases are counted in Chapter 10.

It must be remembered that not all cases of sudden collapse in the puerperium are due to pulmonary embolism. For example, a woman who suffered a sudden fall in blood pressure two days after delivery was initially investigated for pulmonary embolism. The actual cause of her death, haemorrhage from the internal iliac vessels, was a rarity but intra-peritoneal haemorrhage should have been suspected from her pallor and hypotension.

Incidence of antenatal pulmonary embolism

A prospective national case-control study of antenatal pulmonary embolism was undertaken through the United Kingdom Obstetric Surveillance System (UKOSS) between February 2005 and August 2006. UKOSS is discussed in fuller detail in the Introduction to this Report1. Ninety-four incidents of antenatal pulmonary emboli, including several deaths, were reported over the first year, representing an estimated incidence of 13.1 per 100,000 maternities with a 95% confidence interval from 10.6 to 16.1. Seventy-three of the women had one or more identifiable risk factors for thromboembolic disease. The main risk factors for pulmonary embolism in this group were multiparity, with an adjusted odds ratio of 2.90 with a 95% confidence interval 1.37 to 6.13 and a Body Mass Index (BMI) over 30, with an adjusted odds ratio of 2.80 with a 95% confidence interval from 1.12 to 7.02. 

Pulmonary embolism

Of the 33 women who died from pulmonary embolism, ten died during the first trimester of their pregnancy and one during the second trimester. A further three women died antenatally; two following terminations of pregnancy and one following an ectopic pregnancy. An additional four women who collapsed in late pregnancy from a pulmonary embolism were delivered by a peri or post mortem caesarean section; these are also classified as antepartum deaths. No women died during labour. In all, fifteen women died in the postpartum period, eight following a vaginal delivery and seven after a caesarean section.

The women who died

Risk factors for thromboembolism were identifiable in 26 of the 33 women. Sixteen were overweight and four women had a past or family history of venous thromboembolism (VTE). Two died after air travel in pregnancy, one had hyperemesis gravidarum and one had ovarian hyperstimulation syndrome (OHSS). Three women had a history of surgery unrelated to pregnancy and one underwent craniotomy in the puerperium. Seven had no recorded risk factors but in four of these cases details were inadequate.

Of the 21 women whose pregnancies exceeded 12 weeks' gestation, four did not attend for regular antenatal care. In one case, an asylum seeker saw her General Practitioner early in pregnancy but did not receive a booking appointment until after five months had elapsed. The other three women had complex lives and were known to either be substance misusers, have child protection issues, or both. Six of the 21 women were Black African or Caribbean and two were South Asian. Three women could not speak English.

Risk factors
Weight

The National Institute for Clinical Excellence (NICE) guideline on antenatal care recommends that every woman should have her BMI checked at the first antenatal visit and that women with a BMI over 35 are not suitable for routine midwifery led care2. The mother’s weight was recorded in only 25 cases and the BMI could be calculated for only 21. Of these, sixteen were overweight, with a BMI of over 25. Twelve of these were classified as obese with a BMI over 30, including eight who were morbidly obese with a BMI over 35. The latter included two who died after caesarean section. The highest reported BMI was 62, and another five women had BMIs over 40. Two of the morbidly obese women inappropriately had midwife-only care. Two of the three women who suffered a Late Direct death from pulmonary embolism were also obese or morbidly obese.

Women with a BMI of 40 or above are at a high risk of VTE but current RCOG guidelines3,4,5 recommend the same prophylactic doses of low molecular weight heparin (LMWH) for all women with a BMI over 30 or a weight exceeding 90Kg. The RCOG guideline on thromboprophylaxis during pregnancy, labour and after normal vaginal delivery2 recommends that “one or two risk factors alone may be sufficient to justify antenatal thromboprophylaxis with LMWH, for example an extremely obese woman admitted to the antenatal ward.” This advice relies on clinical judgement and was reinforced in the last Report, but of the eight morbidly obese women whose deaths are discussed in the present Report, six received no thromboprophylaxis, one received an inadequate dosage and one received the correct dose but not until some time after her caesarean section. A specific guideline is now required on thromboprophylaxis for morbidly obese women.

Age

The ages of the women ranged between 18 and 39 years with a median of 30 years. Their age distribution is shown in Table 2.3 together with mortality rates per 100,000 maternities. This suggests a shift to a younger age of death, despite an overall increase in age at childbearing. Although no difference was detected in the mortality rates overall, the rate increased significantly among women aged under 25 and decreased among those aged 40 and over.

Table 2.3 Numbers of deaths attributed to pulmonary embolism and rates per 100,000 maternities by age; United Kingdom: 1985-90* and 1997-2005.

  Under 25 25-29 30-34 35-39 40 and
over
Total
Numbers            
1985-90 3 19 12 13 7 54
           
1997-99 5 6 11 8 1 31
2000-02 3 8 7 6 1 25
2003-05 9 8 10 5 1 33
           
1997-2005 17 22 28 19 3 89
Overall mortality rates        
1985-90 0.18 1.17 1.28 4.07 12.02 1.17
1997-2005 1.05 1.28 1.51 2.15 1.80 1.43
Difference 0.88 0.11 0.23 -1.92 -10.22 0.26
95 per cent CI 0.35,1.52 -0.68, 0.89 -0.83,1.10 -4.92,0.15 1.80,12.02 -0.19, 0.69

* Detailed analyses by age were not published for 1991-93 or 1994-96.

Air travel

Of the two women died after air travel, only one followed a long-haul flight. One occurred in the first trimester and one in the second, suggesting that the risk is related to prothrombotic changes and not venous stasis in late pregnancy. Unfortunately the RCOG has now withdrawn its advice for preventing deep vein thrombosis for pregnant women travelling by air from its website. The RCOG guideline on thromboprophylaxis2, however, includes “long-haul travel” in its list of risk factors as shown in the Annex to this Chapter. The recommendation of the NICE guideline on antenatal care1 is as follows: “Pregnant women should be informed that long-haul air travel is associated with an increased risk of venous thrombosis, although whether or not there is additional risk during pregnancy is unclear. In the general population, wearing correctly fitted compression stockings is effective at reducing the risk.”

Family history

In two deaths there was a family history of thromboembolism and the woman’s weight was an additional factor in both cases. In one Late death a woman had been diagnosed with thrombophilia after family screening when she was a child, but when she developed deep venous thrombosis after pregnancy she took her anticoagulant medication only intermittently and died of pulmonary embolism.

Previous history

Two women had had a previous VTE. One was very obese and also had a family history of VTE. Another had had thrombophilia screening after her previous VTE but the result was negative and this appears to have given false reassurance regarding her management in pregnancy. The current guideline is that if thrombophilia screening is negative and there are no other risk factors then LMWH is not recommended2.

Immobility

One woman had been admitted to hospital with hyperemesis gravidarum and so had both immobility and dehydration as risk factors.

Surgery unrelated to pregnancy

Previous surgery may have been a factor in three cases. One woman had abdominal surgery during pregnancy and the other two had complex surgical histories and underwent caesarean section. All three received routine thromboprophylaxis.

Assisted conception

A woman known to be at risk of ovarian hyperstimulation syndrome (OHSS) underwent superovulation and had a large number of oocytes collected and embryo transfer performed. She subsequently developed abdominal pain, collapsed within two weeks of the procedure and died a few days later. She had been counselled about the risks of superovulation but embryo transfer should not be performed when there is a high risk of OHSS.

Antepartum deaths

Of the eighteen women had a pulmonary embolism in their antenatal period, thirteen died during the first trimester (up to and including 12 weeks of gestation). Six women appear to have suddenly collapsed without prior warning but five of the remaining eight women who complained of symptoms in early pregnancy, three to their GP and two to hospital doctors, did not have their complaints taken seriously and were not investigated. There is insufficient awareness that women are at risk of thromboembolism from the very beginning of pregnancy.

Of the two morbidly obese women who died in their first trimester, one actively avoided doctors and midwives completely. Morbid obesity is a distressing condition and sufferers may find it difficult to talk to clinicians for fear of stigmatisation. By contrast, the other woman, who besides her obesity had a history of thrombophilia, booked for antenatal care early and, although an appointment was made with a haematologist, died in the interim. Maybe such high-risk women should be treated as emergencies in future. It is clear that, wherever possible, obese women should have pre-pregnancy counselling about its associated risks.

Although pregnancy nowadays is often promptly diagnosed, and the NICE antenatal care guidelines recommend early booking2, it is not always encouraged and early antenatal care may be uncoordinated:

An obese, parous woman was booked at home by a midwife in early pregnancy. A few days later she telephoned her General Practitioner (GP) because of mild breathlessness and was told to contact the practice again if it got worse. The next day a relative phoned and requested a home visit and was told that the doctor would attend after morning surgery. The woman died a few minutes later.

There is no record of the recommended needs and risk assessment2 being undertaken during the home booking, or of any communication between the midwife and the GP. The GP later commented that the relative did not convey a sense of urgency over the phone but it is unrealistic to expect a lay person to know that sudden and continuing breathlessness in an obese pregnant woman is a medical emergency. This fact should, however, be known by doctors and midwives.

Five women developed pulmonary embolism in later pregnancy and all underwent caesarean section. Four were perimortem but one was not:

A woman with a history of thromboembolism in her earlier life as well as previous pregnancies became pregnant again. She had also had a previous postpartum thromboembolism which required a thoracotomy and a filter in her inferior vena cava. Although her thrombophilia screen was negative she most probably had some as yet unidentified thrombophilia. Despite thromboprophylaxis and exemplary combined care she had a pulmonary embolism in mid-pregnancy. She underwent an elective caesarean section early in the third trimester. Her baby survived but she had further embolisms and died a few weeks after delivery.

The staff are to be commended on their excellent care. One midwife commented: “I think she always knew how ill she was and all she wanted was a baby.”

In the other four cases the pattern was of collapse in late pregnancy followed by a perimortem or postmortem caesarean section. Worryingly, the pattern was also that medical staff inappropriately reassured these women about their symptoms, which were often of dizziness, feeling flu-like and faint and having shortness of breath. One woman who returned from a holiday involving air travel and attended hospital feeling dizzy, faint and upset was told this was due to postural hypotension and sent home. She died the next day. The obstetrician commented that there were “no learning points” in this case but it illustrates the importance of taking these symptoms seriously. Although not many pregnant women who return from holiday have symptoms severe enough for them to attend hospital, in one case the woman’s symptoms were severe enough for her GP to call the hospital:

A woman with marked varicose veins developed thrombophlebitis in her third trimester and was given graduated compression stockings. At term she complained of increasing breathlessness to her GP, who phoned the obstetric registrar and was reassured. She was asked to return for review but required urgent referral to hospital following a collapse the next day. She did not receive anticoagulant treatment until more than eight hours after admission and when she collapsed yet again a perimortem caesarean section was carried out. Her baby survived.

Breathlessness severe enough to cause the GP to phone the hospital should be investigated. In this case the midwife later commented that thromboembolism had developed “in an otherwise low risk pregnancy”. It is important to remember that labelling women as “low risk” does not preclude the need to maintain vigilance and take symptoms seriously. These lessons were reinforced in the other two deaths in early pregnancy. It is important also to remember that when breathlessness first appears in late pregnancy, pulmonary embolism should be considered.

In all four cases the women were inappropriately reassured by GPs and/or hospital staff including obstetricians, midwives and physicians. Of course clinical judgement is imperfect but these cases are a reminder of how subtle the symptoms of thromboembolism can be, and of how careful staff should be before offering reassurance.

Deaths after ectopic pregnancy or termination of pregnancy

One woman died after laparoscopic salpingectomy for early ectopic pregnancy despite the use of antiembolism boots and graduated compression stockings. Two other deaths in early pregnancy occurred after terminations of pregnancy and the lessons from these three cases suggest there is insufficient knowledge that such women are at risk. For example:

A young woman with complex social problems and a history of domestic abuse underwent a mid-trimester termination of pregnancy. Three weeks later she attended the Emergency Department (ED) with chest pain and a pulse rate of 120 bpm. A diagnosis of “urinary tract infection or pelvic inflammatory disease” was made, and she was referred to the gynaecological team but not admitted. She died a few days later.

Chest pain and tachycardia in an apyrexial woman who has recently been pregnant are suggestive of pulmonary embolism or other serious cardiorespiratory pathology, as is sudden onset breathlessness, which was misattributed to anaemia in the other case.

Intrapartum deaths

There were no intrapartum deaths from pulmonary embolism in this triennium.

Deaths after vaginal delivery

Eight women died after vaginal delivery. Six women had delivered spontaneously and two by vacuum extraction. Known risk factors were present in seven of these cases; three were either overweight or obese, three were morbidly obese with BMIs exceeding 40 and one mother was aged over 40. In the remaining two cases the mothers’ weight was not recorded. Five of the deaths were between postpartum days 8 and 28, as shown in Table 2.4.

Table 2.4. Time between delivery and death from pulmonary embolism; United Kingdom: 2003-05.

Time after
delivery, days
Method of delivery All
  Vaginal Caesarean
section
 
0-7
1 1 2
8-14
2 2 4
15-28
3 2 5
29-42
2 1 3
42-365
2 2 4
Total
11 6 18

 

Two women were misdiagnosed in hospital as their breathlessness was attributed to chest infection. One had dyspnoea and haemoptysis eight days after delivery and was diagnosed with bronchopneumonia although she also received full heparinisation:

After an assisted vaginal delivery a woman complained of breathlessness for several days before calling her GP, who admitted her to hospital with a suspected pulmonary embolism. Her pulse rate was 130/minute, respiratory rate 30/bpm and her oxygen saturation was 92%. She was apyrexial. The medical registrar diagnosed pneumonia. She was transferred to the ward with a blood pressure of 84/48 mm/Hg and died a few hours after admission.

Her care was sub-standard. Tachycardia and tachypnoea without pyrexia in a recently delivered woman strongly suggest thromboembolism. The internal hospital report stated that the ED was “busy”. It is a pity that she was not promptly treated as the GP had made the correct diagnosis and had referred her appropriately. A GP with concerns about a patient being referred to the ED should contact the ED consultant directly.

Three morbidly obese women with a BMI over 40 did not receive thromboprophylaxis. For example:

An extremely obese woman was classed as a “low risk” case and received midwifery-only care. She underwent induction of labour, had three attempts at suturing a third-degree tear and was discharged home with a haemoglobin of less than 9.0g%. She collapsed and died some weeks after delivery.

Her care was also sub-standard. Because of their co-morbidity, morbidly obese women are unsuitable for midwife-only care. As with the other two women, this mother should also have received thromboprophylaxis, particularly as additional risk factors developed. Another woman with a BMI over 40 was also classified as “low risk” and received inappropriate midwifery-only care. In her case she complained of pain in her leg a few days after delivery and her midwife reassured her and advised her to see her GP if the pain worsened. She died a few weeks later. In this case she was wrongly reassured about a symptom suggestive of deep venous thrombosis.

The third very obese woman with a BMI over 40 had a socially and psychologically complex pregnancy and was very anxious throughout. She had a difficult labour resulting in an instrumental delivery and went home a few days later. She collapsed a few days afterwards. In her case it is possible that thromboprophylaxis may have been overlooked because the staff were focussed on her psychological state. In all three cases a management protocol for the morbidly obese woman would have been helpful. Such a protocol should combine medical assessment with the sensitive midwifery and obstetric support these women require.

Deaths after caesarean section

Seven women died after caesarean section. Two others died later in the puerperium and are classified as Late deaths. The intervals between the delivery and death were shown in Table 2.4. All the women received thromboprophylaxis. In contrast to the women who died after vaginal delivery, only two of the women who died following a caesarean section were morbidly obese. Care, however, was sub-standard, for example:

A morbidly obese woman required a wheelchair because she weighed almost 200Kg at the end of her pregnancy. Correctly she was assessed antenatally by the anaesthetist and excellent care was provided when fetal distress developed in labour and a caesarean section was required. She had thromboprophylaxis (tinzaparin 5000 units daily) and was discharged within a week of delivery. Shortly afterwards she complained of breathlessness but this was attributed to her obesity. She died a few days later.

Although the general care provided for this woman was excellent, she presented a very difficult problem and once again guidelines on the management of the morbidly obese woman may have been helpful. The prophylactic dose of tinzaparin was appropriate for normal body weight but the RCOG guideline recommends 4,500 units 12-hourly for a woman with a body weight over 90Kg. The other woman also required an urgent caesarean section which was complicated by bleeding from the uterine angle and blood transfusion was needed. Thromboprophylaxis, in her case 40mg enoxaparin, was given but not until well after the operation. She collapsed and died two days later. Her thromboprophylaxis was delayed and the caesarean section in such a difficult case should have been performed by a consultant.

An intravenous drug user also presented difficulty:

A young woman who had used intravenous drugs and had suffered domestic and childhood abuse was classed as a low risk and received midwife-only care. Her membranes ruptured early and on admission a footling breech presentation was diagnosed. Preparations were made for a caesarean section but, due to sclerosis, peripheral venous access was impossible and a femoral central line was inserted. She was given thromboprophylaxis but she died a few days later.

Here too midwifery-only care was inappropriate. The state of her veins should have been noted and she should have been assessed in advance by an anaesthetist. Access via a neck vein may have been preferable to a femoral vein.

Late deaths

Three Late Direct maternal deaths from pulmonary thromboembolism are counted in Chapter 14. All the women had known risk factors. One had thrombophilia (protein S deficiency) and the other two were obese.

Cerebral vein thrombosis

Eight women died of cerebral venous thrombosis. Their ages ranged between 22 and 34 years, with a median age of 26 years. In the four cases where weight was recorded, two were obese, with a BMI over 30 and two were overweight, with a BMI over 25. Four women died in the first trimester, one in the second and two in the third, both requiring perimortem caesarean section. One died in the puerperium. There was one additional Late death, of an older woman, who was also obese, counted in Chapter 14.

There were was only one case of sub-standard care, where a woman died after developing ovarian hyperstimulation syndrome (OHSS) during assisted conception treatment. She had had superovulation followed by embryo transfer but no thromboprophylaxis. Thromboprophylaxis should always be given in OHSS. It is concerning that two deaths in this Chapter and one in Chapter 6 - Early pregnancy deaths, resulted from in vitro fertilisation procedures involving ovarian stimulation to produce large numbers of mature follicles.

The characteristic clinical picture of all of the women who died from central venous thrombosis was of a relatively short history of headache followed, sometimes very quickly, by neurological signs such as clouding of consciousness or confusion. One woman was an asylum seeker who did not speak English and psychiatric referral was considered but the correct diagnosis was quickly made. No woman was diagnosed at the stage of headache alone. A severe headache of new onset can be an indication for neuro-imaging in, or after pregnancy even in the absence of focal signs.

There is a striking similarity between cerebral and pulmonary thrombosis with regard to risk factors, including obesity. It is to be hoped that increasing application of thromboprophylaxis among at-risk women will reduce deaths from both forms of thromboembolism.

Sub-standard care overall

Care was judged to be sub-standard in only one case of cerebral vein thrombosis, but present in two-thirds (22 of the 33) cases of pulmonary embolism. The main reasons were inadequate risk assessment in early pregnancy compounded by a failure to recognise or act on risk factors and a failure to appreciate the significance of signs and symptoms in the light of known risk factors. There were also failures to initiate treatment promptly or in adequate dosages. Giving thromboprophylaxis to morbidly obese women in doses recommended by current guidelines was not judged to be sub-standard care provided that the higher recommended dose was given to women to women with body weight over 90kg.

There was poor risk assessment in early pregnancy (or before pregnancy in the case of morbidly obese women), and failure to recognise the significance of symptoms such as leg pain and breathlessness. Better awareness of symptoms among professionals and women themselves could reduce the number of deaths from this condition. New guidelines are needed on thromboprophylaxis for morbidly obese women, especially those with a BMI over 40. Current guidelines recommend that the prophylactic and therapeutic doses of low molecular weight heparin depend on the woman’s weight. This was followed sometimes but not in all cases and a specific guideline on morbid obesity is needed.

Conclusions

With increasing rates of obesity, more and further air travel, a rise in the average age at childbearing and caesarean section rates of around 23%, it is pleasing that the number of maternal deaths from thromboembolism has hardly changed since 1985-87. This is almost certainly due to increasing vigilance among obstetricians and midwives and the careful application of thromboprophylaxis protocols. The fall in deaths from postpartum embolism after caesarean section shows the effectiveness of this strategy.

The same strategy should now be applied to prevent deaths in early pregnancy and postpartum deaths after vaginal delivery. Thromboembolism is not a “bolt from the blue”. Risk factors were identified in 27 of the 41 women whose deaths are counted in this Chapter. Of the ten women who died in the first trimester of pregnancy, seven had identifiable risk factors. Four were obese or morbidly obese. We repeat our previous recommendation that public health education is necessary so that women at risk because of their weight, family history or past history can seek advice before becoming pregnant.

The inappropriate classification of obese women, and those with complex pregnancies and risky lifestyles, as “low risk” is a worrying trend. A full risk and needs assessment in early pregnancy must be undertaken before care plans are decided. Partly as a result of recommendations made in preceding Reports, and in Maternity Matters6 , NICE is in the process of developing such a risk assessment tool which should be used at all booking appointments as soon as it is available. Antenatal care must reflect clear and objective judgement and this point is also made in the midwifery Chapter (Chapter 16) of this Report. Again we repeat the recommendation that “All women should undergo an assessment of risk factors in early pregnancy or before pregnancy. This assessment should be repeated if the woman is admitted to hospital or develops other intercurrent problems.”

False reassurance, including reassurance over the telephone when the woman has not even been examined, is another worrying trend which is also picked up in the new Chapter for GPs. Early symptoms of life-threatening embolism are generally mild and reassurance is too easy to give and accept.

Finally, our examination of these 41 cases reinforces our view that only a national survey such as this can draw useful conclusions about emerging trends. Reflection on individual cases in Trusts is necessary but local investigations may be insufficiently self-critical or indeed too self-critical, and may not reveal important new factors such as the high risks run by morbidly obese women. Our main recommendation for this triennium is that there is an urgent need for a guideline on management of obese pregnant women.

References

  1. Knight M, Kurinczuk JJ, Spark P and Brocklehurst P. United Kingdom Obstetric Surveillance System (UKOSS) Annual Report 2007. National Perinatal Epidemiology Unit, Oxford.
  2. National Collaborating Centre for Women’s and Children’s Health commissioned by the National Institute for Clinical Excellence. Antenatal care: routine care for the healthy pregnant woman. London: RCOG Press, 2003. Available at www.nice.org.uk
  3. Royal College of Obstetricians and Gynaecologists. Thromboprophylaxis during pregnancy, labour and after normal vaginal delivery. Guideline no.37. London: RCOG Press; 2004. Available at www.rcog.org.uk
  4. Royal College of Obstetricians and Gynaecologists. Thromboembolic disease in pregnancy and the puerperium: acute management. Guideline no.28. London: RCOG Press; 2001. Available at www.rcog.org.uk
  5. Royal College of Obstetricians and Gynaecologists. Report of the RCOG Working Party on prophylaxis   against thromboembolism in gynaecology and obstetrics. London: RCOG Press; 1995.
  6. Department of Health.  Maternity Matters: choice, access and continuity of care in a safe service. London: Department of Health; April 2007. www.dh.gov.uk