Dr Kirsty Maclennan1, Dr Chandrima Biswas1, Dr Charlotte Frise3, Mrs Rachel Rees1, Dr Vidya Shyam-Sundar2, Mr Julian Sutton1, Dr Louise Page1
1Maternity and Newborn Safety Investigations, London, United Kingdom, 2Royal Free NHS Foundation Trust, London, United Kingdom, 3Imperial College Healthcare Trust, London, United Kingdom
Biography:
Miss Louise M Page, FRCOG MSc
Interim clinical director – Maternity and Newborn Safety Investigation (MNSI) programme.
Consultant Obstetrician and Gynaecologist, Chelsea & Westminster Hospital NHS Foundation Trust – West Middlesex site.
Abstract:
Introduction: The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology¹ , into maternity events, including maternal deaths. Standardisation of care for women with hyperemesis gravidarum (HG) is lacking. Awareness of its severity and associated risks of morbidity and mortality are essential to provide safe antenatal care.²
Method: MNSI investigated 245 maternal death cases between April 2019 and December 2023. 25 complete investigations, where the woman died in the first trimester, were thematically reviewed.
Results: 28% (7 of 25) of first trimester deaths were a result of venous thromboembolism (VTE) in the presence of HG.
6 of the 7 women contacted a healthcare provider to seek treatment for severe vomiting. 5 of the 7 women were treated in hospital, 1 was managed in primary care. All died within 2 weeks of healthcare contact (average time, 6 days).
Of the 5 women cared for in hospital, 4 were not assessed for VTE risk on admission, 1 was assessed and received low molecular weight heparin (LMWH). 4 women were discharged from hospital, none received LMWH. All women would have been eligible to received LMWH on account of their continued hyperemesis and immobility.³
Safety prompts include:
1. Embedding routine use of approved scoring systems (such as pregnancy-unique quantification of emesis (PUQE) score) to enable a consistent approach to assessing the severity of HG
2. Consideration of the need for LMWH in women who are dehydrated and immobile as inpatients or at home
3. Robust advice about indicators of VTE for women with HG
4. Consideration in the next VTE guidance to reflect ‘severe nausea and vomiting’ rather than waiting for a label of ‘hyperemesis gravidarum’ to be made.
Keywords
First trimester deaths
Hyperemesis gravidarum
Venous thromboembolism
References
1. Maternity and Newborn Safety Investigations. Investigation overview for NHS. www.mnsi.org.uk.
2. Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; the Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024; 131(7): e1–e30. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/the-management-of-nausea-and-vomiting-of-pregnancy-and-hyperemesis-gravidarum-green-top-guideline-no-69/
3. Nelson-Piercy C, MacCallum P, Mackillop L et al; the Royal College of Obstetricians and Gynaecologists. Reducing the Risk of Thrombosis and Embolism during Pregnancy and the Puerperium (Green-top Guideline No. 37a). https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/reducing-the-risk-of-thrombosis-and-embolism-during-pregnancy-and-the-puerperium-green-top-guideline-no-37a/