Skip to main content
SpringerLink
Log in

„Why mothers die“

Was wir von der Analyse anästhesiebedingter mütterlicher Sterbefälle (1985–2013) gelernt haben

“Why mothers die”

Learning from the analysis of anaesthesia-related maternal deaths (1985–2013)

  • Fehler und Gefahren
  • Published:
Der Anaesthesist Aims and scope Submit manuscript

Zusammenfassung

Täglich sterben weltweit über 800 Frauen an schwangerschafts- oder geburtsassoziierten Komplikationen. In den Confidential Enquiry of Maternal Deaths Reports (CEMD) wird seit 1952 die Müttersterblichkeit im Vereinigten Königreich Großbritannien und Irland erfasst und aufgearbeitet. Die vorliegende Arbeit analysiert die CEMD der Jahre 1985–2013 hinsichtlich anästhesie- und analgesiebedingter mütterlicher Todesursachen in der Schwangerschaft, peripartal und im Wochenbett. Im untersuchten Zeitraum zeichnete sich eine Abnahme direkt anästhesiebedingter mütterlicher Sterbefälle auf aktuell 4,3 % ab. Jedoch kam es zu einer Zunahme anästhesieassoziierter mütterlicher Sterbefälle. Die Rate an tödlichen Komplikationen im Rahmen einer geburtshilflichen Regionalanästhesie hat sich in den letzten Jahren verdoppelt, während das Risiko im Rahmen einer geburtshilflichen Vollnarkose zu sterben rückläufig ist.

Viele der geschilderten mütterlichen Sterbefälle wären möglicherweise vermeidbar gewesen. Jeder geburtshilflich tätige Anästhesist sollte sich mit dem schwangerschaftsspezifischen Vorgehen, peripartal und auch im Wochenbett vertraut machen, bestenfalls mithilfe der geforderten Simulationsübungen. Das Monitoring von Patientinnen nach geburtshilflichen Eingriffen muss dem nicht geburtshilflicher Patienten entsprechen, sogenannte Modified Early Obstetric Warning Scores sollten hierbei zur Anwendung kommen. Im Rahmen der Regionalanästhesie sind aktuelle Hygienestandards strikt einzuhalten und Postpunktionskontrollen durchzuführen. Interdisziplinäre Kommunikation und Zusammenarbeit sind essenziell, jedoch weiterhin verbesserungswürdig. Für Risikopatientinnen sollte bereits im Schwangerschaftsverlauf ein interdisziplinärer Geburtsplan erarbeitet werden.

Abstract

Every day, more than 800 women die from causes related to pregnancy or childbirth. Since 1952 the Confidential Enquiry of Maternal Deaths Reports (CEMD) have collected and analysed data on maternal mortality in the United Kingdom and Northern Ireland. This publication analyses the CEMD from 1985–2013 regarding anaesthesia- and analgesia related maternal deaths during pregnancy or peripartum. During this period, there has been a reduction in directly anaesthesia-related maternal deaths to 4.3 %. Yet, an increase in anaesthesia-associated maternal deaths has been recorded. The rate of fatal complications during obstetric regional anaesthesia doubled in recent years, while the fatality risk for obstetric general anaesthesia has decreased. Many of the reported maternal deaths could presumably have been avoided. The anaesthesiologist has to be familiar with state-of-the-art, guideline-based concepts for anaesthesia during pregnancy, childbirth or post partum, especially using tools like simulation. Vital sign monitoring after obstetric anaesthesia has to be identical to other postoperative monitoring, and Modified Early Warning Scores should be used for this purpose. In regional anaesthesia, current standards for hygiene have to be adhered to and patients have to be visited after spinal/epidural anaesthesia. Interdisciplinary communication and collaboration still have to be improved; careful interdisciplinary planning of childbirth in high-risk obstetric patients is strongly advised.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4

Literatur

  1. Alkema L, Chou D, Hogan D et al (2016) Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet 387:462–474

    Article  PubMed  Google Scholar 

  2. Barnardo, Jenkins JG (2000) Failed tracheal intubation in obstetrics: a 6 year review in a UK region. Anaesthesia 55(7):690–694

    Article  CAS  PubMed  Google Scholar 

  3. Basaranoglu G, Lyons G, Columb M (2010) Failure to predict difficult tracheal intubation for emergency cesarean section. Eur J Anaesthesiol 27(11):947–949

    Article  PubMed  Google Scholar 

  4. Bateman BT, Berman MF, Riley LE et al (2010) The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 110(5):1368–1373

    Article  PubMed  Google Scholar 

  5. Bose P, Regan F, Paterson-Brown S (2006) Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG 113(8):919–924

    Article  CAS  PubMed  Google Scholar 

  6. Buchanan SL, Patterson JA, Roberts CL et al (2012) Trends and morbidity associated with oxytocin use in labour in nulliparas at term. Aust N Z J Obstet Gynaecol 52(2):173–178

    Article  PubMed  Google Scholar 

  7. Bundesinstitut Für Bevölkerungsforschung (2015) Glossareintrag „Müttersterblichkeit“. http://www.bib-demografie.de/SharedDocs/Glossareintraege/DE/M/muettersterblichkeit.html. Zugegriffen: 11. Dez. 2015

    Google Scholar 

  8. Callaghan WM, Kuklina EV, Berg CJ (2010) Trends in postpartum hemorrhage: United States, 1994–2006. Am J Obstet Gynecol 353:e351–e356

    Google Scholar 

  9. Calthorpe N, Lewis M (2012) Acid aspiration prophylaxis in labour: a survey of UK obstetric units. Int J Obstet Anesth 14:300–304

    Article  Google Scholar 

  10. Cluver C, Novikova N, Hofmeyr GJ et al (2013) Maternal position during caesarean section for preventing maternal and neonatal complications. Cochrane Database Syst Rev 3:Cd007623

    PubMed  Google Scholar 

  11. Conforth BM, Dalgiesh DJ, Bromilow J et al (2006) Use of an information leaflet to improve general practicioners´ knowledge of post dural puncture headache. Int J Obstet Anesth 15:28–32

    Article  Google Scholar 

  12. Cook TM, Woodall N, Frerk C (2011) Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 106(5):617–631

    Article  CAS  PubMed  Google Scholar 

  13. Crofts JF, Draycott TJ, Winter C et al (2007) Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG 114(12):1534–1541

    Article  CAS  PubMed  Google Scholar 

  14. Cyna AM, Andrew M, Emmett RS et al (2006) Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Rev 18(4):CD002251

    Google Scholar 

  15. Dekeyser V, Woods DD (1990) Fixation errors: Failures to revise situation assessment in dynamic and risky systems. In: Colombo SDB (Hrsg) Systems Reliability Assesment. Kluwer Academic Publishers, Boston, S 231–2521

    Chapter  Google Scholar 

  16. Dellinger RP, Levy MM, Rhodes A et al (2013) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 39:165–228

    Article  CAS  PubMed  Google Scholar 

  17. Deutsche Gesellschaft für Anaesthesiologie und Intensivmedizin (1997) Apparative Ausstattung für Aufwachraum, Intensivüberwachung und Intensivtherapie. Gemeinsame Empfehlung des Engeren Präsidiums der DGAI und des Präsidiums des BDA. Anästh Intensivmed 38:470–474

    Google Scholar 

  18. Djabatey EA, Barclay PM (2009) Difficult and failed intubation in 3430 obstetric general anaesthetics. Anaesthesia 64:1168–1171

    Article  CAS  PubMed  Google Scholar 

  19. Drife J (2005) Why mothers die. J R Coll Physicians Edinb 35:332–336

    Google Scholar 

  20. El-Messidi A, Mallozzi A, Oppenheimer L (2012) A multidisciplinary checklist for management of suspected placenta accreta. J Obstet Gynaecol Can 34:320–324

    Article  PubMed  Google Scholar 

  21. Feige A (2011) Probleme der belegärztllichen Behandlung in der Geburtshilfe. In: Arbeitsgemeinschaft Rechtsanwälte im Medizinrecht e. V. (Hrsg) 25 Jahre Arbeitsgemeinschaft – 25 Jahre Arzthaftung Von der Krähentheorie zum groben Behandlungsfehler. Springer, Berlin Heidelberg, S 55–62

    Google Scholar 

  22. Gaba D (1992) Dynamic decision-making in anaesthesiology: cognitive training and training approaches. In: Evans P (Hrsg) Advanced models of cognition for medical training and practice. Springer, Berlin, S 122–147

    Google Scholar 

  23. Geschäftsstelle Qualitätssicherung Im Krankenhaus (2014) Weiterführende Datenerhebung zu mütterlichen Sterbefällen im stationären Bereich der Geburtshilfe im Rahmen der Qualitätssicherung (Strukturierter Dialog). http://www.geqik.de/index.php?eID=tx_dvssecurefiles&gid=0&enc=1&cmFnZWJvZ2VuX011ZXR0ZXJsaWNoZV9TdGVy YmVmYWVsbGVfMjAxNC5wZGY=. Zugegriffen: 29. Nov. 2015

    Google Scholar 

  24. Gogarten W, Vandermeulen E, Van Aken H et al (2010) Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 27:999–1015

    Article  CAS  PubMed  Google Scholar 

  25. Haeri S, GaR D (2012) Maternal mortality from hemorrhage. Semin Perinatol 36(1):48–55

    Article  PubMed  Google Scholar 

  26. Heslehurst N, Rankin J, Wilkinson JR et al (2010) A nationally representative study of maternal obesity in England, UK: trends in incidence and demographic inequalities in 619 323 births, 1989–2007. Int J Obes (Lond) 34:420–428

    Article  CAS  Google Scholar 

  27. Hodges RJ, Bennett JR, Tunstall ME et al (1959) General anaesthesia for operative obstetrics: with special reference to the use of thiopentone and suxamethonium. Br J Anaesth 31:152–163

    Article  CAS  PubMed  Google Scholar 

  28. Isaacs RA, Wee MY, Bick DE et al (2014) A national survey of obstetric early warning systems in the United Kingdom: five years on. Anaesthesia 69(7):687–692

    Article  CAS  PubMed  Google Scholar 

  29. Jenkins JG (2005) Some immediate serious complications of obstetric epidural analgesia and anaesthesia: a prospective study of 145,550 epidurals. Int J Obstet Anesth 14:37–42

    Article  CAS  PubMed  Google Scholar 

  30. Jenkins JG, Khan MM (2003) Anaesthesia for Caesarean section: a survey in a UK region from 1992 to 2002. Anaesthesia 58:1114–1118

    Article  CAS  PubMed  Google Scholar 

  31. Johnso RV, Lyons GR, Wilson RC et al (2000) Training in obstetric general anaesthesia, a ‘vanishing art. Anaesthesia 55:712–713

    Article  Google Scholar 

  32. Kerwat K, Steinfeldt T, Kessler P et al (2015) Überarbeitete Handlungsempfehlung: Hygieneempfehlungen für die Regionalanästhesie. Anästh Intensivmed 56:34–40

    Google Scholar 

  33. Kinsella SM, Walton B, Sashidharan R et al (2010) Category-1 caesarean section: a survey of anaesthetic and peri-operative management in the UK. Anaesthesia 65:362–368

    Article  CAS  PubMed  Google Scholar 

  34. Kinsella SM, Winton AL, Mushambi MC et al (2015) Failed tracheal intubation during obstetric general anaesthesia: a literature review. Int J Obstet Anesth 24:356–374

    Article  CAS  PubMed  Google Scholar 

  35. Knight M, Callaghan WM, Berg C et al (2009) Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth 9:55

    Article  PubMed  PubMed Central  Google Scholar 

  36. Knight M, Kenyon S, Brocklehurst P et al. (2014) on behalf of MBRRACE-UK. University of Oxford: Saving Lives, Improving Mothers’ Care – Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12

  37. Knight M, Tuffnell D, Kenyon S et al (Hrsg) (2015) Saving Lives, Improving Mothers’ Care – Surveillance of maternal deaths in the UK 2011–13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. Oxford: University of Oxford

    Google Scholar 

  38. Kodali BS, Chandrasekhar S, Bulich LN et al (2008) Airway changes during labor and delivery. Anesthesiology 108:357–362

    Article  PubMed  Google Scholar 

  39. Kramer MS, Dahhou M, Vallerand D et al (2011) Risk factors for postpartum haemorrhage: can we explain the recent temporal increase? J Obstet Gynaecol Can 33(8):810–819

    Article  PubMed  Google Scholar 

  40. Lockhart EM, Baysinger CL (2007) Intracranial venous thrombosis in the parturient. Anesthesiology 107:652–658

    Article  PubMed  Google Scholar 

  41. Lucas DN, Yentis SM (2015) Unsettled weather and the end for thiopental? Obstetric general anaesthesia after the NAP5 and MBRRACE-UK reports. Anaesthesia 70:375–379

    Article  CAS  PubMed  Google Scholar 

  42. Marcus HE, Behrend A, Schier R et al (2011) Anesthesiological management of Caesarean sections: nationwide survey in Germany. Anaesthesist 60:916–928

    Article  CAS  PubMed  Google Scholar 

  43. Mellin-Olsen J, Staender S, Whitaker DK et al (2010) The Helsinki declaration on patient safety in anaesthesiology. Eur J Anaesthesiol 27:592–597

    Article  PubMed  Google Scholar 

  44. Merién AE, Van De Ven J, Mol BW et al (2010) Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review. Obstet Gynecol 115:1021–1031

    Article  PubMed  Google Scholar 

  45. Mohammed A, Wu J, Biggs T et al (2013) Does use of a World Health Organization obstetric safe surgery checklist improve communication between obstetricians and anaesthetists? A retrospective study of 389 caesarean sections. Int J Obstet Gynaecol 120:644–648

    Article  CAS  Google Scholar 

  46. Morin AM, Kerwat KM, Klotz M et al (2005) Risk factors for bacterial catheter colonization in regional anaesthesia. BMC Anesthesiol 5:1

    Article  PubMed  PubMed Central  Google Scholar 

  47. Murdoch H, Scrutton M, Laxton CH (2013) Choice of anaesthetic agents for caesarean section: a UK survey of current practice. Int J Obstet Anesth 22:31–35

    Article  CAS  PubMed  Google Scholar 

  48. Murphy JD, Togioka BM (2011) Aspiration in early pregnancy: risk factors revisited. J Clin Anesth 23:435–436

    Article  PubMed  Google Scholar 

  49. Mushambi MC, Kinsella SM, Popat M et al (2015) Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 70:1286–1306

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Palanisamy A, Mitani AA, Tsen LC (2011) General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update. Int J Obstet Anesth 20:10–16

    Article  CAS  PubMed  Google Scholar 

  51. Pandit JJ, Andrade J, Bogod DG et al (2014) 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth 113:549–559

    Article  CAS  PubMed  Google Scholar 

  52. Pratt SD (2012) Focused review: simulation in obstetric anesthesia. Anesth Analg 114:186–190

    Article  PubMed  Google Scholar 

  53. Quinn AC, Milne D, Columb M et al (2013) Failed tracheal intubation in obstetric anaesthesia: 2 yr national case-control study in the UK. Br J Anaesth 110:74–80

    Article  CAS  PubMed  Google Scholar 

  54. Royal College of Obestetricians and Gynaecologists (2011) Maternal Collapse in Pregnancy and the Puerperium – Green-top Guideline No. 56

  55. Rucklidge M (2013) Up-to-date or out-of-date: does thiopental have a future in obstetric general anaesthesia? Int J Obstet Anesth 22:175–178

    Article  PubMed  Google Scholar 

  56. Samangaya R, Pennington R, Vause S (2010) Factors relating to a rising incidence of major postpartum haemorrhage. BJOG 117(3):370–371

    Article  PubMed  Google Scholar 

  57. Schlembach D, Mortl MG, Girard T et al (2014) Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D‑A-CH consensus group PPH (Germany–Austria–Switzerland). Anaesthesist 63:234–242

    Article  CAS  PubMed  Google Scholar 

  58. Shibli KU, Russell IF (2000) A survey of anaesthetic techniques used for caesarean section in the UK in 1997. Int J Obstet Anesth 9:160–167

    Article  CAS  PubMed  Google Scholar 

  59. Soar J, Pumphrey R, Cant A et al (2008) Emergency treatment of anaphylactic reactions – guidelines for healthcare providers. Resuscitation 77:157–169

    Article  PubMed  Google Scholar 

  60. Stabille DM, Diogo FA, Mandim BL et al (2015) Frequency of colonization and isolated bacteria from the tip of epidural catheter implanted for postoperative analgesia. Braz J Anesthesiol 65:200–206

    Article  PubMed  Google Scholar 

  61. Tamma, Ault KA, Del Rio C et al (2009) Safety of influenza vaccination during pregnancy. Am J Obstet Gynecol 201:547–552

    Article  CAS  PubMed  Google Scholar 

  62. Tao W, Edwards JT, Tu F et al (2012) Incidence of unanticipated difficult airway in obstetric patients in a teaching institution. J Anesth 26:339–345

    Article  Google Scholar 

  63. Thomas TA (1991) Anaesthesia and Maternal Mortality. Curr Anaesth Crit Care 2(2):85–91

    Article  Google Scholar 

  64. Thompson MG, Li DK, Shifflett P et al (2014) Effectiveness of seasonal trivalent influenza vaccine for preventing influenza virus illness among pregnant women: a population-based case-control study during the 2010–2011 and 2011–2012 influenza seasons. Clin Infect Dis 58:449–457

    Article  PubMed  Google Scholar 

  65. United Nations (2000) 55/2. United Nations Millennium Declaration

  66. Volk T, Engelhardt L, Spies C et al (2009) Incidence of infection from catheter procedures for regional anesthesia: first results from the network of DGAI and BDA. Anaesthesist 58:1107–1112

    Article  CAS  PubMed  Google Scholar 

  67. Volk T, Graf BM, Gogarten W et al (2009) Empfehlungen zur Lipidbehandlung bei der Intoxikation mit Lokalanästhetika. Anästh Intensivmed 50:698–702

    Google Scholar 

  68. Walker E, Moore P (2005) Obstetric recovery practice: a survey of UK obstetric anaesthetists. Int J Obstet Anesth 14:193–199

    Article  CAS  PubMed  Google Scholar 

  69. Waterstone M, Bewley S, Wolfe C (2001) Incidence and predictors of severe obstetric morbidity: case-control study. BMJ 322(7294):1089–1093

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  70. Wilkins KK, Greenfield ML, Polley LS et al (2009) A survey of obstetric perianesthesia care unit standards. Anesth Analg 108:1869–1875

    Article  PubMed  Google Scholar 

  71. World Health Organization (2010) Accelerating progress towards the health-related. Millenn Dev Goals 1:1–16

    Google Scholar 

  72. World Health Organization (2009) Human factors in patient safety review of topics and tools. In: WHO methods and measures working group of patient safety. http://www.who.int/patientsafety/research/methods_measures/human_factors/en/. Zugegriffen: 29. März 2016

  73. World Health Organization (2015) Maternal mortality Fact sheet N°348. http://www.who.int/mediacentre/factsheets/fs348/en/. Zugegriffen: 11. Dez. 2015

    Google Scholar 

  74. World Health Organization (2014) Trends in Maternal Mortality: 1990 to 2013 – Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division, S 56. http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/ Zugegriffen: 29. März 2016

    Google Scholar 

  75. Zeidan A, Farhat O, Maaliki H et al (2006) Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature. Int J Obstet Anesth 15:50–58

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    S. Neuhaus, C. Neuhaus, S. Hofer, R. Schreckenberger & M. A. Weigand

  2. Universitätsfrauenklinik Heidelberg, Heidelberg, Deutschland

    H. Fluhr

  3. Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland

    D. Bremerich

Authors
  1. S. Neuhaus
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. C. Neuhaus
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. H. Fluhr
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. S. Hofer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. R. Schreckenberger
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. M. A. Weigand
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. D. Bremerich
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to S. Neuhaus.

Ethics declarations

Interessenkonflikt

D. Bremerich, H. Fluhr, S. Neuhaus, C. Neuhaus, R. Schreckenberger geben an, dass kein Interessenkonflikt besteht. S. Hofer hat Honorare von CSL Behring, Boehringer Ingelheim, Novo Nordisk, Bayer, Köhler Chemie und MSD Sharp & Dohme erhalten, die nicht in Bezug zum eingereichten Manuskript stehen. M.A. Weigand hat Honorare von Astellas Pharma, Astra Zeneca, B. Braun, Biosyn, CSL Behring, Eli Lilly, GE Healthcare, Gilead, GlaxoSmithKline, Janssen, Köhler Chemie, MSD Sharp & Dohme, Novartis, Orion Pharma, Pfizer Pharma und CytoSorbents erhalten, die nicht in Bezug zum eingereichten Manuskript stehen. Er ist/war Mitglied wissenschaftlicher Beiräte von Astellas Pharma, B. Braun, Gilead, MSD Sharp & Dohme, Pall Medical und Pfizer Pharma.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Neuhaus, S., Neuhaus, C., Fluhr, H. et al. „Why mothers die“. Anaesthesist 65, 281–294 (2016). https://doi.org/10.1007/s00101-016-0155-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00101-016-0155-6

Schlüsselwörter

Keywords

Search

Navigation