MBRRACE UK Rapid Report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK

(March - May 2020) 
 
Following the SARS-CoV-2 virus, MBRRACE initiated a rapid notification system for maternal deaths associated with the virus. Expedited reviews were conducted to collate information relating to the virus for pregnant people “with confirmed or suspected SARS-CoV-2 infection during or up to one year after pregnancy, and any deaths of women who died from mental health-related causes or domestic violence, which might have been influenced by public health measures introduced to control the epidemic such as lockdown.” The reviews reported were from deaths occurring in the period of March to May 2020. Healthcare Safety Investigation Branch (HSIB) also contributed to this report using data from their own investigations of maternal deaths linked to SARS-CoV-2. 
 
The key lessons and recommendations:  
 

1. Senior obstetric review of pregnant people is crucial in the context of COVID-19. Where relevant multidisciplinary team care should be given with daily review. The most likely person to be overlooked is someone who is unwell but not displaying a need for “continuous level 3 care, but with multiple problems and for whom therefore no-one takes a leadership role” in their overall care.  
2. Critical care treatment should be provided in another setting if beds are not readily available, treatment should not be postponed. 
3. Infection with COVID-19 should be considered as an additional risk factor for thromboembolism. This should be addressed by prompt reassessment and proactive management. Emerging evidence points to a link between COVID-19 and increased risk of thrombotic disease. Pregnant people have further increased risk for thromboembolic events even more so in the 3rd trimester, caesareans increase the risk further.  
4. A minimum standard of orientation should be given for staff working in new clinical environments. This relates to medical staff being redeployed at short notice to new clinical environments who were unfamiliar with the critical care equipment that they were required to use and monitor in order to care for patients. 
5. Pregnant or postpartum people with medical complications should be treated the same as non-pregnant people when considering antiviral or therapeutic treatment for COVID-19 as part of early care or compassionate use programmes. Exclusion from clinical trials should only occur when there is a clear reason. 
6. Pregnant people need clear guidance on when to speak to their midwife or go to the hospital. If necessary this should be provided by an interpreter. The stay at home/self-isolate guidance for COVID-19 and partner restrictions resulted in pregnant people staying at home and self-medicating for several days without seeking additional support. Clear guidance is required for pregnant and postpartum people about the risks of deterioration and when to seek urgent medical attention. People from Black and Minority Ethnic backgrounds or those with other risk factors should be advised to seek additional guidance without any delay if they have any health concerns. 
7. Communication with families and partners and facilitating visits when people are critically ill is a priority. An interpreter should be used when required.  
8. Continuation of perinatal mental health services is essential. In some instances, face-to-face care is necessary in some instances to prevent people from taking their own lives. Referral on more than one instance with mental health concerns should be considered a ‘red flag’ requiring clinical review to avoid patients being sent to different mental health services without being seen by someone with mental health expertise. Using video as a tool for professional review should be considered and the thresholds for face-to-face consultations should be lowered to take into account the additional stress of the COVID-19 context. 
9. People experiencing domestic violence need adequate safeguarding, this may include moving to a safe environment even in the context of COVID-19 restrictions. The issue of safety and care should not just be focused on the child(ren) but any person experiencing domestic violence. 

 
Whilst the report provides guidance primarily directed at those providing clinical care, key takeaways can be taken from the above summary for those supporting families or clients who are pregnant or in their postpartum period. 
 
Source MBRRACE Rapid Report 23 March 2021 
https://www.npeu.ox.ac.uk/mbrrace-uk/reports#main 

Written by Elizabeth Odunlami