Reducing Risk of Stillbirth, Beta Blockers and the Public Enquiry into Stafford Hospital

Last week, following an inquest lasting almost a year, the results of the enquiry into
Stafford Hospital were released and the findings are very serious. The report found that
patients died needlessly due to poor care. The report makes 290 recommendations for 
improvements. In 2007, higher than expected death rates were reported at the hospital,
leading to investigation, and some of the findings were target driven managers, poor 
standards of nursing care, a culture of bullying, complaints being ignored and doctors
continuing to work under these poor conditions without speaking out. It should be noted 
that mortality rates are only one way of looking at how a hospital is performing. Rates
can vary for many other reasons with poor quality healthcare being only one. Nonetheless
the results from the enquiry deserve the high level of publicity which they have received
and should lead to important lessons being learned for other health boards. 

Working in obstetrics and gynaecology at the moment, naturally I've taken more interest
in related articles. There was an interesting one in the BMJ this week about identifying risk
factors for stillbirth. One of the common reasons for patients presenting to the maternity
outpatients department seems to be for ? reduced fetal movements. Fortunately most of the time a CTG 
(cardiotocograph) is reassuring, showing good fetal movements and fetal heart rate, meaning that the patient can be
safely discharged. Fetal stillbirth remains to be one of the few potentially avoidable maternal and child health
complications which hasn't declined in recent years. Patients who present to the out-patients are assessed for their
risk of stillbirth, but perhaps we should be doing more in the community to reduce the risk of stillbirth. Fetal growth
restriction, smoking and obesity are three important risk factors. Smoking in particular is easily modifiable (patients
must be encouraged to stop smoking), and fetal growth restriction should not go unrecognised. Despite this, a recent
population based study has found that in pregnancies ending in stillbirth, unrecognised fetal growth restriction was 
associated with 32% of all deaths. Identifying fetal growth restriction and smoking cessation are therefore important 
goals for antenatal care and could be the key to reducing the rates of stillbirths in Scotland.

Beta blockers have long been know to result in favourable outcomes in heart failure, and a recent study published in 
the BMJ this month has shown that beta blockers exert a class effect with no one particular drug showing favourable 
outcomes. The 'big three' beta blockers investigated were carvedilol, metoprolol and bisoprolol (these ones have the 
strongest evidence base). Recommendations are that unless there are obvious contra-indicationns (eg. asthma), 
stable patients with an ejection fraction of 40% or less should receive one of the drugs, but there is no one drug which
is preferable. Areas which require further study in the future include the global population variations in penetrance of 
beta blockers, and the use of beta blockers in patients with COPD as a co-morbidity (cardioselective vs. 
non-cardioselective agents).