Saving Mothers' Lives: - Public Health Agency for Northern Ireland

Quality of care
Care was considered sub-standard in seven of the sixteen Indirect maternal deaths from myocardial
infarction and/or ischaemic heart disease. In some instances this involved doctors and midwives failing to
recognise the classic symptoms of acute coronary syndrome/myocardial infarction, such as crushing chest
pain radiating to the shoulder, or jaw, or a failure to identify obvious ischaemic changes on an ECG reading:
A socially disadvantaged women with type 2 diabetes and epilepsy, who had been advised to
delay pregnancy until she had been formally counselled by her specialist consultants regarding
her diabetes and epilepsy, became pregnant. She was admitted early in her third trimester
with abdominal pain and vomiting and, although the pain was so severe to require morphine,
no diagnosis was made. She may also have developed pre-eclampsia. When her condition
deteriorated with further epigastric pain an ECG was fi nally performed but, although clearly
abnormal showing an acute anterior myocardial infarction (MI), it was not reported as such. It
is not clear who or how many people reviewed the ECG trace. She continued to be unwell and
arrested four days later. Autopsy revealed an acute MI and a left anterior descending coronary
artery that was occluded at its midpoint by atheroma and thrombus.
The following vignette demonstrates another area of concern:
A parous woman who was a heavy smoker developed preterm pre-eclampsia. Labour was
induced and she eventually required a caesarean section for fetal distress. She returned home
three days later even though she remained hypertensive and felt unwell. She also complained
of wind and nausea but none of her symptoms were investigated further. Eventually she
was admitted with an acute antero-lateral myocardial infarction but the cardiologist advised
against thrombolysis because of her recent operation. At cardiac catheterization, atheroma
and thrombosis were identifi ed in her left anterior descending coronary artery. She died shortly
afterwards of a complication related to the coronary intervention.
This mother should not have been discharged so shortly after delivery having had a history of pre-term preeclampsia,
a caesarean section and on-going hypertension. Her symptoms should have been investigated
further and the benefi ts of thrombolysis should have been balanced against the risks two weeks after
surgery.
The RCOG study group on heart disease in pregnancy 2 concluded “thrombolysis may cause bleeding from
the placental site but should be given in women with life-threatening thromboembolic disease or acute
coronary insuffi ciency”.
Although there are few data relating to thrombolysis in acute coronary syndrome in pregnancy, a literature
review 8 of 200 cases of thrombolysis for massive pulmonary embolism in pregnancy reported a maternal
death rate of 1% and concluded that thrombolytic therapy is reasonably safe.
Outside pregnancy, primary angioplasty has been shown to be preferable to thrombolysis provided this is
achievable within 90 minutes to 3 hours. In pregnancy urgent coronary angiography is even more important
since not only does this allow differentiation between coronary artery dissection, thrombosis (relatively
more common related to pregnancy) and atheroma, but also it allows for intervention with stenting to treat
a dissection.
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