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

Box 9.3
Learning points: peripartum cardiomyopathy
Women in late pregnancy or within fi ve months of delivery with symptoms of breathless, oedema or
orthopnoea and the signs of tachypnoea and tachycardia may have peripartum cardiomyopathy and
investigation with a chest x-ray and an echocardiogram are indicated.
The presence of a wheeze may not necessarily indicate asthma and may be a feature of heart failure.
Women with peripartum cardiomyopathy should be managed by cardiologists with expertise in this
condition, and their care discussed, if appropriate, with the regional cardiac transplant centre.
Treatment with ACE inhibitors, beta blockers and full anticoagulation is appropriate for postpartum woman.
Myocardial fi brosis and myocarditis
Three women died from myocardial fi brosis, the same number as in the last Report. All died following
sudden collapse and in all three the care was considered sub-standard. Two of these women had
inadequate autopsies, which represents a degree of sub-standard care. One woman was inappropriately
booked for midwifery led care despite a previous history of myopericarditis. Another woman who died of an
unheralded cardiac arrest a few days after delivery, and who had been treated with a nasogastric tube for
a postoperative ileus, had no monitoring of her urea and electrolytes and hypokalaemia could have been a
contributory factor.
Two women died from myocarditis. One who became unwell in mid pregnancy received very good care.
She had a timely and appropriate referral into hospital from her GP, but she died shortly after admission.
An excellent autopsy made the diagnosis of widespread medium and small vessel vasculitis. Even if the
diagnosis had been made before her death, and treatment with immunosuppression begun, this would
have been very unlikely to have prevented death which occurred hours after admission.
Hypertensive heart disease
The following vignette describes the key learning points in relation to the planning and provision of care for
women known to be at higher risk of medical complications, including hypertensive heart disease:
A multiparous, obese woman was prescribed clomiphene for infertility. Her booking blood pressure
was high and thereafter her hypertension was suboptimally controlled. She also developed
gestational diabetes. Her general practitioner (GP) prescribed salbutamol for “wheezing” and she
saw a cardiologist for breathlessness and dizziness. A suboptimal echocardiogram was reported
as showing mitral regurgitation but no features of heart failure. Postnatally there was inadequate
monitoring of her blood pressure and the midwives did not appreciate the signifi cance of a “rattly”
chest and chest pain. She died of hypertensive heart failure fi ve days after delivery. Autopsy
revealed a grossly enlarged heart with left and right ventricular hypertrophy, and evidence of
longstanding back pressure on the lungs and congestive cardiac failure.
This case raises the issue of whether or not her GP or gynaecologist had checked her BP, or counselled
her regarding the risks of obesity in pregnancy, prior to prescribing clomiphene. It is possible that her
wheezing was due to heart failure and not asthma. Despite the diagnosis of “asthma”, a betablocker was
prescribed. Despite the presence of mitral regurgitation on her echocardiogram she did not receive cardiac
antibiotic prophylaxis for delivery, and the possibility of left ventricular dilatation and poor function as an
explanation for her symptoms and mitral regurgitation was not considered. Hypertensive heart disease is
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