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

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9 Cardiac disease
a long-standing condition and would not have appeared over days. There were warning signs antenatally
and it is likely given the autopsy fi ndings that the echocardiogram was abnormal. Perhaps the examination
should have been repeated antenatally. Her postnatal care was also sub-standard.
Rheumatic heart disease
Until this triennium there had been no maternal deaths reported from rheumatic fever since the 1991-1993
Enquiry. However, in this Report, there were two maternal deaths from mitral stenosis; both in recently
arrived immigrant women. This probably refl ects an increase in the numbers of newly arrived immigrant
mothers with a history of rheumatic heart disease. Since rheumatic heart disease has become so rare in
the United Kingdom, and many maternity health professionals will not have seen a case, it is imperative
that all pregnant women with rheumatic heart disease and/or mitral stenosis be referred to tertiary cardiac
centres for advice regarding their management in pregnancy. The following vignette illustrates some of the
many problems with the care of such women:
A previously well young immigrant woman, with little English, was booked for midwifery led care
and only ever saw her midwife or her GP. She was admitted to an emergency department (ED)
at the end of her second trimester with cough, breathlessness and chest pain. She was hypoxic
and markedly tachycardic and, not unreasonably, the diagnosis was assumed to be a pulmonary
embolus. Her chest was clear and no murmur was heard. The ED junior doctor discussed the
case with the obstetric trainee, who did not review her personally but advised that heparin was
safe in pregnancy, and with the medical trainee who advised against a chest x-ray (CXR). Her
ECG showed P mitrale, suggesting an enlarged left atrium, but this was missed. She was given
low molecular weight heparin (LMWH) but her condition deteriorated and she suffered a cardiac
arrest from which she was resuscitated. She was then transferred to the Critical Care Unit. An
echocardiogram was suggestive of only mild mitral stenosis but she had signifi cant pulmonary
hypertension (pulmonary artery pressure 55 + jvp mm/Hg) which should have raised concerns that
the mitral stenosis was more severe, as was diagnosed at autopsy. She died the following day.
Omitting to do a CXR was an error. This would have been an appropriate investigation even if pulmonary
embolus was suspected. It may also have shown pulmonary oedema. A full physical examination by a
doctor at her booking visit may also have revealed the murmur of mitral stenosis. Although the diagnosis
was missed on her fi nal admission, at this stage she was very tachycardic which would have made it
harder to hear the soft diastolic murmur of mitral stenosis.
Box 9.4
Learning points: rheumatic mitral stenosis
Although extremely rare in the United Kingdom, rheumatic heart disease is still common in less
developed countries, and mitral stenosis often complicates pregnancy. Newly arrived women from such
parts of the world therefore require a full physical examination when they present for booking.
Although seemingly well in early pregnancy, women with mitral stenosis commonly decompensate at the
end of the second trimester.
Symptoms of breathlessness, orthopnoea and the signs of tachypnoea and tachycardia, especially in
an immigrant woman should raise the possibility of mitral stenosis and a CXR and an echocardiogram
should be requested.
Pregnant women with mitral stenosis should be managed in tertiary centres with cardiological and
obstetric services on a single site and by cardiologists and obstetricians with expertise in this condition.