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

Liver disease
There were four maternal deaths from liver disease including one from liver rupture and three from liver
failure. Liver rupture in pregnancy is usually a complication of severe pre-eclampsia, however one of these
deaths was a complication of possible connective tissue disease thought to be Ehlers Danlos syndrome
(EDS) type 4. Of the deaths in association with liver failure one was due to alcohol abuse and another due
to chronic active hepatitis:
A woman had chronic active hepatitis which had caused acquired antithrombin defi ciency,
which in turn had increased her thromboembolic risk suffi cient to have caused a previous
pulmonary embolus. She also had oesophageal varices, ulcerative colitis, and had had several
previous miscarriages. She sought IVF and became pregnant again which resulted in an
unexpected vaginal breech delivery. She then required blood products for a postpartum bleed
and soon became breathless. It was eventually thought she had pulmonary hypertension. She
then deteriorated further, had a seizure and was considered to have had another pulmonary
embolus for which she was given thrombolysis. This caused massive vaginal and generalised
haemorrhage from which she died.
Her autopsy confi rmed pulmonary hypertension with characteristic changes in the heart and lung
vasculature. There was no acute pulmonary embolus but it was thought that the pulmonary hypertension
was consequent to her previous pulmonary thromboembolic disease. It is diffi cult to believe that
this woman had adequate pre-pregnancy counselling before she had IVF. This case reinforces the
recommendation that all women with serious medical problems must have adequate pre-pregnancy
counselling even if they are not immediately seeking pregnancy and particularly before they have assisted
reproduction.
The other case of pregnancy liver failure was in a woman with HIV infection being treated with antiretroviral
drugs who developed liver failure in the third trimester. This may have been due to acute fatty
liver of pregnancy or to anti-retroviral drugs but since the latter seems more likely in her case it has been
counted here. The case of a woman who died from fatty liver of pregnancy is counted in Chapter 3.
Pancreatitis
Two maternal deaths from pancreatitis are counted here. One occurred in very early pregnancy in
association with alcoholism and, although the other woman who died may also have had an alcohol
dependency problem she also had gall stones. There were also two Late deaths from pancreatitis, one
of which is of concern because she was found dead a few hours after admission to a psychiatric unit. It
appears that the staff there did not realise she was physically ill. This case is discussed in Chapter 11 -
Psychiatric deaths.
Ruptured appendix and intestinal perforation
Two women died of the consequences of acute abdomen and/or surgical complications. In one case:
A young very obese primigravida attended with abdominal pain in mid pregnancy for which
no reason could be found. She was readmitted with more pain and again no abnormality was
found and she was discharged. It was only following a subsequent readmission, a few hours
later still, that she was fi nally seen by a consultant. The consultant requested a surgical review
and she had an urgent appendectomy. However her condition deteriorated and she died shortly
afterwards of adult respiratory distress syndrome and sepsis.
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