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

Diseases of the circulatory system
Four women died from a ruptured splenic artery aneurysm and one from a rupture of a pseudo aneurysm
of the splenic artery. This latter case was complicated by autoimmune disease, secondary antiphospholipid
syndrome and a previous bowel thrombosis. It was thought that the pseudo aneurysm related to a previous
splenectomy. There were two deaths from rupture of the iliac artery, one counted here and the other
counted in Chapter 5 - Amniotic fl uid embolism, because it was thought that this was more likely to be the
cause of her death. The tendency of blood vessels to rupture in pregnancy has been commented on in
previous Reports and several of these cases gave cause for concern. For example:
A woman with an uncomplicated pregnancy required an instrumental delivery. Shortly afterwards
she collapsed with pallor, hypotension and tachycardia. There was no revealed haemorrhage.
Blood was taken for haemoglobin and cross matching. Over half an hour later the on-call
anaesthetic team was called and fl uids were started. The anaesthetic team performed a haemocue
(near patient) estimation of haemoglobin, which was very low, and only then were the on call
consultant obstetrician and anaesthetist called. An urgent laparotomy was performed with further
hypotension at induction of anaesthesia. Massive intra-abdominal bleeding from the splenic angle
was discovered and could not be controlled. Although the general surgeons were called to help, by
the time they arrived she had died from haemorrhage from a splenic artery aneurysm.
In addition one woman died from a pulmonary arterio-venous malformation:
A woman with no apparent past medical history was found dead in late pregnancy. At autopsy
2.5 litres of blood were found in her right pulmonary cavity. It had come from a pulmonary arteriovenous
malformation arising because of plexigenic pulmonary arteriopathy. There was right
ventricular hypertrophy but no other evidence of pulmonary hypertension.
On refl ection there were clues that she might have underlying disease. She had complained of
breathlessness since mid-pregnancy but this was discounted as physiological. A relative had indicated she
sometimes turned blue and this too was thought to be irrelevant. Her clinicians were falsely reassured by a
haemoglobin level in excess of 13 G/litre when she fi rst complained of breathlessness. This is relatively high
for this stage of pregnancy and could have been related to chronic hypoxemia. Her GP incorrectly discounted
a loud second heart sound as a feature of normal pregnancy. Breathlessness is diffi cult to evaluate in
pregnancy and maybe a symptom of life threatening disease. Although it may be caused by pregnancy alone,
this is a diagnosis by exclusion and any additional abnormality is an indication for further investigation
The early detection of severe illness in pregnant mothers remains a challenge to all involved in their
care. The relative rarity of such events combined with the normal changes in physiology associated
with pregnancy and childbirth compounds the problem. Modifi ed early warning scoring systems have
been successfully introduced in other areas of clinical practice and systems appropriately modifi ed for
the obstetric patient have been described in Chapter 19 - Critical Care, These should be introduced for
all acute obstetric admissions and should help to reduce the cases in which death has followed the late
recognition of serious illness. This is one of the top ten key recommendations of this Report.
Other deaths
A number of women died from other conditions including one or two for whom the underlying cause
could not be ascertained. These cases are traditionally counted here. One woman died from Moyamoya
disease, a rare condition affecting cerebral blood vessels, and most frequently described in the Japanese.
It tends to present in early childhood with symptoms of brain ischaemia or in later in adult life with cerebral
haemorrhage. The appearance of cerebral blood vessels on MRI angiography is distinctive. Extracranial-
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