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

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17 Issues for General Practitioners
On reviewing this case it was clear that the woman’s GP had failed to take an adequately detailed history
of her symptoms; this is substandard care. The GP later commented that the woman’s husband did not
convey a sense of urgency, but all GPs should know that sudden and continuing breathlessness in an
obese pregnant woman is a medical emergency. The risks of such telephone consultations are discussed
later in this Chapter. This was not the only case where a GP’s judgement was open to question:
Another multiparous woman, of normal weight, had known thrombophilia. She was managed in a
joint obstetric / haematology clinic throughout her pregnancy and received dalteparin prophylaxis
both during pregnancy and for six weeks postnatally. A few weeks after she stopped dalteparin
she presented with an extensive deep vein thrombosis (DVT) for which she was anticoagulated
with warfarin. Some weeks later she saw her GP with a cough and shortness of breath: a chest
infection was diagnosed and cough medicine prescribed. She had been poor in attending for her
international normalised ratio (INR) tests and admitted to forgetting to take her warfarin. On the
day before her death she attended the practice nurse for a blood test: her INR result was 1.3.
The next day she collapsed and died of a massive pulmonary embolus.
This woman was known to be at high risk and was already on treatment for a DVT; her GP should have
noticed that her compliance with blood tests and medication was poor. A diagnosis of a chest infection
in this situation should only have been made once pulmonary embolism had been excluded by hospital
investigations. This woman might have survived had she been referred promptly by her GP when she
attended with a cough and shortness of breath.
Box 17.4
GP learning points: pulmonary embolism
A sudden onset of breathlessness in a pregnant or postpartum woman, in the absence of a clear
cause, such as asthma, should raise the suspicion of pulmonary embolus, especially if the woman
has risk factors.
Women with suspected pulmonary embolus should be referred as an emergency to hospital as the
diagnosis of pulmonary embolus can only be made or excluded by secondary care investigations.
Severe headaches may be suggestive of pre-eclampsia or cerebral haemorrhage
Although, fortunately, in this triennium no women died from eclampsia because their GP had failed to
identify headaches or hypertension indicative of pre-eclampsia or eclampsia, this has not always been
the case. Severe headaches in pregnancy can also be indicative of intracerebral bleeding. During 2003-
05, 21 pregnant or recently delivered women died from intracerebral haemorrhage, 12 of which were due
to subarachnoid haemorrhage, a condition for which pregnancy, and hypertension in pregnancy, are risk
factors. The following is a typical case:
After a normal pregnancy and birth, a mother developed a severe headache with new onset
hypertension early in her puerperium. Her headache was not relieved by analgesics and was
described as very severe. The midwife reassured the mother but she still had a very painful
headache two days later: no action was taken. Her midwife had planned to review her again four
days later but, before that, she was admitted to the Emergency Department (ED) with a fatal
subarachnoid haemorrhage.
Although she had not been seen by a GP, it is worth emphasising that a severe new onset headache, the
worst a patient has ever described, must be taken seriously. This is especially the case for pregnant or
recently delivered women. Patients with fatal subarachnoid haemorrhage often have preceding warning