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

headaches. The indications for emergency referral of women with headaches given in the learning point
box below are taken from the PRECOG guidelines 2 and are included as a brief reminder of good practice.
The other recommendations are taken from the fi ndings in the relevant Chapters, 3 and 10, of this Report.
Box 17.5
GP learning points: severe headaches in or after pregnancy/ pre-eclampsia and cerebral bleeds
Women with a headache severe enough to seek medical advice or with new epigastric pain should have
their blood pressure taken and urine checked for protein as a minimum.
Women with severe incapacitating headaches described as the worst they have ever had should have
an emergency neurological referral for brain imaging in the absence of other signs of pre-eclampsia.
The threshold for same day referral to an obstetrician is hypertension ≥ 160mmHg systolic and or ≥ 90
mm Hg diastolic or proteinuria ≥1+ on dipstick. The systolic BP is as signifi cant as the diastolic.
Automated blood pressure machines can seriously underestimate blood pressure in pre-eclampsia.
Blood pressure values should be compared with those obtained by auscultation (an anaeroid
sphygmomanometer is acceptable).
Ectopic pregnancies continue to be missed, and can mimic gastroenteritis
Ten women died from ectopic pregnancy; care was sub standard for seven. The two previous Reports have
highlighted the lesser-known presentations of ectopic pregnancy, especially with vomiting and diarrhoea
in the absence of vaginal bleeding3, 4 . It is important that GPs are aware of the possibility of ectopic
pregnancy in all women of childbearing age. Avoidable deaths continue:
A young woman developed abdominal pains, diarrhoea and vomiting (D&V) with one episode of
fainting and a history of amenorrhoea. She had telephone contact with an out of hours GP but
was not visited. The next day she had a home visit as her D&V persisted but no action was taken
and the possibility of an ectopic pregnancy was not considered. The following day a relative
asked for another home visit as she had been “restless” overnight, although her diarrhoea had
settled. She was found dead in bed by the GP when he visited later in the day. At postmortem
she had a ruptured ectopic pregnancy.
Gastroenteritis is common in the community, but clinicians should be aware that in women of child bearing
age diarrhoea should raise suspicion of an ectopic pregnancy, especially if there has been abdominal
pain, amenorrhoea or episodes of fainting. The absence of vaginal bleeding does not exclude an ectopic
pregnancy. Once again, this case highlights the potential perils of telephone consultations.
Box 17.6
GP learning points: ectopic pregnancy
Clinicians in primary care need to be aware of atypical clinical presentations of ectopic pregnancy and
especially of the way in which it may mimic gastrointestinal disease.
Fainting in early pregnancy may indicate an ectopic pregnancy.
Puerperal fever is not a disease of the past
For many years puerperal sepsis, “childbed fever”, was a leading cause of maternal death and its
signs and symptoms were widely known. The advent of antibiotics means that this illness has largely
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