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

Box 17.8
GP learning points: Heartburn and ischaemic heart disease
The prevalence of ischaemic heart disease in pregnancy and the puerperium is increasing.
The possibility of ischaemic pain should be considered in women who have risk factors and
atypical heartburn.
If a woman is suspected of having cardiac chest pain she should be admitted as an emergency.
Recognising urgent conditions when pregnant women need “fast track” referral to secondary care
Apart from the “red fl ag” conditions and signs and symptoms discussed above, there were other instances
when women with serious medical conditions were not referred urgently by their GP and where such a
referral may have changed the outcome.
Congenital cardiac disease
More women who have had surgery for signifi cant congenital heart disease are reaching an age when
they become pregnant. Fallot’s tetralogy is the commonest form of cyanotic heart disease (1:3600) and
surgically repaired tetralogy of Fallot is probably the commonest condition likely to be seen in general
practice. A woman and her GP may not appreciate the cardiovascular risks of pregnancy:
A young woman had a repair for a congenital heart condition and was under paediatric
cardiac follow up every few years. She was well and asymptomatic and due for transfer to
adult congenital heart disease services. When she became pregnant she saw her GP early in
pregnancy and was referred to the local specialist “teenage” midwifery service. She collapsed
and died in the second trimester, probably from an arrhythmia.
In this case the GP should have referred her urgently for a cardiological opinion at the start of pregnancy.
And, although it would be helpful for her to have the specialist support that a teenage pregnancy service
could provide, she clearly needed more specialist medical care. Paediatric cardiologists and GPs have
a responsibility to counsel their teenage patients at any opportunity about the risks of pregnancy and to
seek specialist care as early as possible should the patient wish to become pregnant. They should also be
proactive in discussing the need for adequate contraception. A consensus view from the 51st RCOG Study
Group on heart disease and pregnancy reads:
“A proactive approach to preconception counselling should be started in adolescence and this
should include advice on safe and effective contraception. Proper advice should be given at the
appropriate age and not delayed until transfer to the adult cardiological services 5 ”.
Epilepsy
Eleven women died from epilepsy; six of the deaths were from sudden unexpected death in epilepsy
(SUDEP). Previous Reports have emphasised that pregnant women with epilepsy should have prompt
specialist care from a consultant obstetrician and a neurologist or specialist physician with an interest in
epilepsy and pregnancy. Pregnant woman should also be seen as soon as possible after such a referral is
made. In this triennium there were examples where urgent referrals were either not made by GPs or not
responded to by neurologists:
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