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

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17 Issues for General Practitioners
A woman with a history of epilepsy since childhood had experienced intolerable side effects
from anticonvulsants so stopped treatment. When she became pregnant she did not want to try
newer drugs because she was concerned about teratogenicity. She saw her GP after she had a
single fi t, then again at the start of her second trimester, by which time she had had a few more
fi ts. Her GP did not refer her back to her neurologist. She was referred urgently, by letter, by the
obstetric registrar. He had found out about her fi ts because she reported them to the radiologist
undertaking her routine fetal anomaly scan. The neurology appointment was given for a month
later, by which time she had already died from SUDEP.
Epilepsy is dangerous in pregnancy because it may be more diffi cult to control. This may be because
therapeutic drug levels decline or because women may be reluctant to take their medication. Women who
stop anticonvulsant therapy in pregnancy must be made aware of the risk of SUDEP. Here the GP missed the
opportunity to refer her both at the start of pregnancy and urgently when her fi ts started. The obstetric registrar
made an appropriate referral when he saw the woman, but a phone call would have been more effective than a
letter. The neurologist did not recognise the urgency of the situation and responded too slowly.
Mental health problems during pregnancy and /or after delivery
Ninety-eight pregnant women or new mothers who died within a year of delivery, from whatever cause,
were affected by or died as a result of a psychiatric disorder. These include deaths from suicide and drug
overdose and violent deaths from murder, accidents etc. Although many of these deaths were not directly
related to pregnancy these fi gures highlight the impact that ongoing mental health and substance abuse
problems, particularly amongst the more vulnerable, have on maternal health. This Report has been
recommending for the last few years that women are routinely asked in early pregnancy about signifi cant
severe past mental health problems, and, if necessary, referred to the local perinatal psychiatric services
to develop pre-emptive care and management plans. These policies have been widely adopted and it
is gratifying to see that the number of women who died from suicide from a perinatal mental illness is
signifi cantly reduced in this triennium.
It needs to be more widely known that women who have had a previous episode of a serious mental
illness either following childbirth or at other times, are at an increased risk of developing a postpartum
onset illness even if they have been well during pregnancy and for many years previously. This risk of
recurrence is estimated at least one in two for women with previous puerperal psychosis, as discussed in
detail in Chapter 12. It is also known that a family history of bipolar disorder increases the risk of a woman
developing puerperal psychosis following childbirth. The last two Reports 3, 4 found that over half of those
women who died from suicide had a previous history of serious mental illness. Even if this history is known
it may be communicated poorly to other members of the team,
A young woman with existing children killed herself by violent means some weeks after the
birth of her next child. She had a previous history of bipolar disorder with a number of hospital
admissions for mania. She was last seen by psychiatric services shortly before the beginning of
pregnancy and stopped her mood stabiliser medication at about this time. Her GP had mentioned
her previous psychiatric history in his referral letter to the obstetrician, but the midwife was
unaware of this history at the booking clinic. The woman was well during pregnancy, but no steps
were taken to monitor her mental health following delivery.
This woman faced a risk of recurrence of at least 50% in the fi rst three months after delivery. Her
psychiatric team should have made the woman, her family and her GP aware of this. When she became
pregnant again her GP should have told her midwife and should have referred her back to the psychiatric
team so that a management plan could have been put into place. She should have restarted her