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

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17 Issues for General Practitioners
A young single parent with a history of polydrug misuse and psychiatric problems attended
infrequently during her pregnancy but claimed to have stopped all her drugs by the third trimester.
Although her baby was delivered prematurely and admitted to special care, the mother discharged
herself immediately after the delivery. The GP then supervised her postnatal methadone
prescribing, unsupported by a specialist in substance abuse. The administration of methadone was
not supervised by the pharmacist. She died from a methadone overdose some weeks after delivery,
shortly after a case conference at which the baby was placed on the “at risk” register.
This GP was working beyond his/her level of expertise and should have referred her to a specialist drug
team. It may be that the woman refused such care, but their advice should have been sought at the
very least. She may have left hospital immediately after delivery to re-establish her drug supply. Lack of
supervised consumption postnatally may have contributed to an unreliable supply of opiates and diversion
to the black market. In this case the involvement of social services may also have been a factor in her
death and this risk factor for suicide is discussed in more detail in Chapter 12.
Box 17.9
GP Learning points: mental health and substance misuse
NICE have recently produced guidance on the management of antenatal and postnatal mental health
and all GPs should be encouraged to read, and follow them 6 .
It may be safer for women who misuse drugs to continue their maintenance treatment during and after
pregnancy to prevent inadvertent overdose from street drugs.
Pregnant drug users may be diffi cult to engage in treatment. This may be because they do not recognise
pregnancy, have chaotic lifestyles or have fears about the consequences of social services involvement.
Pregnancy in refugees and asylum seekers
Women who have recently arrived from countries around the world, particularly those from Africa and the
Indian sub-continent, but increasingly from central Europe, tend to have poorer overall general health
and are at risk from illnesses that have largely disappeared from the UK, such as TB and rheumatic heart
disease. They are also more likely to be at risk of HIV infection. Some may also have suffered female
genital mutilation/cutting (FGM/FGC). All of these conditions, alone or in combination, contributed to a
number of the maternal deaths considered in this Report. If newly arrived women are unwell, GPs may
need to consider unfamiliar possibilities in their differential diagnoses.
Rheumatic heart disease
No pregnant women have died from the consequences of rheumatic heart disease since the 1991-1993
Enquiry7 . However, in this current triennium, two immigrant women died from mitral stenosis as a result of
rheumatic heart disease. Rheumatic heart disease is likely to become even more common with increasing
numbers of women who are asylum seekers or refugees, who may never have had a cardiac assessment8 .
A previously well young immigrant woman with poor English booked for midwifery-led antenatal care
and was seen only by her midwife and GP. Her GP did not examine her heart. She was admitted to an
ED at the end of her second trimester with cough, breathlessness and chest pain. Even though she
was admitted, the diagnosis of mitral stenosis was not considered until she was moribund.
If she had been examined by her GP the murmur of mitral stenosis may have been picked up. It can be
hard to hear the soft diastolic murmur of mitral stenosis if a woman is already sick and has a tachycardia.