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

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18 Emergency Medicine
Scoring systems such as the modifi ed early obstetric warning system (MEOWS) described in Chapter
19 - Critical care, and included as one of the overarching recommendations of this Report, can be used to
elucidate the level of “unwellness”. Essentially this adds together a score for heart rate, respiratory rate,
blood pressure, GCS and temperature and gives an overall score. However early warning systems are only
useful if they are regularly repeated and acted upon.
Shortness of breath and the diagnosis of pulmonary embolism
Pulmonary embolism (PE) continues to be a diffi cult diagnosis which is often made too late. Whilst some of
the women who died from PE could not have been saved no matter when the diagnosis was made, a small
number went unrecognised, mainly because PE was not considered early enough. The diagnosis of PE is
already challenging in the non-pregnant patient but in pregnancy it becomes even more diffi cult. Of those
women who died from a potentially salvageable PE many had felt breathless prior to admission. Traditional
teaching allows clinicians to assume that isolated breathlessness is a normal feature of pregnancy and this
can often reduce the awareness of its severity. It is unusual to be breathless at rest in pregnancy or in the
postpartum period, especially in the presence of tachycardia:
A woman presented to her GP with breathlessness, pyrexia and hypotension. She was referred to
the medical registrar who saw her on the ambulatory medical unit (AMU) and made a diagnosis
of pneumonia with a differential of PE. Intravenous antibiotics were commenced and a raft of
tests done, all of which were abnormal. Although she was patently unwell she was transferred to
a gynaecology ward where she suffered an arrest from which she could not be resuscitated. A
postmortem diagnosis of PE was made.
The importance of tachycardia
Tachycardia is without doubt the most signifi cant clinical feature of an unwell patient and is regularly
ignored or misunderstood. Measurements of respiratory rate and heart rate are infi nitely more important
than measurements of blood pressure. A normotensive patient may all too often be unwell and
compensating. A tachycardic patient is hypovolaemic until proved otherwise. A patient with tachypnoea has
a cardiorespiratory cause until proved otherwise. Attributing tachycardia and tachypnoea to anxiety is naïve
and dangerous. For example:
A woman was seen three times in the ED with abdominal pain and diarrhoea. She was
discharged on the fi rst two occasions with a diagnosis of gastroenteritis, even though she had a
history of collapse and measured heart rates of 130 and 144 beats per minute. She arrested and
died on her third presentation. At postmortem she was found to have had an ectopic pregnancy.
Ectopic pregnancy
Mismanaging ectopic pregnancies has always been easier than making the correct diagnosis, partly
because cases present infrequently (1 in 100 pregnancies) but mainly because their presentation may not
be classical. The triad of symptoms described in textbooks of emergency medicine is bleeding, abdominal
pain and amenorrhoea, but many of the women who died, as well as some who survive, have a variety
of non-specifi c symptoms including diarrhoea, vomiting and collapse. Many of the women who come
into the ED with symptoms from ectopic pregnancy do not know or volunteer that they are pregnant. It is
disappointing that occasionally these women do not have a pregnancy test done as a routine. Without
a pregnancy test it is hard to include ectopic pregnancy in the differential diagnosis. It is crucial that the
risk factors for ectopic pregnancy are taught and recognised. The following case is an example of the
consequences of misdiagnosis: