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

A woman collapsed at home following an episode of diarrhoea. On admission to the ED she
was tachycardic, hypotensive and IV access was diffi cult. No pregnancy test was carried out.
She arrested and was resuscitated after a very prolonged period of CPR. On the return of
spontaneous circulation she was noted to have a haemoglobin of 8 dl. An ultrasound scan was
carried out, which led to further delays, and free fl uid was noted . At her eventual laparotomy a
ruptured ectopic pregnancy was revealed but she suffered a further, fatal, cardiac arrest.
Box 18.1
ED learning points: ectopic pregnancy
ED clinicians need to be aware of atypical clinical presentations of ectopic pregnancy and especially
of the way in which it is often associated with diarrhoea and vomiting and may mimic gastrointestinal
disease. Fainting in early pregnancy may also indicate an ectopic pregnancy.
There must be a low threshold for ßhCG testing in women of reproductive age attending the ED with
abdominal symptoms.
Pregnant women with abdominal pain should be reviewed by staff from the Obstetrics &
Gynaecology department.
Education and training
Teaching of ED staff
All departments have formal teaching for medical and nursing staff in addition to the shop fl oor teaching
to which EDs particularly lend themselves. EDs see a huge range of patients including children, surgical
emergencies, patients with mental health needs, medical emergencies and major and minor trauma. Thus
pregnancy-related complications form a small but important component of the daily workload. The ability to
organise a teaching programme which encompasses all eventualities is crucial. In addition the teaching has
to be delivered early in the clinician’s post, repeated to those who are unavailable, and competency tested.
This challenge is made more complex by the changing nature of job applicant experience and length of post
in the ED.
“Red fl ag” teaching is usually carried out early on in the post or on induction days. This highlights conditions
not to be missed, their recognition and management. The red fl ag signs and symptoms are those which call
out for early attention due to their importance and refl ection of life-threatening illness. Early teaching about
the pregnant woman must include recognition of the sick mother, PE and ectopic pregnancy.
Locums/Agency staff
There is little point in having perfect systems in place if they fall apart when locum or agency staff are
working. Many Trusts have a policy whereby locums cannot get paid until they go through an e-learning
exercise which should contain important departmental protocols. At the very least new clinicians should be
closely monitored.
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