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Chapter 14: General practicePF 450 l/minute). She was subsequently treated withprednisolone, but her PF, pulse and respiratory rate werenot recorded and no follow up was arranged. A few weekslater, she suddenly became breathless, collapsed and died ofasthma.She was inaccurately advised about stopping her inhaledcorticosteroid in pregnancy and was clearly requestingexcessive repeat prescriptions of salbutamol without the GPnoticing. Postnatally, the severity of her asthma was unrecognised,inadequate observations were taken and no followup was arranged. If she had been treated using nationalguidelines, her death may have been avoided. 3 Short- andlong-acting beta agonists and inhaled corticosteroids aresafe in pregnancy.In a review of the effects of pregnancy on asthma, 10increased hospital admission was associated with a lack ofuse of inhaled corticosteroids. In general, the effect of pregnancyon known asthma was one-third improved, onethirdworse and one-third unchanged. Most women withasthma have mild disease and require primary care duringpregnancy. GPs need to provide adequate detail about theseverity of asthma, so that maternity services can assesswomen who need specialist care (see learning points).Asthma: learning points• GPs must inform maternity services about the severityof pregnant women’s asthma.• Most pregnant women with asthma can be cared forin primary care. Only women with persistent poorcontrol, a history of hospital admission as an adult,respiratory arrest or continuous or frequent coursesof oral steroids would usually require specialist referralto a chest physician during pregnancy.Psychiatry and substance misuseDeaths from psychiatric causes are counted and discussedin Chapter 11. As in the last Report, there were cases whereknown previous psychiatric history and family history didnot prompt early psychiatric referral and care planning toanticipate problems after delivery. It appears that GPs arestill not aware that the risk of recurrence of puerperal psychosisis about 50% with a previous history. 11 With planning,some of these deaths might have been prevented:A pregnant woman had a history of severe postnatal depressionthat required hospital admission after her previouspregnancy and a family history of psychotic illness. She wastaking venlafaxine before and during pregnancy. She wasbooked for low-risk care because the midwife did not obtainher mental health history at booking. In the third trimester,she was admitted with severe depression but dischargedherself and failed to attend follow-up appointments. Afterdelivery, the midwife, as instructed, telephoned the psychiatristto say she had delivered, but no follow up wasarranged. She did not see her GP after delivery and died ofviolent means some weeks later.She should not have taken venlafaxine in pregnancy.With her history, she should have been referred to a perinatalpsychiatrist at the start of pregnancy to develop amanagement plan. Following her admission for severedepression in pregnancy and after delivery, the GP shouldhave contacted her. The GP did not communicate with themidwife at any stage. As a result of strategic policy changes,this GP and midwife were no longer working on the samesite and did not share computer systems; this was a barrierto good communication.In another case, despite a detailed postnatal mentalhealthcare plan, as recommended in previous Reports,when the woman became psychotic she was treated athome inappropriately rather than being admitted to hospitalas stated in the agreed plan. A care plan needs to be apractical document, rather than a ‘tick box’ exercise, otherwiseit is not worth the paper it is written on.In three other cases where there was no specialist perinatalservice, ill women were not accepted by psychiatric servicesbecause they did not meet the local referral criteria,having been labelled incorrectly as ‘anxious’. If specialistperinatal services had been available, they may have beenmore sensitive to the early symptoms of severe depressionor psychosis, and the outcome may have been different.Vulnerable women can pose a challenge for health professionals:A woman with a history of domestic abuse and a chaoticlifestyle had a previous partner who had died from a heroinoverdose. No personal history of drug use was obtained atbooking. She was referred to social services by the police,having reported abuse. She attended the Emergency Departmentin mid-pregnancy after an assault, intoxicated withcrack cocaine, but the letter to the GP recorded only theassault. Several safeguarding conferences were held; drugmisuse was recorded in all the reports. The baby was placedon the child protection register from birth. The GP startedher on citalopram for depression shortly after delivery, buthe did not arrange any follow up and did not inform thehealth visitor, who worked on a different site. The womandied of an overdose of alcohol and cocaine a few weekslater.The GP failed to consider the possibility of drug misuse,despite clues from the history. This is a recurring theme ofcases examined, probably because women are afraid of theconsequences of disclosure. Maintenance treatment duringpregnancy by an addictions team or specialist GP mayª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 163