6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

HulbertPre-eclampsia/eclampsia: learningpointsObstetric referral is recommended if any of the followingare present:• hypertension• proteinurea• epigastric pain• vomiting.Ectopic pregnancyWhen the classical triad of symptoms (abdominal pain,vaginal bleeding and syncope) is present, ectopic pregnancycan still be difficult to diagnose. This is mainly becausethese symptoms can be attributed to other less serious conditions,including pregnancy itself. Furthermore, as hasbeen repeatedly stressed in earlier Enquiry reports, ectopicpregnancy often presents with nonspecific symptomssuch as diarrhoea. Unless ectopic pregnancy is high onthe differential diagnosis list, it can be easily missed. Forexample:A woman was referred to hospital by her GP because ofdiarrhoea, vomiting and abdominal pain, with suspectedgastroenteritis. Her haemoglobin value was 10.9 g/dl withtachycardia on admission, but a pregnancy test was notperformed. She was then seen by several junior hospitaldoctors and, during the following few hours, received severallitres of intravenous fluids with a urinary output of lessthan 500 ml and a severe fall in haemoglobin. She diedbefore diagnosis. At autopsy, her abdominal cavity containedabout nine litres of bloody fluid and clot, togetherwith a ruptured tubal pregnancy.In addition to the classical symptoms of vaginal bleeding,abdominal pain and amenorrhoea, diarrhoea, vomiting andfainting should all be taken seriously with a view to ectopicpregnancy as part of the differential diagnosis.Ultrasound scanning is now part of the curriculum forhigher specialist trainees in Emergency Medicine. However,this is Focused Assessment Sonographic Trauma (FAST)scanning, which will simply reveal free fluid in the abdomen,and not specialised abdominal or indeed transvaginalscanning, which should only be carried out by a clinicianskilled in this diagnostic imaging technique.Women who present with ectopic pregnancy-relatedsymptoms occasionally do not know their pregnant state,and estimation of urine and serum levels of b-human chorionicgonadotrophin is required. Many departments includepregnancy testing in all women of childbearing age whopresent with abdominal and other nonspecific symptoms.The Early Pregnancy deaths chapter of this Report, Chapter6, also suggests that all women with gastrointestinal symptomsshould be tested. Although this may result in manynegative results, it may well reveal previously unknownpositives. In some cases in this triennium, extremely youngand much older women were not tested and their pregnancywas missed as a result. In a few other cases, thewomen were not informed of their pregnancy test results,which may have contributed to their fatal outcome. Therewere also cases of women who did not know that they werepregnant even though this information was entered in thenotes. It is of crucial importance that, once a pregnancy testhas been found to be positive, action results:A very young girl with a complex social history was unwellfor a year or so with vomiting and severe loss of weight.Her symptoms were ascribed to an eating disorder, althoughshe did not seem to have been referred for psychiatric care.Early in her illness, she attended the local ED with a historyof vomiting, abdominal pain and irregular periods. Herpositive pregnancy test at the ED was overlooked and notfollowed up. During the succeeding months, she repeatedlyreturned to the ED with similar symptoms, but no furtherpregnancy test was done, perhaps because of her age. Hersymptoms were either ascribed to an eating disorder or gastritis.Nearly a year after her positive pregnancy test, shewas admitted and died of a cerebrovascular accident as theresult of a disseminated choriocarcinoma.Ectopic pregnancy: learning pointsIn addition to the classical symptoms of vaginal bleeding,abdominal pain and amenorrhoea, the symptoms ofdiarrhoea, vomiting and fainting should all be takenseriously with a view to ectopic pregnancy as part of thedifferential diagnosis. These features need to be emphasisedto all clinical staff.All positive pregnancy tests carried out in the EDshould be followed up and acted upon by the relevantclinician.Cardiorespiratory diseaseThe diagnosis of pneumonia in pregnancy can also be challenging,as once again, breathlessness was too often wronglyperceived to be a normal state in pregnancy.Tachycardia is seen in both pneumonia and in otherforms of sepsis and may be ignored when other parametersare stable. Tachycardia is particularly relevant in emergencymedicine and should never be allowed to exist in theabsence of a diagnosis.Women who are pregnant but have a co-existing diagnosisof asthma should be carefully managed, as breathlessnessand wheeze are so often attributed to mild asthma when,170 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203