Medical Complications of Pregnancy

Useful information for the ED setting

Sarah Winfield

Consultant Obstetrician with a Special Interest in Maternal Medicine

Leeds Teaching Hospitals NHS Trust

RCEM Spring Conference April 2017

There is a long list

• Pre-eclampsia.

• Gestational Diabetes.

• Hyperemesis gravidarum.

• Pelvic girdle pain.

• High blood pressure.

• Deep vein thrombosis.

• Anemia.

• VTE

• Sepsis/Infection…….

• etc.

Medical Disorders

• Can be caused by pregnancy pre-eclampsia, Gestational Diabetes, Hyperemesis etc.

• Can pre-date the pregnancy and become worse OR revealed for the first time –renal disease, cardiac disease, type 2 diabetes

Mrs R

• 21 years old, married, from Eritrea. Spoke reasonable English

• Came to UK with husband 2 years ago for his work.

• 1st baby. Mum “usually fit and well”

• FGM type 3 – defibulation under spinal anaesthetic at 28 weeks gestation. Consultant team. All went well

• 20.09.16 Forceps delivery healthy baby girl at term

• Post partum haemorrhage 1.2 litres. (Pre-delivery HB around 100g/L)

• Treated with Ergometrine. “Stable” so home the next day

• BUT, pathology IT system at LTHT was ‘down’. Hb 66 g/L

• Pathology alerted ward staff who tried to ring her. No reply

• By then readmitted via the ED on 22/09/16 with SOB

• Junior ED doc – listened to chest – NAD. Dx “Anaemia”

• Sent up to maternity ward for transfusion 2 units red cells

• Clerked by GP trainee and was transfused overnight

• GP trainee on ward was asked to see at 10am the next day

• Persistent SOB now & overnight - “was just SOB when trying to sleep”

• Tachycardia persisted overnight but now settled while “sat up in bed”.

• Resp Rate 24/min now but <19 overnight

• Listened to chest. NAD

• “Ongoing SOB and raised RR secondary to ?anaemia”

• ABG showed HB 85 g/L

• “Recheck Obs in 1 hour. If pulse and resps normal then home with oral iron”

• Home. Visited by Health visitor that day - “no complaints”

• Husband rang up Maternity Assessment Centre at 16.55

• SOB all afternoon and into the evening, especially while lying flat

• Went to bed and Mrs R got up in early hours and collapsed

• Husband rang 999 at 04.04 hrs. Wife unresponsive

• Put her on duvet, dragged down the stairs & into the street

• CPR on pavement until ambulance arrived

• Arrived at ED. Resuscitation unsuccessful.

• Pronounced dead 05.16

• Postmortem: Unrecognised Mitral Valve Stenosis

Mrs R. “Red Flags”

• Recently arrived from overseas (not born in the UK) – risk of childhood rheumatic fever causing valve disease

• Persistent SOB and tachypnoea in a postnatal mum despite correcting the anaemia

• History – Patient and her husband telling staff (on several occasions) that she could not lie flat when trying to sleep as she quickly became short of breath and described “rib pain”

The investigation into Mrs R’s death

• PROBLEMS• Process to assess PMHx at

booking is inadequate• Failure of Trust Pathology System• Failure to consider an alternative

diagnosis for the SOB• Lack of Senior input/review on the

ward • Triage Process in MAC focusses on

predominantly antenatal issues

• LESSONS LEARNED• Cannot rely on info from GP and

MW to identify potentially serious health issues

• A good history is essential at booking and at any other contact

• SOB in peripartum period needs clear guidance for Ix and Rx (ECHO)

• Peripartum acute admissions need Consultant review/discussion

• The SBAR used in MAC needs to reflect both AN and PN care

3 P’s in a Pod

• Pregnancy – “think chest”

• Postnatal – “think head”

• Pick it up – the problem /the phone

Every other day a pregnant or recently pregnant woman dies in the UK.

Remember it’s ok to ask...

Pick up the phone, pick up the problem and let’s prevent maternal morbidity and mortality.

Working as a team will improve women’s care and save lives.

P REGNANCY

“THINK CHEST ”

23% maternal mortality caused by CARDIAC conditions Cardiac output increases by 50% in pregnancy and there is an increased risk of cardiac failure Search for cardiac causes of persistent breathlesness.

14% maternal mortality caused by PNEUMONIA or INFLUENZA CXR should not be withheld. Prompt treatment with antibiotics or antivirals advised. Be aware of a pre-existing medical condition e.g. asthma or obesity as this can increase severity. 11% maternal mortality caused by VENOUS THROMBO-EMBOLISM Risk evolves. Assess at every encounter and consider LMWH.Treat promptly with high dose LMWH if suspicious of VTE. Pregnancy is not a contraindication to thrombolysis if massive PE.

P OST NATAL

“THINK HEAD ”

11% maternal morta l i ty caused by NEUROLOGICAL condi t ions Never stop anti-epileptics unless discussed with an expert. First fit in pregnancy or worsening epilepsy is an urgent situation and phone referral to neurology is necessary. 9% materna l mor ta l i ty caused by MENTAL HEALTH disorders Urgent care and follow up is necessary for women who report new thoughts of self harm, sudden onset or rapidly deteriorating mental health symptoms or persistent feelings of estrangement from their baby.

P ICK IT UP

“THINK HIGH RISK ” P ick up the phone P ick up the problem Pregnant women are different and you won ’t always know what to do. Improvement in communication and team working with appropriate escalation to seniors, alongside prompt treatment and management is necessary if we are to reduce maternal morbidity and mortality together.

For Further information:

#threepsinapod

http://rcp.sg/maternalhealth

www.e-lfh.org.uk/programmes/medical-problems-in-pregnancy/

of maternal mortality is due to a medicalor mental health condition, not pregnancy itself.

Every other day a pregnant or recently pregnant woman dies in the UK.

23/

“Medical Complications of Pregnancy”

• We’re still not getting it right – MBRRACE data for indirect deaths shows that acquired cardiac disease, sepsis and flu are killing women in the UK

• Increasingly co-morbid pregnant population

• Some don’t even realise they have a problem/condition

• Many will come through the ED for the first time during pregnancy

• “Phone a friend”

Thank you for your attention

Every other day a pregnant or recently pregnant woman dies in the UK.

Remember it’s ok to ask...

Pick up the phone, pick up the problem and let’s prevent maternal morbidity and mortality.

Working as a team will improve women’s care and save lives.

P REGNANCY

“THINK CHEST ”

23% maternal mortality caused by CARDIAC conditions Cardiac output increases by 50% in pregnancy and there is an increased risk of cardiac failure Search for cardiac causes of persistent breathlesness.

14% maternal mortality caused by PNEUMONIA or INFLUENZA CXR should not be withheld. Prompt treatment with antibiotics or antivirals advised. Be aware of a pre-existing medical condition e.g. asthma or obesity as this can increase severity. 11% maternal mortality caused by VENOUS THROMBO-EMBOLISM Risk evolves. Assess at every encounter and consider LMWH.Treat promptly with high dose LMWH if suspicious of VTE. Pregnancy is not a contraindication to thrombolysis if massive PE.

P OST NATAL

“THINK HEAD ”

11% maternal morta l i ty caused by NEUROLOGICAL condi t ions Never stop anti-epileptics unless discussed with an expert. First fit in pregnancy or worsening epilepsy is an urgent situation and phone referral to neurology is necessary. 9% materna l mor ta l i ty caused by MENTAL HEALTH disorders Urgent care and follow up is necessary for women who report new thoughts of self harm, sudden onset or rapidly deteriorating mental health symptoms or persistent feelings of estrangement from their baby.

P ICK IT UP

“THINK HIGH RISK ” P ick up the phone P ick up the problem Pregnant women are different and you won ’t always know what to do. Improvement in communication and team working with appropriate escalation to seniors, alongside prompt treatment and management is necessary if we are to reduce maternal morbidity and mortality together.

For Further information:

#threepsinapod

http://rcp.sg/maternalhealth

www.e-lfh.org.uk/programmes/medical-problems-in-pregnancy/

of maternal mortality is due to a medicalor mental health condition, not pregnancy itself.

Every other day a pregnant or recently pregnant woman dies in the UK.

23/