Mrs Y, a 39-year-old chef, opted to M see consultant obstetrician Mr B for private antenatal care. It was her first pregnancy and other than a BMI of 30 she had no pre-existing medical problems. She was reviewed regularly throughout her pregnancy and noted to have elevated blood pressure through the first trimester, between 126/83 – 157/90. Methyldopa was considered at 23 weeks but not initiated since a pre-eclampsia screen was negative, and close monitoring continued. 

At 36 weeks Mrs Y presented to the emergency department complaining of a headache and feeling generally unwell. Her BP was 170/120 and she was admitted that afternoon and commenced on both methyldopa and nifedipine. Despite commencing this treatment, her hourly observations showed a persistently elevated blood pressure with proteinuria in spite of ongoing antihypertensive therapy. Mr B was contacted by the ward team and provided telephone advice to continue antihypertensives. The following morning the decision was made to deliver by caesarean section on a semi-urgent basis, and Mrs Y gave birth to a healthy son. She was discharged on oxprenolol to control her blood pressure.

A week following delivery Mrs Y continued to have elevated BP readings of 160/90. Mr B asked her to see her GP Dr A. Dr A arranged a routine home visit two days later and found Mrs Y had a headache and a raised BP of 180/90. He treated her with voltarol suppositories and a combination of bisoprolol and irbesartan.

Three days later Mrs Y was unchanged. Dr A visited her at home again. Her BP remained elevated at 160/90. He issued metaclopramide and meptazinol and wrote to consultant neurologist Dr D requesting a second opinion. He described her headaches as “vigorous” with some neck stiffness and photophobia, and queried a degree of meningeal irritation from a small bleed versus “functional overlay”.

The following morning, with no relief of her symptoms, Mrs Y was admitted to hospital where a scan confirmed a cerebral haemorrhage.She died four days later

Learning points

It is easy to attribute any new symptoms a woman may develop during pregnancy to the pregnancy itself, but this should not distract from red flag symptoms, which require urgent assessment.

As always, documentation is essential. Dr A later commented that the patient was understandably reluctant to be admitted, and that he did take a more thorough history than he documented; but years down the line if a complaint comes in, the notes are the only record you have to rely on.

Mr B was criticised for not reviewing Mrs Y early enough when she was an inpatient. It is important to have back-up options in these situations, to ensure patients have access to appropriate care when you are not available.