Amy D.* was in what should have been the happiest time of her life: 4 days out from having her much wanted and long awaited first child, a daughter. She was 32 and her husband Eric* was 34 when they found out they were expecting and read every book they could get their hands on to prepare for the days and months ahead. Amy followed her doctor’s instructions to the letter, being careful with her diet, taking her prenatal vitamins, drinking plenty of water and getting adequate rest. They had everything ready: the nursery, a nanny lined up for when she returned to work at 12 weeks, diapers, breast pump and even planned the preschool their daughter would someday attend. Amy and Eric had attended all her prenatal appointments together, and she had no complications during her entire pregnancy. Everything was textbook perfect.
Amy began having contractions late on a Thursday night. The couple expected everything to go smoothly as it had all through the pregnancy and were overjoyed to be hours away from meeting their daughter. As night moved into the early hours of Saturday morning, it was time to head to the hospital.
Once she arrived and was settled in, Amy’s nurse completed her history and noted her initial blood pressure of 134/85 but stated as Amy was “in pain and anxious”’ she was not immediately alarmed. Throughout the morning on Friday, Amy’s labor progressed like clockwork and by 1:00 pm, she had delivered her daughter and was happily breastfeeding and soaking up every nuance of new motherhood. Eric had never left her side and was making calls to grandparents, friends and coworkers, proudly announcing the birth. During her recovery period, Amy had complained of a headache and feeling “kind of weird” as if she were looking down a long tunnel. She chalked it up to the stress and physical effort of giving birth and took the ibuprofen offered her by her nurse. Her blood pressures during this time were consistently 130-140 over 80-90. A little high, but again, not alarming to the nurse or Amy’s obstetrician.
On Sunday afternoon, mother and baby were discharged from the hospital and arrived home to find family and friends with a week’s worth of meals prepared and the nursery readied for the daughter they had named Ellena Marie. Amy left Ellena in the capable hands of her mother and lay down for a nap, still complaining of a nagging headache and vision that would occasionally become blurry. She also had what she called ‘heartburn’. She took a couple of ibuprofen and heartburn chewable tablets and tried to rest.
All through that night, Amy’s headache continued to worsen, and her heartburn became a constant, dull ache in her upper abdomen. Just after midnight on Monday, Amy was complaining of a worsening headache and felt as if she couldn’t catch her breath, telling Eric “something is wrong with me.” Eric called his mother to come and stay with Ellena while he took Amy to the emergency room a short ride away.
On arrival to the ER, Amy was triaged and left in the waiting room to wait her turn. Her blood pressure at that time was 162/105, but the ER triage nurse wasn’t too concerned. After all, patients were regularly seen in the ED with much higher blood pressures, so she was tagged as a low-level triage and told to wait. As she sat in the waiting room with Eric by her side, she continued to have a worsening headache and shortness of breath. After about an hour, she stopped talking to Eric and became still with what he described as a “blank look in her eyes”. She slumped to the floor and began to seize. In a matter of minutes, Amy suffered a stroke and died, without ever leaving the waiting room.
How could this have happened? Don’t we have the best medical care in the world at our disposal? How could things have gone so wrong so quickly? Sadly, this is a story played out in some variation in the United States all too often. Despite the still largely unknown etiology, the incidence of pre-eclampsia in pregnancy and labor is well documented and most hospitals and providers have clear protocols and algorithms for managing it well. However, most hypertensive associated seizures and death occur in the postpartum period, with many of these patients having no prior hypertension in pregnancy1.
We send new moms home with copious instructions for infant care, breastfeeding, perineal care, and how to spot the signs of a possible infection in mother and baby. Very little, if any, is discussed regarding the warning signs of preeclampsia and the seriousness of the condition. Compounding the issue is that many women won’t reach alarmingly high blood pressures during the postpartum period, but tend to have lower pressures that may not be impressive to staff in a busy ER2.
How can we improve our care of postpartum women and prevent this kind of tragedy? First, by being diligent as nurses with monitoring blood pressures during labor, delivery and postpartum and comparing these to the baseline in the prenatal record. Second, we can give verbal as well as written instructions regarding warning signs after discharge, with clear instructions regarding when to contact their provider or seek emergent care. Third, we can all - as a healthcare system - forego the assumption that maternal women are without considerable risk after giving birth. In the US, we lose more women to pregnancy and birth complications than any other developed nation3, and this should be appalling. Two of the leading causes are hemorrhage and preeclampsia, both of which are easily preventable.
Those of us who are obstetric nurses and providers are well versed in the signs and symptoms of preeclampsia, but after discharge, where do these women present? To the local ER or urgent care center most likely - where knowledge of the warning signs may be woefully lacking. In my hospital, we have taken postpartum preeclampsia simulation scenarios to ER staff as well as to area EMS staff to improve recognition of and response to this deadly condition. We have yet to collect data on outcomes improvement, but the education has been well received and reported as eye-opening to staff who have participated.
Only by educating our patients, their families, and all health care workers about the warning signs of preeclampsia can we increase awareness and prevent these tragic deaths in a population that should be happy, healthy, and enjoying the most profound experience of their lives. No woman should have to die from an easily treatable condition in the greatest healthcare system in the world.
*Names and story are fictional, based on actual events.
References
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Berstein P., Martin J., Barton J., et.al. Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period. Journal of Obstetrics, Gynecology and Neonatal Nursing. 46, 77-787. 2017.
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American College of Obstetrics and Gynecology Practice Bulletin: Gestational Hypertension and Preeclampsia #222. June 2020.
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Geller, S.E, Koch, A.R., Garland, C.E. et al. A Global View of Severe Maternal Morbidity: Moving Beyond Maternal Mortality. Reprod Health 15, 98. 2018.
