Maternal Deaths in the UK are extremely rare. However according to the Confidential Enquiry into Maternal and Child Health (CEMCH) [1], the leading cause of maternal deaths in the UK is hypertension.

What is a Maternal Death?

Maternal Death is classed as the death of a woman during or shortly after a pregnancy.

What is Hypertension?

Hypertension is also known as high blood pressure. In pregnant women it can develop into what is known as pre-eclampsia [2]. Pre-eclampsia can progress to a life-threatening condition called eclampsia [3], which is the development of protein in the urine, generalised swelling, and severe seizures.

Hypertension in pregnancy can also include;

  • chronic hypertension [4], this is usually the case when hypertension is present at the first antenatal booking or before the first 20 weeks of pregnancy
  • Gestational hypertension, hypertension presenting after 20 weeks of pregnancy without significant proteinuria [5].
  • Pre-eclampsia, hypertension presenting after 20 weeks of pregnancy with significant proteinuria. - Severe pre-eclampsia, pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or hematological impairment.
  • Eclampsia, a convulsive condition associated with pre-eclampsia - HELLP syndrome [6], haemolysis [7], elevated liver enzymes and low platelet count.
  • Significant proteinuria.

Factors which can Increase the Risk of Hypertension During Pregnancy

  • A first pregnancy
  • Older mothers-to-be (aged over 40)
  • A Body Mass Index (BMI) [8] over 35 at first antenatal visit
  • A family history of pre-eclampsia
  • Multiple pregnancy [9]
  • Previous diagnosis of hypertension or condition which may cause hypertension such as chronic renal disease or diabetes.

If you have hypertension, what can it mean?

Hypertension can have serious health implications, babies are more likely to be premature, stillborn or smaller than average and mothers are at an increased risk of developing high blood pressure later in life. Untreated it can have devastating effects.

NICE reports that a UK study reported that one-third of severe maternal morbidity was a consequence of hypertensive conditions. A study from one region of the UK reported that 1 in 20 (5%) women with severe pre-eclampsia or eclampsia were admitted to intensive care. More recently, the long-term consequences for women with a diagnosis of hypertension during pregnancy have become clear, in particular chronic hypertension and an increase in lifetime cardiovascular risk.

Hypertensive disorders also carry a risk for the baby. In the most recent UK perinatal mortality [10] report, 1 in 20 (5%) stillbirths in infants without congenital abnormality occurred in women with pre-eclampsia. The contribution of pre-eclampsia to the overall preterm birth rate [11] is substantial; 1 in 250 (0.4%) women in their first pregnancy will give birth before 34 weeks as a consequence of pre-eclampsia and 8–10% of all preterm births result from hypertensive disorders. Half of women with severe pre-eclampsia give birth preterm.

Most Maternal deaths however are preventable had the medical staff involved known how to correctly deal with pregnant women suffering with hypertension or recognise danger signs after birth.

The much publicised case of Laura Touche hit the headlines back in 1999 when she died at the Private Portland Hospital, London, after giving birth to twins by caesarian section. The midwives on call failed to adhere to the Hospitals own protocol stating that she should have been checked every 15 minutes and failed to recognise early warning signs of post natal hypertension when Mrs Touche complained of agonizing headaches and her blood pressure was rising. Mrs Touche sadly died nine days after giving birth to her sons. An inquest in January 2002 found that Mrs Touche died from natural causes "contributed to by neglect". The midwife involved admitted three counts of misconduct at her disciplinary hearing.

Fiona Milne, who is a trustee of the charity, Action of Pre-eclampsia, developed pre-eclampsia when she was 35 years old and pregnant with her first child. She also helped to develop the new guidelines.

She said " I was diagnosed with pre-eclampsia during my first pregnancy and sadly, my baby was stillborn at 37 weeks. It was a traumatic time that deeply affected a lot of people; family, friends, doctors and nurses. This guideline which I played a part in developing, will mean pregnant women and those planning a pregnancy who have or may develop a hypertensive disorder, will receive the best possible care and attention to keep them and their unborn babies safe and healthy."

NICE guideline to drive down hypertension in pregnancy

Whilst deaths from hypertension are rare, NICE issued new guidelines on 25th August 2010, to help healthcare professionals including GPs, midwives and obstetricians care for women, with, or at risk of, developing hypertension during their pregnancy.

There is national guidance on the care of women with severe pre-eclampsia or eclampsia and on screening for hypertensive disorders during pregnancy [12]. However, there has been no guidance on the assessment and care of women and their babies after a diagnosis of hypertension (including the use of antihypertensive treatment [13]) or on maternity care for women with chronic hypertension.

The key recommendations for obstetricians, midwives and other health care professionals in the new NICE guidelines include taking a low dose of aspirin each day from the 12th week of pregnancy. Other guidelines are advising hypertensive women who are wishing to start a family to ensure a healthy BMI, and for those who are hypertensive offering a comprehensive care package [14].

Healthcare professionals have welcomed these new guidelines which set out a clear pathway of care to guarantee that women are looked after in the best way possible no matter where they live. Health Professionals and mothers to be should now be better informed about the risks of developing such a condition and most importantly what to do to try and prevent it and if necessary to treat it.

The full NICE clinical guideline 107 – Hypertension in pregnancy: the management of hypertensive disorders during pregnancy can be found at http://guidance.nice.org.uk.

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  1. Saving Mother's Lives: Reviewing maternal deaths to make motherhood safer 2003-2005, published December 2007. 
  2. Pre-eclampsia is a medical condition in which hypertension arises in pregnancy (pregnancy-induced hypertension) in association with significant amounts of protein in the urine. 
  3. Eclampsia is an acute and life-threatening complication of pregnancy, is characterised by the appearance of tonic-clonic seizures, usually in a patient who had developed pre-eclampsia. Eclampsia includes seizures and coma that happen during pregnancy but are not due to preexisting or organic brain disorders. 
  4. Chronic Hypertension is a condition where your blood pressure is usually higher than normal, over a long time. 
  5. Proteinuria describes the presence of protein in the urine. It is often defined as an amount in excess of 300 mg per day. 
  6. HELLP syndrome is a group of symptoms that occurs in pregnant women who have pre-eclampsia or eclampsia and who also show signs of liver damage and abnormalities in blood clotting. 
  7. Haemolysis is the destruction of red blood cells (erythrocytes). Within the body, haemolysis may result from poisoning, infection, or the action of antibodies; it may occur in mismatched blood transfusions. It usually leads to anaemia. 
  8. The body mass index (BMI), or Quetelet index, is a heuristic measure of body weight based on a person's weight and height. Though it does not actually measure the percentage of body fat, it is used to estimate a healthy body weight based on a person's height. 
  9. More than one baby at the same time i.e. twins or more. 
  10. The World Health Organization defines perinatal mortality as the "number of stillbirths and deaths in the first week of life per 1,000 live births". 
    preterm birth refers to the birth of a baby of less than 37 weeks gestational age. 
  11. Royal College of Obstetricians and Gynaecologists (2006) The management of severe pre-eclampsia/eclampsia; National Institute for Health and Clinical Excellence (2008) Antenatal care. NICE clinical guideline 62. London: National Institute for Health and Clinical Excellence. Available from www.nice.org.uk/guidance/CG62. 
  12. Antihypertensive is used to describe drugs or treatments designed to control hypertension. 
  13. Full medical advice must be sought and this article must not be relied upon as medical advice.