Conditions that threaten women’s lives in childbirth & pregnancy

What is a life threatening complication in pregnancy and childbirth?

This module is about severe maternal illnesses experienced by women who are about to, or have just given birth. These are illnesses or complications that would lead to the mother’s death without urgent medical help and are sometimes known as “near misses”. They are rare – affecting less than one in every hundred giving birth in the United Kingdom*. In this introduction, Professor Marian Knight** tells us more about the conditions that can be life threatening to women during and after childbirth.

There are several conditions that can lead to a life threatening emergency for women during or shortly after childbirth. Some of these conditions can be diagnosed during pregnancy, for example, pre-eclampsia (a blood pressure problem) or some problems with the placenta. But some conditions may only develop as an emergency. These different conditions mean that women’s experiences of their emergencies will be very varied. What they have in common is a life threatening and traumatic birth they had not expected.
Haemorrhage
A haemorrhage is heavy uncontrolled bleeding during or after the delivery of a baby. A life-threatening haemorrhage after childbirth (a post-partum haemorrhage – PPH) is when a woman loses more than 500ml (approximately one pint) of blood. This might be in the first 24 hours (primary PPH) or up to 6 weeks after the birth (secondary PPH). Haemorrhage can have several causes including:
  • an atonic uterus (where the womb does not contract naturally)
  • trauma (e.g. rupture of the womb)
  • retained placenta (when the placenta is not delivered after the birth as it should be)
  • other problems with the placenta (e.g. placenta praevia or accreta)
  • some of the other conditions described in more detail below.
In some cases, if the bleeding cannot be stopped, a hysterectomy (removal of the womb) may have to be performed to save the mother’s life.
 
Problems with the placenta
Disorders of the placenta (the organ which attaches to the womb and provides nourishment for the growing baby) include placenta praevia, placenta accreta and placenta percreta. Placenta praevia, also known as low lying placenta, can have different degrees of severity. If the placenta is near or lying across the cervix (neck of the womb), it can block the baby’s way out. If the placenta is low in the womb, there is a higher chance of bleeding during pregnancy or during childbirth. Placenta accreta is when the placenta is embedded too deep into the wall of the womb. Placenta percreta is where the placenta grows through the womb wall and into the bladder.
 
Retained placenta is a condition in which some, or all, of the placenta remains in the womb after birth. This can lead to bleeding or infection later on. Placenta accreta is one of the causes of retained placenta, but it can happen for other reasons too.
Placental abruption is a condition in which the placenta starts to come away too early from the inside of the womb wall. It can cause bleeding and pain.
Blood pressure and related problems (hypertensive disorders)
Women who develop pre-eclampsia have high blood pressure, fluid retention (oedema or swelling) and protein in the urine. If pre-eclampsia is not treated it can lead to serious complications. While mild pre-eclampsia can be monitored with blood pressure and urine tests at regular antenatal appointments or by the GP, more serious cases need to be monitored in hospital. Treatment focuses on lowering blood pressure, but the only way to cure pre-eclampsia if it is severe is to deliver the baby, which can be dangerous for the baby if it is premature.
 
There is a rare condition called HELLP syndrome which also belongs to this group. HELLP syndrome is a combined blood clotting and liver disorder that can affect pregnant women. The letters in the name, HELLP, stand for each part of the condition' Haemolysis (red blood cells in the blood break down), EL (elevated or raised liver enzymes) and LP (low number of platelets in the blood, which affects the blood’s ability to clot). The only way to treat the condition is to deliver the baby. The main danger to the baby is if it is premature or if the mother becomes extremely ill. Acute fatty liver of pregnancy is another rare condition related to high blood pressure.
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Blood Clots (Pulmonary embolism, PE or Deep Vein Thrombosis, DVT)
Blood clots in the legs or lungs (also known as thromboembolic conditions) are a leading cause of illness associated with pregnancy and birth and can be life-threatening. Blood clots form in one of the blood vessels, usually the legs (deep vein thrombosis or DVT) and can break away, causing a blockage elsewhere, for example in the lungs (pulmonary embolism or PE – a blood clot in the main artery of the lung).
Sepsis
Sepsis is an infection that can develop before or after the baby has been delivered. Infections can be more severe in pregnancy, and after delivery women may be at particular risk of infection of the womb or birth canal (genital tract infections). It used to be known as puerperal sepsis, or childbed fever, and was a leading cause of maternal deaths. Septicaemia is where the infection spreads into the blood stream. These infections can develop very quickly, or take several days or weeks to build up. Women need to be treated with antibiotics and, in some cases, may need to be admitted to an intensive care unit.
 
Amniotic Fluid Embolism
Amniotic fluid is the liquid in which the baby floats in the womb. Amniotic fluid embolism is a very rare complication of pregnancy in which amniotic fluid, fetal skin or other cells enter the woman’s blood stream and trigger an allergic reaction. Women with this condition may collapse suddenly during the birth of their baby and it often results in the death of the mother.
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While one in one hundred births may be a near miss, some of the conditions are very rare, so doctors and midwives may not see them that frequently. Often women will need to be admitted into an intensive care unit or high dependency unit for a few hours or days. Sometimes their baby will also need care in a neo natal intensive care unit. In many cases mother and newborn baby are not able to be together straight away.
This module is based on interviews with women who have experienced life threatening complications in childbirth, and also interviews with partners who were witness to events. The summaries we have written reflect what people told us were the most important issues to them during and after their emergency. Although rare, these illnesses represent a considerable, and sometimes long–lasting, burden to the women who experience them and their families.
 
*Waterstone, M., S. Bewley, and C. Wolfe, Incidence and predictors of severe obstetric morbidity' case-control study.BMJ, 2001.322(7294)'p. 1089-93; discussion 1093-4.
**Professor Marian Knight, National Institute for Health Research (NIHR) Research Professor in Public Health, National Perinatal Epidemiology Unit, Oxford University. Chief Investigator for the National Maternal Near-miss Surveillance Programme (UKNeS)

Last reviewed April 2016.

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