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A woman and her unborn daughter died just two weeks before she was due to give birth after she suffered a heart attack while in bed with her husband.
An inquest heard tragic Emily Teague woke up gasping for air at 4am and her husband, Simon, dialled 999 and began CPR.
The 33-year-old mum-to-be suffered a heart attack in the early hours of October 11, 2018, and was rushed to Royal Derby Hospital but medics could not save her or unborn daughter Isabelle.
During the hearing a coroner heard how due to a history of cardiovascular health issues in her family Mrs Teague should have been referred to specialists years before her death, DerbyshireLive reports.
If that had happened Isabelle could have been delivered safely via planned c-section, a cardiologist revealed, but Mrs Teague would likely still have died.
The court was told that in the weeks leading up to her death Mrs Teague, of Alvaston, Derby, had complained several times to medical staff about feeling lightheaded, having blurred vision and feeling nauseous.
On one occasion the data analyst was admitted to hospital where she stayed overnight, but was discharged the next day, and the inquest heard these symptoms were not related to her heart condition.
The heartbreaking incident took place shortly after 4am while Mrs Teague was sleeping in bed with her husband, Simon.
The inquest heard that Mrs Teague had woken up and sat up in bed and appeared to be gasping for breath, before she suddenly became unresponsive. Mr Teague quickly began CPR and rang for an ambulance, which transported her to hospital.
Dr Alastair McCance, a cardiologist at the Royal Derby Hospital, said if this had happened she would have been periodically monitored to check the condition of her heart and cardiovascular system, and advice would have been given if she decided to have a child.
He said: "We think she should have been referred and the most appropriate place to be referred to would have been myself or Dr [Damian] Kelly."
Dr McCance, who was not the member of staff who dealt with Mrs Teague in 2014, said this should have happened particularly "in view of the family history" which had seen similar issues in at least three other family members.
He said if this had happened she would have been reviewed every two years to see if the size of her aorta was changing, and action would have been taken if needed.
However, he noted: "Her aorta was a long way away from the size at which it was likely we would have recommended surgery, but we would have recommended surveillance."
Dr McCance told the inquest that he agreed with the pathologist when they said Mrs Teague's pregnancy had increased the risk of her suffering an aortic dissection, although he said had he seen her before pregnancy he would have suggested she was at low risk of this happening.
"Pregnancy is a known risk factor for aortic dissection," he said.
"Progesterone [a hormone released during pregnancy] weakens connective tissue. That's why we think people are particularly prone to developing that during pregnancy."
He added that had she been in contact with the clinic while being pregnant, it would have been suggested that Mrs Teague undergo a planned c-section to deliver her child at between 37-38 weeks into her pregnancy, to try to prevent the stresses associated with a natural birth.
He says while this may have been enough to save Isabelle, who had been healthy up until the incident, it would not have saved Mrs Teague.
"The hormonal changes [from pregnancy] persist for several weeks afterwards," Dr McCance said.
"I think she would have had the dissection anyway, and I think it would have been fatal whatever we had done.
"It's a tragic case. I would like to reiterate our deepest condolences."
Peter Nieto, area coroner for Derby and Derbyshire, recorded a conclusion of death by natural causes, saying he felt on the balance of probabilities, that even if Mrs Teague had been referred to the clinic years before and received reviews, she still would have died as a result of the pregnancy.
"The hospital trust accepts that the cardiologist who saw and assessed her should have referred her for senior review and the specialist congenital cardiac clinic," he said.
"This would have led to further periodic review."
He added: "If she had had a c-section at 37 weeks she would have remained at risk of aortic dissection because it takes a number of weeks for the hormones to subside.
"The advice would likely have been that the risk was low in terms of an aortic dissection.
"That's why I find it's not possible the outcome would have been different.
"I do understand the perfectly legitimate concerns her family have about the fact these steps were not taken."
Cathy Winfield, executive chief nurse at University Hospitals of Derby and Burton NHS Trust, said what had happened was an "absolute tragedy".
"On behalf of the trust, I’d like to express my sincere condolences to Mrs Teague’s family," she said.
"The loss of both Mrs Teague and her baby was and still is an absolute tragedy, so it is absolutely imperative that we carefully consider any lessons we can take from this inquest to help prevent other cases like this from happening again in the future."