Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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104 7 Genital tract sepsis Tachycardia, over 100 bpm, and unusually severe abdominal pain are important and common signs and symptoms requiring urgent review by a doctor. Gastro-intestinal symptoms, especially diarrhoea, are common in pelvic sepsis. Pyrexia is not always present although a temperature of 38°C or higher should always prompt a thorough investigation for infection including vaginal, cervical, wound and throat swabs and blood and urine cultures. The white cell count is not always elevated and may be low. C-reactive protein (CRP) is a useful indicator of infection. Box 7.6 Common symptoms and signs of genital tract sepsis Symptoms • Fever • Diarrhoea • Vomiting • Abdominal pain • Rash (generalised streptococcal maculopapular rash) • Vaginal discharge, wound infection Signs • Tachycardia • Tachypnoea • Pyrexia • Possible elevated white cell count • Elevated C-Reactive Protein In some cases routine observations were often not taken or their signifi cance was not appreciated. One woman did not have her temperature taken for over 24 hours after delivery, when she collapsed. Routine observation of vital signs is essential for the early detection of severe illness. In hospital practice, a Modifi ed Obstetric Early Warning Scoring (MEOWS) system such as one recommended and discussed in Chapter 19 - Critical Care, should help to reduce deaths due to the late recognition of serious illness. Once septicaemia develops the woman’s clinical condition may deteriorate very rapidly over the course of a few hours, particularly when endotoxin-producing organisms are responsible. The features of septicaemic shock are shown in Box 7.7. Increased respiratory rate and severe tachycardia are important symptoms. Hypotension results in inadequate organ perfusion and lactic acidosis. Rapid development of disseminated intravascular coagulation (DIC) is a common complication. Several of the women who developed septic shock around the time of delivery had massive haemorrhage due to a combination of unresponsive uterine atony and DIC. Cardiac arrest in septic women often occurs with little warning and resuscitation is often unsuccessful.
Box 7.7 Features of septicaemic shock • Tachycardia over 90 beats per min • Tachypnoea over 20 breaths per min • Pyrexia over 380C • Hypothermia below 350C • Hypotension Systolic BP 90mm/Hg or below in absence of other causes e.g. bleeding • Hypoxemia • Poor peripheral perfusion, mottled skin • Oliguria • Metabolic acidosis • Elevated lactate • Positive blood cultures • Abnormal coagulation and bleeding • Abnormal liver and renal function tests Treatment A recurring feature in the cases described here and in previous Reports is a delay in starting intravenous antibiotics. In some cases no antibiotic was ever given. In one case antibiotics were stopped because a streptococcal rash was mistaken for a drug allergy. The guiding principles are given in Box 7.8. Box 7.8 Guiding principles for antibiotic therapy in genital tract sepsis If pelvic sepsis is suspected prompt early treatment with a combination of high-dose broad-spectrum intravenous antibiotics, such as cefuroxime and metronidazole, may be lifesaving. Do not wait for microbiology results. Ensure that serum levels of antibiotics are within the therapeutic range. The expert advice of a consultant microbiologist should be sought at an early stage. Microbiology results should be obtained as soon as possible. If there is no response within 24-48 hours or the woman’s condition is deteriorating, the antibiotics should be changed and gentamicin or alternative antibiotics added, guided by microbiological advice. The source of sepsis should be sought and dealt with if possible and appropriate, for example - by delivery or ultrasound scans to detect retained intrauterine products and evacuation of products if present. 105
Page 1 and 2:
Confidential Enquiry into Maternal
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Saving Mothers’ Lives: Reviewing
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Contents Maternal deaths Indirectly
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Foreword Having a baby is a joyous
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The ‘top ten’ key recommendatio
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Migrant women 4. All pregnant mothe
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Clinical skills 7. Maternity servic
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Early warning scoring system 9. The
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References 1 Redshaw M, Rowe R, Hoc
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Working together to save mothers’
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Severe maternal morbidity, “near
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At a national level In every countr
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Table 1 Defi nitions of maternal de
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For the past nine years, ONS have b
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Chapter 1 Which mothers died, and w
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Key fi ndings for 2003-05 Maternal
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Figure 1.1: Overall maternal mortal
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Coincidental deaths The deaths of 5
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Leading causes of maternal deaths:
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Table 1.5 Maternal deaths by gestat
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Table 1.7 Number of maternal deaths
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of note is that every women who die
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Table 1.11 Numbers and percentage o
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These messages are repeated in many
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Doctors may need specifi c training
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Table 1.13 Total number of Direct a
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Ovarian hyperstimulation syndrome (
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The obese women who died From the n
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Pre-pregnancy counselling and weigh
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Table 1.19 Direct and Indirect mate
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double the number of cases in the l
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was ill and he should take her to a
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Table 1.22 Characteristics of the a
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Most staff reported learning clinic
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exception. The health service has a
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17 Shah A, Sands J, Kenny L. Matern
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Country of birth and migration A fa
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Table A1.4 Direct and Indirect deat
Page 81 and 82: Body mass index varies with age, be
Page 83 and 84: 2 Thrombosis and thromboembolism Ja
Page 85 and 86: Pulmonary embolism Of the 33 women
Page 87 and 88: Family history In two deaths there
Page 89 and 90: vigilance and take symptoms serious
Page 91 and 92: Deaths after caesarean section Seve
Page 93 and 94: of pregnancy, seven had identifi ab
Page 95 and 96: Annex 2.1 Summary of the key recomm
Page 97 and 98: The grades of recommendations (B or
Page 99 and 100: High risk patients Patients assesse
Page 101 and 102: Table 3.2 Numbers of deaths from pr
Page 103 and 104: publication from the United States
Page 105 and 106: References 1 Knight M, Kurinczuk JJ
Page 107 and 108: obstetricians and anaesthetists rou
Page 109 and 110: Detailed guidelines for the managem
Page 111 and 112: acute bleeding situation although i
Page 113 and 114: References 1 Brace V, Penney G, Hal
Page 115 and 116: Table 5.1 Direct deaths attributed
Page 117 and 118: of over ten litres. Despite a hyste
Page 119 and 120: References 1 Clark SL, Pavlova Z, G
Page 121 and 122: The women who died The ages of the
Page 123 and 124: A woman who had not been long in th
Page 125 and 126: 7 Genital tract sepsis Ann Harper G
Page 127 and 128: Sepsis in early pregnancy Six women
Page 129 and 130: Box 7.3 Learning points: Sepsis in
Page 131: Risk factors for, and the identifi
Page 135 and 136: 8 Anaesthesia Griselda Cooper and J
Page 137 and 138: The third case also highlights the
Page 139 and 140: A woman suffered a concealed haemor
Page 141 and 142: Sepsis Poor anaesthetic or resuscit
Page 143 and 144: What did you learn from this case a
Page 145 and 146: 9 Cardiac disease Catherine Nelson-
Page 147 and 148: Table 9.2 Causes of maternal death
Page 149 and 150: an estimated incidence of 1.1 per 1
Page 151 and 152: Quality of care Care was considered
Page 153 and 154: y a doctor, with a systolic blood p
Page 155 and 156: Box 9.3 Learning points: peripartum
Page 157 and 158: Infectious endocarditis Two women d
Page 159 and 160: 10 Other Indirect deaths Michael de
Page 161 and 162: Table 10.1 Causes of Other Indirect
Page 163 and 164: Fifty-eight of the eighty-seven wom
Page 165 and 166: Previous Reports have emphasised th
Page 167 and 168: Aspergillosis usually occurs in imm
Page 169 and 170: Liver disease There were four mater
Page 171 and 172: Diseases of the circulatory system
Page 173 and 174: 11 Cancer and other tumours Gwyneth
Page 175 and 176: her delivery, but her case should h
Page 177 and 178: Severe abdominal and back pain, sci
Page 179 and 180: References 1 Drife, J O. The contri
Page 181 and 182: Psychiatric deaths: Specifi c recom
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cut off point for maternal deaths,
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Report, 26 deaths from suicide were
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Current psychiatric treatment In th
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12 Deaths from psychiatric causes S
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caring for the woman. Nonetheless,
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Commentary on deaths related to dru
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It is known that women presenting w
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antibiotics nor returned to her gen
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It is still evident that there is a
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13 Domestic abuse Gwyneth Lewis Dom
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The mothers affected: 2003-05 Durin
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Of the women who were murdered: •
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Annex 13.1 The recommendations of t
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Road traffi c accidents during and
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Table 14.2 Late deaths known, or no
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Table 15.2 Quality of autopsy repor
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Haemorrhage Thirteen of the sevente
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association with obesity as eight o
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Obesity was present in 55% of these
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Toxicology showed non-lethal citalo
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Box 15.6 Pathology learning points:
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References 1 Royal College of Patho
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16 Issues for midwives Grace Edward
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effective service for women who may
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Professional accountability and com
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Box 16.1 Key physical signs that ma
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Midwives’ responsibility for vuln
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Table 16.1 Poor or non attenders fo
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Action checklist for midwifery prac
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17 Issues for General Practitioners
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Box 17.1 Summary of the key issues
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Box 17.3 Risk factors for venous th
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headaches. The indications for emer
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Box 17.8 GP learning points: Heartb
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medication after delivery and been
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Women with mitral stenosis may seem
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signifi cance in the pregnancy. It
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References 1 RCOG. Thromboprophylax
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Introduction For the fi rst time in
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measures were of a good or excellen
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A woman collapsed at home following
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never preclude requesting opinion f
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admissions represented 0.9% of all
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Modifi ed early warning scoring sys
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Box 19.3 Critical care learning poi
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her initial collapse she was transf
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Chapter 19 Annex A This Annex is av
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Table 20.1 Inclusion criteria used
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Table 20.3 Numbers and rates of sev
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References 1 Baskett TF,.O’Connel
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The Director of the Maternal Death
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Verifi cation of Ascertainment Asce
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Scotland A single panel of assessor
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CEMACH Regional Managers East of En
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Regional Assessors in Pathology Eas
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NORTHERN IRELAND Department of Heal
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Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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