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

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17 Issues for General Practitioners
disappeared from the collective memory of health professionals and patients. However, women continue to
die from puerperal sepsis in this, as in previous Reports. For example:
A woman had early discharge from hospital after normal delivery despite having pyrexia and
tachycardia. Her community midwife visited daily for a few days but failed to recognise the signs
and symptoms of developing sepsis. Despite the mother’s continuing pyrexia, a tachycardia of
140 bpm, abdominal pain and diarrhoea, the midwife took no action and advised that she would
phone the following day and visit again in a few days time. An emergency GP was called who
advised analgesia and fl uids. The woman was admitted to hospital a few hours later and died
rapidly from septic shock.
In this case both the midwife and GP provided substandard care. In the early stages of sepsis symptoms
can be insidious in onset and non-specifi c. Fever and offensive lochia are not always present; diarrhoea
is common. By the time sepsis is obvious clinically, infection is already well established and clinical
deterioration into widespread septicaemia, metabolic acidosis, coagulopathy and multi-organ failure is
very rapid and often irreversible. The best defence against this situation is awareness of the early signs
of sepsis by routine basic clinical observations for several days after delivery; these should include
pulse, temperature, BP, respiration, and lochia. The diagnosis of sepsis should always be considered in
recently delivered women who feel non-specifi cally unwell. A white cell count, urine and vaginal cultures
should be taken and the woman should be treated with antibiotics proactively while awaiting the results of
investigations. There should be a low threshold for emergency admission for intravenous antibiotics if a
woman fails to respond to treatment or has symptoms such as abdominal pain and fever or tachycardia.
Good communication is essential between hospital and community carers.
Box 17.7
GP learning points: sepsis
Puerperal infection is not a disease of the past and health professionals are still failing to recognise its
classic early symptoms and signs.
Puerperal sepsis should be considered in all recently delivered women who feel unwell and have
pyrexia.
Women with sepsis can deteriorate rapidly, with the potentially lethal consequences of severe sepsis
and septic shock. Abdominal pain, fever and tachycardia are indications for emergency admission for
intravenous antibiotics.
Heartburn may be ischaemic heart disease
Sixteen women died from ischaemic heart disease, representing a continuing rise in the number of cases.
This refl ects both the trend towards older motherhood as well as public health risk factors such as smoking
and the rising incidence of obesity. Therefore, although cardiac disease is rare in pregnant women, GPs
need to consider the possibility in women with risk factors and typical symptoms. For example:
A parous woman who smoked and who had a family history of ischaemic heart disease presented
late in the second trimester with a history of retrosternal pain radiating to the jaw. Her GP attributed
the symptoms to heartburn. She collapsed and died the next day from a myocardial infarction.
This woman’s care was substandard: she had risk factors and classical angina pain. Her GP should have
arranged for an emergency cardiological referral. Although heartburn is a common symptom of pregnancy
it can mask serious pathology. Radiation of retrosternal pain to the jaw is rare in heartburn and should alert
clinicians to the possibility of ischaemic pain.