6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

Chapter 7: SepsisObstetric Surveillance System (UKOSS) surveillance studyfrom February 2010 until February 2011.As highlighted in Chapter 10, pregnant women withunderlying disease, including sickle cell disease, should bemanaged jointly under the care of a consultant obstetricianand a specialist consultant in their underlying condition, inthis case a haematologist. All immunisations, includingagainst pneumococcus, should be up to date. Any infectionsshould be treated promptly and prophylactic penicillinis recommended. A clear plan of management shouldbe documented in the chart early in pregnancy. A nationalguideline would also be helpful.Sepsis in early pregnancyEight women, including seven counted in this Chapter andone Late death, died from complications of infections arisingbefore 24 completed weeks of gestation. Two women diedfrom septic miscarriage and two after a termination of pregnancy.Of these, one did not receive post-procedure prophylacticantibiotics and another died from Clostridium septicumsepticaemia and necrotising fasciitis. Clostridium infection isa rare but previously reported cause of maternal death,including after termination of pregnancy. Vaginal carriagewas the most likely source of infection and the inflammatoryfocus in the uterus the most likely portal of entry. Necrotisingfasciitis is characterised by an overwhelming fulminantcourse with severe pain and muscle inflammation or necrosis;the majority of patients die within 24 hours of onset.Sepsis following pregnancy loss:learning pointsAll units should have an effective and robust system inplace to ensure that peri-abortion antibiotic prophylaxis(metronidazole 1 g rectally at the time of abortion plus,commencing on the day of abortion, either doxycycline100 mg orally twice daily for 7 days or azithromycin 1 gorally) is offered routinely in accordance with RCOGguidelines. 6Infection must be suspected and actively ruled out whenwomen who have had a recent termination of pregnancyor spontaneous miscarriage have pyrexia, persistentbleeding or abdominal pain, especially if the pain isconstant and severe. Vaginal swabs, ultrasound scan toexclude retained products of conception and diagnosticevacuation of uterus (evacuation of retained products ofconception) should be considered if there is still doubt;haemoglobin, white cell count, C-reactive protein, andblood cultures if pyrexia >38°C are minimum investigations;and high-dose broad-spectrum intravenousantibiotics should be commenced immediately, withoutwaiting for microbiology results.Four women, including a Late death, died from the consequencesof chorioamnionitis after spontaneous PPROM inthe second trimester. In one case the cause was Morganellamorganii. This is a Gram-negative rod bacterium oftenfound as part of the normal intestinal flora, but it can be arare cause of severe invasive disease and is naturally resistantto many b-lactam antibiotics. Chorioamnionitis andbrain abscess due to Morganella morganii have both beenreported previously. 7Sepsis before deliveryNine women, including eight counted in this Chapter andone Late death, developed sepsis before delivery after24 weeks of gestation. Seven women had group A streptococcalinfection, one had Escherichia coli and for onewoman who was extremely unwell on admission therewas no information about whether any microbiologicalinvestigations were performed before antibiotics weregiven. Four had a caesarean section and five deliveredvaginally. All except two were extremely unwell on admissionto hospital, and many received outstanding care onceadmitted, even though nothing more could have beendone to save them.Most of these women had similar symptoms. Theyhad a short history of feeling unwell; some had a recentsore throat, cough or flu-like illness; several had severediarrhoea; a few had vomiting; some felt hot and coldor shivery and had mild or severe pyrexia, although othershad no temperature. One woman was hypothermicand several were tachycardic and hypotensive on admission.All had contractions and abdominal pain that insome cases was constant, severe and not relieved by analgesia.Severe maternal infection also affects the fetus—fivebabies died in utero, and those delivered by emergencycaesarean section for abnormal fetal cardiotocographsneeded resuscitation after delivery, as did a baby bornvaginally to a woman who had complained of pelvic painin late pregnancy. In her case, when the membranes rupturedat delivery, the liquor was heavily meconium-stainedand smelt offensive. The combination of severe abdominalpain and abnormal or absent fetal heart is more usuallyassociated with placental abruption, but these cases demonstratethat when a woman presents with these symptoms,genital tract sepsis must be considered in thedifferential diagnosis.Severe sepsis is often a cause of atonic uterine haemorrhage,which may be further exacerbated by disseminatedintravascular coagulation. For example, one woman haduncontrollable bleeding after vaginal delivery and suffered acardiac arrest