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

Harperwoman was given several litres of fluid over a few hours,after which she developed severe chest pain and breathlessness,followed by frank pulmonary oedema and cardiacarrest. Another woman with high urea and creatinine andminimal urinary output despite two litres of fluid hadacute renal failure, but dehydration was diagnosed andsome additional litres of fluid over a few hours were prescribedinappropriately.Fluid balance is difficult to manage in septic shock. Septicshock may be defined as sepsis with hypotension whichis refractory to fluid resuscitation. Hypotension is the resultof loss of vasomotor tone causing arterial vasodilationalong with reduced cardiac output because of myocardialdepression, and there is also increased vascular permeabilityso that fluid leaks into the extravascular compartment.Renal failure and use of oxytocic drugs, which are antidiuretic,may compound the problem.Careful monitoring of fluid balance is important. Clear,accurate records of all intravenous fluids given and urinaryoutput and any other fluid loss should be kept and chartedso that significant fluid deficit or excessive input can beeasily detected. Although aggressive fluid resuscitation isusually needed in severe sepsis and septic shock, thisshould always be under close monitoring to evaluate thewoman’s response and avoid the development of pulmonaryoedema. 8 Vasopressors are usually required, and acentral venous pressure line may help to monitor fluid balance.It is essential to involve the anaesthetic and criticalcareteams as early as possible in the care of such criticallyill women.Fluid balance in septic shock:learning pointsSeptic shock is sepsis with arterial hypotension that isrefractory to fluid resuscitation.Fluid overload may lead to fatal pulmonary or cerebraloedema.Clear, accurate documentation and careful monitoringof fluid balance is essential to avoid fluid overload inwomen who are unwell, especially when hourly urineoutput is low or renal function is impaired. The adviceof an anaesthetist and the critical care team should besought at an early stage.Sustained increase in respiratory rate >20 breaths/minuteor low oxygen saturation despite high-flow oxygen aresignificant clinical findings that should prompt urgentexamination of the lung fields, lower limbs (for evidenceof deep vein thrombosis), arterial blood gas measurement,electrocardiogram, and consideration of chest X-ray and ventilation perfusion scan to rule out problemssuch as pulmonary oedema, embolus or infection.Removing the source of sepsisThe focus of infection should be identified as a priority,and, if surgery is necessary to remove the source of sepsis,it should be carried out earlier rather than later or as alast resort—whether laparotomy, evacuation of suspectedretained products of conception, or other procedure. Laparotomieswere performed in several of the women withthe aim of identifying and removing the septic focus.Deciding whether to operate is difficult, particularly whena woman is already critically ill and there is a high risk ofmassive haemorrhage. It is important to stabilise thematernal condition as far as possible before giving anaesthesia,which may further destabilise the woman, and toensure that adequate cross-matched blood and bloodproducts are readily available. When there is massive atonicuterine haemorrhage, conservative measures such ascarboprost may be tried, but if response to initial doses ispoor, hysterectomy undertaken sooner rather than latermay be lifesaving. In most cases laparotomy was undertakenas a last resort, but in a few cases earlier interventionmay have changed the outcome. In one womanwhose uterus was clearly infected, hysterectomy was consideredbut decided against because she was critically illand surgery was considered too risky; in retrospect itmight have offered a chance of survival.Operative intervention: learningpointsPersistent or swinging pyrexia and failure to respond totreatment may be the result of a persistent deep-seatedfocus of infection. Every effort should be made to locateand deal with the source of sepsis. Computed tomographyis a useful investigation but may not show soft tissuechanges clearly, so magnetic resonance imagingshould also be considered.If the uterus is the primary focus of postnatal infection,retained products should be excluded by ultrasoundscan and exploration of the uterine cavity considered ifthere is still doubt. Hysterectomy should be consideredat an early stage, even if the woman is critically ill,because it may be lifesaving.Before surgery, adequate cross-matched blood andblood products should be requested and the maternalcondition should be stabilised as far as possible.Carboprost can be effective in the treatment of uterineatony but has serious adverse effects, including airwayconstriction and pulmonary oedema, so it should beused with great caution—especially if multiple doses arerequired. If there is no response to one or two doses,other methods of dealing with the situation, such ashysterectomy, must be considered.94 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203