Advice to hospitals on the management of pregnant women with suspected sepsis has been updated in the light of the lessons learned from the death of Savita Halappanavar almost two years ago. New guidelines, developed by the HSE and the Institute of Obstetricians and Gynaecologists, have also been issued on the treatment of miscarriage in the second trimester (12 to 24 weeks).
Ms Halappanavar, who was 17 weeks pregnant, died of sepsis in University Hospital Galway in October 2012 following a miscarriage. A subsequent report from the Health Information and Quality Authority said staff failed to recognise and act upon signs of her clinical deterioration in a timely and appropriate manner.
The new guidelines on sepsis have been incorporated into the Irish Maternity Early Warning System, which was not in place in Ms Halappanavar’s ward at the time of her death but has since been introduced in maternity units nationally. The new guidelines state that if two or more indications of sepsis are present and infection is suspected after a medical review, a number of tests and interventions need to be undertaken within one hour.
The indications of suspected sepsis include a temperature of over 38 degrees, a respiratory rate of over 20 breaths a minute and a heart rate of over 100 beats a minute. An elevated white blood cell count, sugar level or an “acutely altered mental state” are other possible indications to be taken into account in assessing whether sepsis is present.
The actions to be taken within the hour include blood and urine tests, the maintenance of a steady oxygen supply, administration of intravenous antibiotics and consideration of intravenous fluids.
The guidelines on miscarriage in the second trimester say delivery should be considered for women with chorioamnionitis (inflammation of the foetal membranes) irrespective of foetal viability. “If the foetal heart is present it may still be necessary to induce delivery irrespective of gestational age, particularly if there is evidence of infection developing.”
Ms Halappanavar sought to have her pregnancy terminated after learning that she would miscarry, but this was refused because of the presence of a foetal heartbeat. Her case led to a change in the law, although promised guidelines on the circumstances in which pregnancies can be terminated have yet to be published.
Ms Halappanavar was diagnosed with chorioamnionitis after her membranes ruptured shortly after she was admitted to hospital. Her case highlighted how quickly infection can lead to a patient’s deterioration, leading to sepsis, septic shock and, ultimately, multi-organ failure. The guidelines recommend the use of the drug mifepristone and a prostaglandin to induce labour, saying this combination is safe and acts quicker than other induction regimes.
One in five pregnancies ends in miscarriage but the vast majority occur in the first trimester of pregnancy. In low-risk women, the risk of second-trimester miscarriage is one in 200.
After delivery, “staff should gently explain to the couple what their baby might look like after birth and they should always be offered the opportunity to see or hold their baby, whatever the gestation,” the guidelines state.
Staff are also advised to make the couple aware of the gender of the infant, unless there is uncertainty because of the low level of gestation.
According to the guidelines, a post mortem examination should be considered, “depending on foetal size”.
