Managing Medical and Obstetric Emergencies and Trauma. Группа авторов

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СКАЧАТЬ section incision. Streptococcal infection has a seasonal rise in incidence between December and April in the northern hemisphere. The link between pregnant women and children with group A streptococcal sore throats is thought to be significant as a possible source of infection.

      In the past, there was an emphasis on the transmission of infection from care‐givers to women, much reduced since the advent of strict hygiene practices in hospitals. It is thought that raising public health awareness of the risks from family members and encouraging women to follow appropriate personal hygiene practices may be helpful in reducing transmission of infection; in particular, pregnant women should be encouraged to handwash both before and after using the toilet to avoid transmitting organisms from other household members.

7.5 Clinical issues and presentation

      Minimising risk from infection in the antenatal period, by avoiding unnecessary vaginal examinations and paying attention to hygiene, may reduce the incidence of sepsis. Early recognition and increased surveillance of those at risk including careful assessment of postnatal mothers, especially those with prolonged rupture of membranes, ragged membranes or possible incomplete delivery of the placenta and women with uterine tenderness or enlargement, will help to identify women developing serious infection. Multiple presentations should be seen as a red flag and requires careful review with escalation to senior staff for assessment.

       Symptoms of sepsis may include:

       Feeling unwell, anxious or distressed

       Shivery or feverish

       Sore throat, cough or influenza‐like symptoms (pneumonia accounts for a significant number of admissions to the intensive care unit in pregnant women in the antenatal period)

       Rash (see Appendix 7.1 for weblink to assessment of pregnant woman reporting viral rash illness)

       Chest pain

       Vomiting and/or diarrhoea

       Abdominal pain, uterine and renal angle pain, and beware ‘after pains’ of a severity that is out of proportion to the known cause and not responding to usual analgesia

       Wound tenderness

       If pregnant may report reduced fetal movements

       Offensive vaginal discharge

       Persistent vaginal bleeding may be a sign of uterine sepsis

       Breast tenderness, suggesting mastitis

       Headache

       Unexplained physical symptoms

      A high index of suspicion and close surveillance will help in identifying women with early sepsis. When assessing a woman who is unwell, revisit the history and consider her clinical condition in addition to the modified early obstetric warning score (MEOWS) and do not be reassured by a single set of observations on the MEOWS chart (Knight et al., 2017). Chronic illness and immunosuppression are risk factors for sepsis. Immunosuppression puts a woman at higher risk of rapid deterioration from sepsis, and sepsis should be considered a likely cause when they are unwell.

Serious clinical signs can be categorised as red and amber flags.

The Sepsis Trust UK Sepsis Screening Tool for Acute Assessment of the pregnant or up to 6 weeks’ post‐pregnancy woman is reproduced in Figure 7.2 and defines the red and amber flags.

Figure 7.2 Sepsis Trust UK Sepsis Screening Tool for Acute Assessment

      Source: Nutbeam T, Daniels R on behalf of the UK Sepsis Trust. © 2019 UK Sepsis Trust

7.6 Monitoring, investigations and urgent treatment

      Monitor women who have red and amber flags with suspected sepsis continuously and record using a MEWS chart (NICE, 2016). The conscious level should also be monitored using ACVPU (alert, new confusion, responds to voice, responds to pain, unconscious). A sepsis care bundle must be applied in a structured and systemic way with urgency. The time to administration of antibiotics is a predictor of mortality in sepsis, do not delay and use local antibiotic prescribing guidance. Antiviral medication may also be appropriate. The woman must be continually reassessed and senior review is essential. Consider ‘declaring sepsis’, analogous to activation of the major obstetric haemorrhage protocol.

The UK Sepsis Trust recommends the Sepsis Six (Algorithm 7.1) with all actions to be completed within 1 hour.

       You can think of it as:

       ‘3 in, 3 out”: fluids, antibiotics and oxygen in / catheter, lactate and blood cultures out.

      Initial blood tests include lactate – either arterial if there is evidence of hypoxia or a venous sample. Any woman in whom sepsis is suspected, who has a lactate >2 mmol/l, needs to have resuscitation started immediately. Raised serum lactate is a marker for poor perfusion and tissue hypoxia from whatever cause and signifies severe illness.

      Additional blood tests include blood cultures, full blood count, coagulation screen, urea and electrolytes, blood glucose, liver profile and C‐reactive protein (CRP). Consider urinalysis, urine for culture, sputum culture, vaginal swabs, breast milk culture and throat swabs. Consider a chest x‐ray in all with suspected sepsis. Consider imaging of the abdomen and pelvis if no likely source of infection is identified after clinical examination and initial tests.

      Airway and breathing

      Maintenance of adequate oxygenation is an important step in the resuscitation of women with sepsis. This includes a patent airway with adequate breathing and supplemental oxygen. Most patients in shock will ultimately need intubation and ventilation because of increased difficulty in breathing, development of acute respiratory distress syndrome (ARDS) or for primary underlying disease.

      Fluids

      Use 20 ml/kg crystalloid as an initial bolus of fluids over 30 minutes whilst looking for haemodynamic improvement. Hypovolaemia is demonstrated when elevation of the legs transiently improves blood pressure. Recording of accurate fluid balance is essential.

      Fluid balance is difficult in septic shock, as there will be an inevitable tendency of fluid to leak into the lungs as a result of increased capillary permeability, myocardial dysfunction, renal impairment and a low plasma oncotic pressure. If there is no improvement in the blood pressure following the fluid bolus, critical care referral is required.

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