Читать книгу Managing Medical and Obstetric Emergencies and Trauma - Группа авторов - Страница 136

A study of severe maternal sepsis in the UK (2011–2012) identified genital tract infection (31%) and the organisim Escherichia coli (21%) to be the most common causes, followed by group A Streptococcus, group B Streptococcus, other streptococci and Staphylococcus. Risk factors for severe sepsis were if the woman was black or of other ethnic minority, primiparous, had a pre‐existing medical problem, had a febrile illness or were taking antibiotics in the 2 weeks preceding presentation, operative vaginal delivery or caesarean. Median time between delivery and sepsis was 3 days. Multiple pregnancy and group A Streptococcus were associated with progression to septic shock. In the women with group A streptococcal infection the progression of sepsis was often rapid. For each maternal sepsis death, 50 women had life‐threatening morbidity from sepsis.

A study from Ireland (2005–2012) looking at maternal bacteraemia again found E. coli to be the predominant pathogen followed by group B Streptococcus. The source of infection was the genital tract in 61% of cases and the urinary tract in 25%; 17% of sepsis episodes occurred antenatally, 36% intrapartum and 47% postpartum. Sepsis was associated with preterm delivery and a high perinatal mortality rate. The most virulent organisms were group A streptococci associated with postpartum sepsis at term and E. coli sepsis preterm.

Group A Streptococcus is a common skin or throat commensal, carried asymptomatically by up to 30% of the population. It is easily spread and is responsible for streptococcal sore throat, a very common childhood condition. Worldwide, however, group A Streptococcus is still the most common cause of postpartum maternal death and can kill pregnant and recently pregnant women with devastating speed. The initial presentation can be vague and non‐specific, thus delaying treatment. Primary symptoms include myalgia, fever, mild confusion, dizziness and abdominal pain.

Transmission in pregnant women is thought to be either through the blood stream with the throat as a portal of entry, or via the perineal route with translocation from colonisation in the vagina, even in the presence of an intact membrane, as bacteria can cross this apparent barrier. Translocation from the vagina may occur from nosocomial exposure at birth or via a caesarean 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.