A 22-year-old female recent migrant presented at 31 weeks gestation (gravida 2 para 0) to the obstetric unit. She was complaining of diminished fetal movements. She had been well up to that morning but was complaining of increasing abdominal discomfort, and was becoming distressed. Examination showed she was not in labour but her abdomen was tender. Cardiotocograph showed a fetal heart rate of 130 bpm and poor variability. Two hours post admission, she was re-examined by obstetricians. Abdominal ultrasound failed to identify a fetal heartbeat. A diagnosis was made of intrauterine death, and initially a placental abruption was suspected. Ultrasound showed no thrombus and an intact placenta and so this was excluded. She was diagnosed as having a late miscarriage and the pain was assumed to be due to ongoing miscarriage. She was transferred to labour ward and a morphine PCA commenced for analgesia.
She received a dose of IV antibiotics on arrival to labour ward. At this point it was noted her oxygen saturations were falling and she was becoming increasingly drowsy, and this was felt to be due to sensitivity to the PCA. She was reviewed by obstetric anaesthetists who performed an arterial blood gas, which showed a marked metabolic acidosis with serum lactate of 6.3, and a diagnosis of severe sepsis was made. There was concern that the retained fetal material was the focus, and she was taken to theatre for emergency caesarian section. She was then transferred to ITU. By this stage she had developed established disseminated intravascular coagulation and pulmonary oedema. She developed rapidly worsening multiorgan failure and shock refractory to large doses of noradrenaline and died that evening, 8 hours post admission. Cause of death was found to be group A streptococcal sepsis.
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