New sets of guidelines have are being given to hospitals on the management of pregnant women with suspected sepsis and second trimester miscarriage.

An update covering the area of sepsis has been added to previous early warning guidelines on maternity care and a new set of guidelines on miscarriage in second trimester (12-24 weeks) pregnancy are now being circulated, irishhealth.com has learned.

The new guidance, drawn up by the Institute of Obstetricians and Gynaecologists and the HSE, covers some of the care failures identified in investigations into the death of Savita Halappanavar at Galway University Hospital in 2012.

Savita died a week after being admitted Galway University Hospital in November 2012 when suffering a miscarriage in the 17th week of pregnancy. Her death was caused by a serious infection which led to severe sepsis, leading to eventual organ failure and cardiac arrest.

The subsequent inquiries pointed to crucial delays in recognising and dealing with Ms Halappanavar's deteriorating condition.

The Irish Maternity Early Warning System, published last year, has now been updated to include a 'consider maternal sepsis' section, as part of the early warning signs.

Under this section, hospital staff are advised that if two or more clinical criteria indicative of sepsis are believed to be present, appropriate intervention, including IV antibiotics and oxygen, should be initiated within one hour.

The new guidelines on second trimester miscarriage which is rare compared to first trimester miscarriage, state that in cases of second trimester miscarriage where there is evidence of maternal compromise such as sepsis, immediate steps towards delivery may be required.

A full clinical assessment is recommended as part of the evaluation of women at risk of miscarriage or following the diagnosis of miscarriage.

The guidelines state that the recently-developed maternity early warning system should be used for all pregnant women admitted to hospital during the second trimester and that laboratory investigations may be required to assess maternal well-being and to rule out any risk factor that may have contributed to the miscarriage.

The miscarriage guidelines state that women with signs of chorioamnionitis (infection of the fetal membranes due to a bacterial infection) should be commenced on broad spectrum intravenous antibiotics without delay.

In Savita's case, chorioamnionitis was linked to her having spontaneous rupture of the membranes the day after she was admitted.

The guidelines also say in the second trimester of pregnancy, delivery should be considered for women with chorioamnionitis irrespective of fetal viability. They state that if the fetal heart is present, it may still be necessary to induce delivery irrespective of gestational age, particularly if there is evidence of infection developing.

In Savita's case, chorioamnionitis was linked to her having spontaneous rupture of the membranes the day after she was admitted.

The guidelines state that where the membranes have ruptured, the woman should be closely monitored clinically for any signs of infection, and, if not already commenced, the maternity early warning score observation charts should be used.

The HSE's investigation into Savita Halappanavar's death said inadequate assessment and monitoring of her deteriorating condition was a key causal factor in her death.

It said Savita's deteriorating condition was due to infection linked to a failure to devise and follow a plan of care that was cognisant of the fact that her inevitable miscarriage was caused by infection and the the risk of sepsis increased following spontaneous rupture of the membranes, which was linked to chorioamnionitis, the day after she was admitted.

Savita later miscarried spontaneously, a diagnosis of sepsis secondary to chorioamnionitis was eventually made and she was admitted to the high dependency unit. A key controversy in the case was the hospital's reported refusal to accede to Ms Halappanavar's request for a termination from early on in her hospital stay.

The HSE review said the risk of infection and sepsis increased with time following admission and especially following the spontaneous rupture of the membranes.

The HSE review also said the hospital failed to adhere to clinical guidelines on the prompt and effective management of sepsis, severe sepsis and septic shock from when it was first diagnosed in Ms Halappanavar.

Another report on Savita's death, by the safety body HIQA, said a more comprehensive plan of care should have been developed from early in Savita's hospital stay.

It said there was a general lack of provision of basic, fundamental care, a failure to recognise that Savita was at risk of clinical deterioration. and a failure to act or escalate concerns to an appropriately qualified clinician when she was showing signs of clinical deterioration. It said there was insufficient monitoring of Savita's condition, and insufficient identification and management of maternal sepsis.

The inquiries into Savita's death, which encompassed two independent reviews and a coroner's inquest, all called for improvements in clinical procedures and for more specific care guidelines in maternity units.