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Sudden Maternal Collapse

Sudden Maternal Collapse. Max Brinsmead PhD FRANZCOG July 2011. Introduction. Rare – but serious (life threatening) 14 – 600 per 100,000 births Once every 8 weeks in Port Moresby Once every 7 years in a unit delivering 1000/year Has a diverse range of causes

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Sudden Maternal Collapse

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  1. Sudden Maternal Collapse Max Brinsmead PhD FRANZCOG July 2011

  2. Introduction • Rare – but serious (life threatening) • 14 – 600 per 100,000 births • Once every 8 weeks in Port Moresby • Once every 7 years in a unit delivering 1000/year • Has a diverse range of causes • Fetal survival depends primarily on effective maternal resuscitation • Maternal survival depends on... • Aetiology • Facilities available • The training and expertise of those on the spot

  3. Differential Diagnosis • Shock syndromes • Vasovagal* • Haemorrhage (see below) • Anaphylaxis • Sepsis • Uterine inversion (3rd stage labour) • Cardiac • Arrhythmia • Acute heart failure • Cerebral • Post ictal (epilepsy)* • Eclampsia • Cerebrovascular accident • *Spontaneous recovery likely

  4. Differential Diagnosis - 2 • Drugs & Metabolism • Prescribed e.g. MgSO4 • Illicit drugs and toxins • Hypoglycaemia • Concealed Haemorrhage • Blood in the uterus (APH or PPH) • Or vagina/paravaginal space • Blood in the abdominal cavity • Ruptured liver, spleen or splenic artery • Post Caesarean • Blood in the chest • Aortic dissection • Pulmonary • Thromboembolism • Amniotic fluid embolism • Pneumothorax • Aspiration syndrome

  5. Treatable Causes of Collapse • 4 H’s and 4 T’s plus E • Hypovolaemia • Hypoxia • Hypo or Hyperkalaemia • Hypothermia • Thromboembolism • Toxins • Tension Pneumothorax • Tamponade (cardiac) • Eclampsia

  6. Obstetric Physiology impacts on Resuscitation • Aortocaval compression • Also known as supine hypotension • Progressively increases from 20w • May reduce cardiac output by up to 40% • Always use a 15 degree tilt position • Pregnant uterus compromises external cardiac massage (ECM) • By up to 90% • Also compromises chest ventilation • So hypoxaemia occurs more rapidly • Empty the uterus if mother is not responding to ECM within 4 – 5 minutes • Blood volume is increased • By up to 50% • But mother may tolerate blood volume loss up to 30% • Increased risk of stomach regurgitation and aspiration

  7. Emergency Management - 1 • Does the mother respond? • To verbal commands • To stimulation • Is she breathing? • Is she cyanosed • Is there a heartbeat? • Capillary filling • Clear the airway • Coma position or prepare for CPR • Always with left lateral tilt • Attempt diagnosis • But proceed with basic life support • Always check that the environment is safe

  8. Emergency Management - 2 • If the mother is not breathing (but a pulse is present)... • Provide oxygen • Assess over 10 sec • Artificially ventilate with a face mask/airway • Early intubation is desirable • If there is no carotid pulse... • Proceed immediately with ECM • 30 compressions, mid chest and vertical • With >4 cm chest movement • At 100 per minute • Then give 2 “breaths” (the 30:2 rhythm) • When intubated 100 ECM/min and 10 breaths/min • Get an ECG connected ASAP • Is it arrhythmia or asystole?

  9. Emergency Management - 3 • The treatment for ventricular fibrillation is... • External Defibrillation • Establish IV lines • Repeat if necessary • The treatment for asystole is... • IV adrenaline 1 mg • Correct reversible causes i.e. • Hypoxia • Hypvolaemia • Hypo or hyperkalaemia • Hypothermia • Repeat adrenaline every 5 min if necessary • Empty the uterus if not responding after 4 min

  10. Emergency Uterine Evacuation • The aim is to facilitate maternal resuscitation • Not to save a baby • To be done even if the baby is already dead • This is the responsibility of the most obstetrically competent person present • Who may be anyone • Should be done “on the spot” • Anaesthesia not required • Only a scalpel and two clamps for the cord required • Incise the abdomen and uterus in any way you like • Can facilitate cardiac compression • Through the diaphragm and against the sternum • If the mother responds to resuscitation then transfer to theatre for anaesthesia and haemostasis

  11. Vasovagal Syndrome • Now after all that excitement let us consider the most common cause of maternal collapse...

  12. Vasovagal syndrome • Typically occurs when mother gets up too soon after her delivery • Make sure that she is not shocked from blood loss • Check PR, BP, Fundus and PV loss • If the mother has a slow but good volume pulse • And she is pink and breathing... • Put her in the coma position and monitor recovery • If she is hypovolaemic get in 1 – 2 IV cannulae ASAP and commence resuscitation with fluids

  13. Acute uterine inversion • Typically occurs with cord traction and the uterus disappears from the abdomen... • Because it is inside out & in the vagina • Degree of shock is out of proportion to blood loss • Resuscitate with IV Fluids • Analgesia if necessary • Attempt manual replacement of the uterus followed by manual removal placenta • O’Sullivans hydrostatic replacement

  14. SEPSIS • May present without fever or a raised white cell count (WCC) • Beware the patient with low WCC • Can progress very rapidly • Principal obstetric organisms... • Streptococci A, B and D • Pneumococci • E Coli

  15. Septic Shock • Requires multidisciplinary care • Take blood culture before giving antibiotics • Antibiotics as per local agreed protocol or as advised by a microbiologist • Measure Serum lactate • For hypotension and/or lactate >4 mmol/L • Give IV crystalloids 20 ml/Kg • Then pressor agents to maintain BP >65 systolic • If not responding... • Insert CVP and intubate for IPPV • Maintain CVP 8 – 12 mm Hg • Consider steroids

  16. Acute Pulmonary Oedema (CCF) • Typically occurs in the known cardiac patient in the third stage of labour • But can occur in the profoundly anaemic patient who is given too much fluid (blood) too quickly • Nurse upright • Give oxygen • Give IV Frusemide • Consider rotating limb cuffs to reduce venous return

  17. Drug Reactions • The maximum dose of Lignocaine is 4mg/Kg • Or 6 mg/Kg for Lignocaine with adrenaline • That is 28 ml 1% Lignocaine in a 70 Kg woman • First sign of overdose is numbness tongue and mouth, slurred speech • Then convulsions and arrest • Treat with CPR, ventilation, sedation and 20% Intralipid (100 ml stat and 400 ml in 20 min) • Penicillin or other antibiotic anaphylaxis • Adrenaline may be life saving • The dose is 0.5 mg maximum and intramuscular • (IV adrenaline 1.0 mg is only for cardiac asystole) • Add IV antihistamine and hydrocortisone 200 mg

  18. Cardiac Arrhythmia • There may be a history of palpitations or PAT • Diagnose by ECG • Carotid massage may work • IV Atropine 0.6 mg sometimes • Best managed by consultation with a cardiologist

  19. Cerebrovascular Accident • Typically occurs with a hypertensive crisis • Maybe after ergometrine given to a preeclamptic patient • There may be localising CNS signs • Check pupils, DTJ’s and Plantars • Look for neck stiffness • A sign of meningeal irritation • May require perimortem Caesarean section • NB Hypertension and bradycardia are signs of cerebral coning

  20. Improving outcomes after maternal collapse • Be Ready • Trained staff • Have emergency equipment assembled & quarantined for emergency use • Have systems that assemble more staff • Practice drills • Be Forewarned • Needs an obstetric early warning system to identify... • The patient at risk • When she is on the slippery slope • Review and Revise • After each event • And each “near miss”

  21. Patients at risk • Increasing maternal age • Maternal mortality rises 5-fold between age 20 – 40 • Obesity • The modern epidemic • Social Class and Ethnicity • Aboriginal • Black • Pre existing Maternal Disease • One of the main reasons for antenatal care

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