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

Fetal survival depends primarily on effective maternal resuscitation

Maternal survival depends on... Aetiology Facilities available The training and expertise of those on the spot

DIFFERENTIAL DIAGNOSIS Shock syndromes

Vasovagal*Haemorrhage (see below)AnaphylaxisSepsisUterine inversion (3rd stage labour)

CardiacArrhythmiaAcute heart failure

CerebralPost ictal (epilepsy)*EclampsiaCerebrovascular accident

*Spontaneous recovery likely

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

TREATABLE CAUSES OF COLLAPSE4 H’s and 4 T’s plus E

HypovolaemiaHypoxiaHypo or HyperkalaemiaHypothermia

ThromboembolismToxinsTension PneumothoraxTamponade (cardiac)

Eclampsia

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

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

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?

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

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

VASOVAGAL SYNDROME

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

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

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

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 DPneumococciE Coli

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

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

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

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

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

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”

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