SUDDEN MATERNAL COLLAPSE Max Brinsmead MB BS Ph

SUDDEN MATERNAL COLLAPSE Max Brinsmead MB BS Ph. D May 2015

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 Anaphylaxis Sepsis Uterine Cardiac (see below) inversion (3 rd stage labour) Arrhythmia Acute heart failure Cerebral Post ictal (epilepsy)* Eclampsia Cerebrovascular accident *Spontaneous recovery likely

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

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

OBSTETRIC PHYSIOLOGY IMPACTS ON RESUSCITATION Aortocaval compression Also known as supine hypotension Progressively increases from 20 w 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 Attempt diagnosis with left lateral tilt 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 Can the patient with low WCC progress very rapidly Principal obstetric organisms. . . Streptococci A, B and D Pneumococci E 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 4 mg/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 Look for neck stiffness A pupils, DTJ’s and Plantars 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 Obesity The mortality rises 5 -fold between age 20 – 40 modern epidemic Social Class and Ethnicity Aboriginal Black Pre existing Maternal Disease One of the main reasons for antenatal care

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