SUDDEN MATERNAL

COLLAPSE

Max Brinsmead MB BS PhD

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

 Maypresent 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
 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

 GiveIV crystalloids 20 ml/Kg
 Then pressor agents to maintain BP >65 systolic

 If not responding...
 InsertCVP 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

 Aftereach 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
Please leave a note on the Welcome
Page of this website

ANY QUESTIONS OR
COMMENTS?