Maternal collapse andmaternal cardiac arrest

Maternal collapse

• What is it?

• Causes

• Early recognition and treatment

• Maternal cardiac arrest

AIRWAY o Obstructed or noisy

BREATHING o Respiratory rate < 5 or > 35 breaths per minute

CIRCULATIONo Pulse rate < 40 or > 140 bpm

o Systolic BP < 80 mmHg or > 180 mmHg

NEUROLOGYo Sudden decrease in level of consciousness

o Unresponsive/only responsive to painful stimuli

APPEARANCE o Woman who ‘looks’ collapsed

What is maternal collapse?

Maternal Cardiac Arrest –MBRRACE 2009-2012

• Maternal death rate UK 2009-2012 : 10 per 100,000 maternities

• Significant decrease in death rates over time

• Primarily due to significant halving in direct maternal deaths (2003-5 to now)

• Despite women with higher care needs (advanced maternal age, obesity, greater proportion of women born outside UK)

MBRRACE – UK 2010-2012Causes – direct

Direct causes of maternal deaths (78 deaths)

Rates per 100 000 maternities

Thrombosis and thromboembolism 1.08

Genital tract sepsis 0.50

Haemorrhage 0.46

Pre-eclampsia & eclampsia 0.38

Early pregnancy deaths 0.33

Amniotic fluid embolism 0.33

Anaesthesia 0.17

Total 3.25

MBRRACE 2010–2012Causes – indirect

Indirect causes of maternal deaths (Deaths 165)

Rates per 100 000 maternities

Other Indirect Causes (sepsis) 2.54

Cardiac disease 2.25

Indirect Neurological conditions 1.29

Psychiatric 0.67

Indirect malignancies 0.13

Total 6.87

Key MBRRACE Messages

• 2/3 of mothers died from medical and mental health problems in pregnancy and only 1/3 from direct causes such as thromboembolism

• ¾ of women who died had medical or mental health problems before they became pregnant

• Women with pre-existing medical and mental health problems need pre-pregnancy advice and joint specialist and maternity care.

Key MBRRACE Messages

• Think Sepsis

– ¼ of women who died had sepsis

– Women with sepsis need

1. Early diagnosis

2. Rapid antibiotics

3. Review by senior doctors and midwives

• Prevent Influenza

– 1 in 11 of deaths were due to influenza

– More than half these deaths were preventable by the flu jab!

Recognition

• Heart rate

• BP

• Respiratory rate

• Temperature

• Simple observation of the woman

• Enables

recognition of

unwell patients

• Provides prompts

for medical review

Early warning chart

Causes of collapse

Action

Structured plan:

1. Initial supportive treatment: ABC

2. Do a ‘primary obstetric survey’

3. Decide ongoing treatment

4. Do a ‘secondary obstetric survey’

5. Decide further investigation and treatment

Initial supportive treatment: ABC

GET HELP

• Airway

o Open airway

• Breathing

o Check for breathing

oBLS protocol if no signs of life

o High-flow oxygen

o Check respiratory rate

o Pulse oximetry

• Circulationo Assess pulse, BP, capillary refill

oBLS protocol if no signs of life

o IV access

o Bloods as appropriate including cross-match

o Consider fluid resuscitation

• Consider patient’s positiono Left lateral

o Sitting if short of breath

o Recovery position

Initial supportive treatment ABC

Primary obstetric survey

Secondary obstetric survey

Decide ongoing treatment

• Fluid resuscitation

– Priority or contraindicated?

• Expedite birth of baby

• Antibiotics

• Further supportive treatment

• Laparotomy

Don’t panic!

Maternal cardiac arrest

• Cardiac arrest during pregnancy carries a very

high maternal and fetal mortality rate

• Very uncommon:

– 1 in 30 000 ongoing pregnancies

• Most staff involved will have no, or very little, experience of a maternal arrest

• Very stressful situation

Resuscitating a pregnant woman is difficult

• Gravid uterus

– Aortocaval compression

– Ventilation difficult – pressure on diaphragm

• Fetus/placenta

– ‘Steals’ oxygen and circulation from mother

• More likely to aspirate

• More difficult to intubate

Extra actions• Displace uterus to relieve

pressure on aorta and vena cava and improve venous return to the heart:

– Keep mother supine and apply left manual uterine displacement

– or 30-degree tilt if on theatre table

• Perimortem caesarean section/assisted vaginal birth

Basic life support

Manual displacement of uterus (left tilt only if on firm tilting

surface)

2010 guidelines

During CPR

• Ensure high-quality CPR: rate, depth, recoil

• Plan actions before interrupting CPR

• Give oxygen

• Consider advanced airway and capnography

• Continuous chest compressions when advanced

airway in place

• Vascular access (IV, intraosseous – not tracheal)

• Give adrenaline every 3–5 minutes

• Correct reversible causes : 4Hs and 4Ts

Attach defibrillator

NON-SHOCKABLE

Adrenaline every 3–5 mins

Perimortem birth: startat 4 mins

CPR 30:2 with mother supine and manual LEFT uterine

displacement Laerdel mask

+/- Ambu bag (2 hands)Oxygen

CPR x 2 mins

Reassess rhythm

Think of 4Hs and 4Ts

Post-resuscitation care

Non-shockable rhythms

Pulseless electrical

activity

Asystole

4 Hs

HypoxiaAsthmaPE

Hypovolaemia Massive haemorrhage

Hypo/hyper/metabolic

Hypoglycaemia

Hyperkalaemia

Hypermagnesimaemia

Hypocalaemia (overdose of nifedipine)

Hypothermia

4 Ts

ThrombosisPEMyocardial infarction

Tamponade Usually following trauma

Toxins

Inadvertent IV local anaesthetic(‘epidural in the arm’)

Opioid overdose

Magnesium toxicity

IV insulin

Anaphylaxis/drug reaction

Tension pneumothorax Following insertion of CVP line

Attach defibrillator

SHOCKABLE: VF or VT

Adrenaline 1 mg after 2nd shock and then every other cycle (every 4 mins)

Perimortembirth: startat 4 mins

CPR 30:2 with mother supine and manual LEFT uterine displacement

Laerdel mask +/- Ambu bag (2 hands)

Oxygen

CPR x 2 mins

Reassess rhythm

Amiodarone 300 mg after 3rd shock

Defibrillate(200 J biphasphic, 360 J monophasic)

Shockable rhythms

Pulseless ventricular tachycardia

Ventricular fibrillation

Advanced

life

support

Cardiac arrest 1 mg adrenaline (epinephrine)every 3minutes

VF/VT 300 mg amiodarone

Opiate overdose 0.4–0.8 mg naloxone

Magnesium toxicity 1 g calcium gluconate

Local anaesthetic toxicity 1.5 ml/kg 20% Intralipid

Drug treatment

Where is it kept? How does it work?

Know your own equipment

Maternal cardiac arrest:top five tips

1. If there are no signs of life, call for help and immediately start basic life support

2. Manual left uterine displacement (30-degree left tilt if on a firm tilting surface)

3. State maternal cardiac arrest

4. Don’t stop basic life support when the anaesthetist arrives

5. Deliver baby within 5 minutes to save the mother

Perimortem Caesarean

• From MBRRACE 30% of women who died (321) were still pregnant at the time of death, 1/3 of these women were less than 20 wks gestation.

• 46 perimortem caesareans were performed

• 50% were stillborn and 20% died in the neonatal period.

• 75% of babies born at less than 37 weeks died.

Cardiac Arrest during hospitalization for delivery in the United States 1998-2011

• 8.5 per 100,000 hospitalizations for delivery

• 1 in 12,000

• Demographic factors (35yrs plus, black, Medicaid)

• Maternal medical conditions (pulmonary HTN, malignancy, CVS disease, liver disease, SLE

• Obstetric conditions (stillbirth, caesarean delivery, severe preeclampsia/eclampsia and placenta previa

Cardiac Arrest during hospitalization for delivery in the United States 1998-2011

Etiology of Cardiac Arrest % of total cardiac arrests

Survival to discharge %

Postpartum Haemorrhage 27.9 55.1

Antepartum Haemorrhage 16.8 53.2

Heart Failure 13.3 71.1

Amniotic Fluid embolism 13.3 52.5

Sepsis 11.2 46.9

Anaesthesia complication 7.8 81.9

Aspiration pneumonitis 7.1 82.9

Venous thromboembolism 7.1 41.5

Eclampsia 6.1 76.5

Puerperal Cerebrovasc disease 4.4 40

Trauma 2.6 23.3

Pulmonary oedema 2.4 70.9

AMI 3.1 56.3

Magnesium toxicity 1.4 85.9

Status Asthmaticus 1.1 53.7

Anaphylaxis 0.3 100

Aortic dissection/rupture 0.3 0

Cardiac Arrest during hospitalization for delivery in the United States 1998-2011

Cause Cause-specific cardiac Arrest Frequency per 1000 women with each condition

Amniotic fluid embolism 252.7

AMI 89.8

Venous thromboembolism 43.9

Aortic dissection/rupture 31

Anaesthesia complication 29.5

Aspiration pneumonitis 20.3

Heart Failure 15.6

Puerperal cerebrovascular disorder 13.6

Status asthmaticus 12.6

Pulmonary oedema 11.2

Anaphylaxis 10.8

Eclampsia 6.2

Magnesium toxicity 5.2

Trauma 3.9

Sepsis 2.1

Antepartum haemorrhage 0.9

Postpartum haemorrhage 0.8