Maternal Collapse in

labour ward

Dr . J. Edward Johnson. M.D., D.C.H.Asst. Professor , Dept. of Anaesthesiology,KGMCH.

DISCUSSION

CAUSES OF MATERNAL CAUSES OF MATERNAL COLLAPSECOLLAPSE

• Haemorrhage (APH, PPH) Haemorrhage (APH, PPH) • Pul.EmbolismPul.Embolism• Amniotic Fluid Embolism Amniotic Fluid Embolism • Pre-eclampsia/eclampsiaPre-eclampsia/eclampsia• Cardiac (Valvular HD) Cardiac (Valvular HD) • SyncopeSyncope• SepsisSepsis• RespiratoryRespiratory

Causes of CollapseCauses of Collapse• 4 H’s:4 H’s:

HypoxiaHypoxia Hypovolaemia (bleeding/block)Hypovolaemia (bleeding/block) HypothermiaHypothermia Hypo/hyperkalaemia (metabolic)Hypo/hyperkalaemia (metabolic)

• 4 T’s:4 T’s: Thromboembolic (PE or AFE)Thromboembolic (PE or AFE) Toxic/therapeutic (local anaesthetic)Toxic/therapeutic (local anaesthetic) Tension pneumothoraxTension pneumothorax TamponnadeTamponnade

• Eclampsia Eclampsia

Leading causes of Direct DeathsLeading causes of Direct Deaths (Mortality rates/Million Maternities)(Mortality rates/Million Maternities)

““Obstetrics is Obstetrics is Bloody Business”Bloody Business”**

““Obstetrics is Obstetrics is Bloody Business”Bloody Business”**

PostpartumPostpartum

HemorrhageHemorrhage

*Cunningham, et. al: Williams Obstetrics, 21st ed., 2001

DIAGNOSISDIAGNOSIS

OF OF

ETIOLOGYETIOLOGY

Postpartum Postpartum

HemorrhageHemorrhage

Diagnosis ofDiagnosis of Causes Causes Postpartum HemorrhagePostpartum Hemorrhage

Retained placenta Retained placenta Placenta AccretaPlacenta Accreta Uterine atonyUterine atony Vaginal and cervical lacerationVaginal and cervical laceration DIC, AFE DIC, AFE Factor disorderFactor disorder Uterine rupture / Uterine inversionUterine rupture / Uterine inversion

MANAGEMENTMANAGEMENT

RESUSITATION RESUSITATION

OF OF Haemorrhagic Shock &Haemorrhagic Shock &

Cardiac Arrest -(CPR)Cardiac Arrest -(CPR)

RESUSITATIONRESUSITATION

Haemorrhagic Haemorrhagic ShockShock

Classification of Classification of HaemorrhageHaemorrhage

Class Acute Blood Loss

% Lost

1 900cc 15

2 1200-1500cc 20-25

3 1800-2100cc 30-35

4 2400cc 40

Baker R, Obstet Gynecol Annu, 1997

ASSESSMENT OF BLOOD LOSS ASSESSMENT OF BLOOD LOSS AFTER DELIVERYAFTER DELIVERY

• DifficultDifficult• Mostly Visual estimation (So, Mostly Visual estimation (So,

Subjective & Inaccurate)Subjective & Inaccurate)• Underestimation is likelyUnderestimation is likely• Clinical picture -MisleadingClinical picture -Misleading• Our Mothers-Malnourished, Anaemic, Our Mothers-Malnourished, Anaemic,

Small built, Less blood volumeSmall built, Less blood volume

SYMPTOMS & SIGNSSYMPTOMS & SIGNS

Blood loss Blood loss (% B Vol)(% B Vol)

Systolic BPSystolic BP( mm of Hg)( mm of Hg)

Signs & SymptomsSigns & Symptoms

10-1510-15 NormalNormal postural hypotensionpostural hypotension

15-30 15-30 slight fallslight fall PR, thirst, weaknessPR, thirst, weakness

30-4030-40 60-8060-80 pallor,oliguria, pallor,oliguria, confusionconfusion

40+40+ 40-6040-60 anuria, air hunger, anuria, air hunger, coma, coma, deathdeath

Recognition is late - >30% B Vol loss

Modified Early Warning Scoring System Modified Early Warning Scoring System (MEWS)(MEWS)

MEWS calculated from 5 physiological MEWS calculated from 5 physiological variablesvariables

• Mental responseMental response• Pulse ratePulse rate• Systolic BPSystolic BP• Respiratory rateRespiratory rate• TemperatureTemperature

• Respiratory rate of ≥25 or <10 breaths per minute. • Arterial systolic blood pressure of <90mmHg. • Heart rate of ≥110 or <55 beats per minute. • Not fully alert and orientated. • Oxygen saturation of <90 per cent.• Urine output over the last four hours of <100ml. • Respiratory rate ≥35 breaths per minute or a heart rate ≥140 beats per minute.

Modified Early Warning Scoring System (MEWS) The senior nurse would call the doctor for

three or more of the following criteria:

Vigilance is great, but you haveVigilance is great, but you have

to remember that studies showto remember that studies show

the half-life of vigilance isthe half-life of vigilance is

about 15 minutes.about 15 minutes.

Author unknownAuthor unknown

DO NOT UNDERESTIMATE BLOOD DO NOT UNDERESTIMATE BLOOD LOSSLOSS

SystemSystem Early ShockEarly Shock Late ShockLate Shock

CNSCNS Altered mental statesAltered mental states ObtundedObtunded

CardiacCardiac TachycardiaTachycardia Cardiac failureCardiac failure

Orthostatic hypotensionOrthostatic hypotension ArrhythmiasArrhythmias

HypotensionHypotension

RenalRenal OliguriaOliguria AnuriaAnuria

RespiratoryRespiratory TachypneaTachypnea TachypneaTachypnea

Respiratory failureRespiratory failure

HepaticHepatic No changeNo change Liver failureLiver failure

GastrointestinGastrointestinalal

No changeNo change Mucosal bleedingMucosal bleeding

HematologicalHematological AnemiaAnemia CoagulopathyCoagulopathy

MetabolicMetabolic NoneNone AcidosisAcidosis

HypocalcemiaHypocalcemia

HypomagnesemiaHypomagnesemia

Clinical Features of Shock

Goals of TherapyGoals of Therapy

• Maintain the following:Maintain the following:

Systolic pressure >90mm HgSystolic pressure >90mm Hg

Urine output >0.5 mL/kg/hrUrine output >0.5 mL/kg/hr

Normal mental statusNormal mental status

• Eliminate the source of hemorrhageEliminate the source of hemorrhage

• Avoid overzealous volume replacement Avoid overzealous volume replacement that may contribute to pulmonary edemathat may contribute to pulmonary edema

Management of Obstetrical Hemorrhage Oxygen by mask 10 liter/min.

– to keep O2 saturation > 94% 1st IV Line: Ringer Lactate with Pitocin 20-40 units

at 1000 ml/ 30 minutes 2nd IV Line: 18 G IV: warm RL - administer wide

open Sample blood; CBC, fibrinogen, PT/PTT, platelets,

T&C and order 4u PRBCs Monitor I&O, urinary Foley catheter Get help

-Senior Obstetrician, Anesthesiologist, Interventional Radiology, Intensivist, Haemotologist etc.

Management of Obstetrical Hemorrhage

LR or NS replaces blood loss at 3:1 Volume expander 1:1 (albumin, hetastarch,

dextran) Anticipate Disseminated Intravascular

Coagulapathy (DIC) Verify complete removal of placenta, may need

ultrasound Inspect for bleeding

-episiotomy, laceration, hematomas, inversion, rupture Emperic transfusion

-2 u PRBC; FFP 1-2 u/4-5 u PRBC -Cryo 10 u, -Uncrossed (O neg.) PRBC – For emergency

Warm all blood products and I.V.infusions -prevent hypothermia, coagulopathy, arrhythmias

Platelets

Random Donor Apheresis

Pooled 4-8 units, ABO+ Rh compatible

Expire 4 h after pooling

Single donor

Expire 4 h after released

3-5 day survival in vivo(in DIC)

(contains all coag factors) PT, PTT > 50% increase or INR > 1.5

Warm

Spin

Cryoprecipitate(VIII, XIII, Fibrinogen, VW)

Fibrinogen 5 mgldL

FFP

Blood Component Blood Component TherapyTherapy

Fresh Frozen Plasma Fresh Frozen Plasma – INR > 1.5 - 2u FFPINR > 1.5 - 2u FFP– INR 2-2.5 - 4u FFPINR 2-2.5 - 4u FFP– INR > 2.5 - 6u FFPINR > 2.5 - 6u FFP

Cryoprecipitate ( 1u/ 10Kg ) Cryoprecipitate ( 1u/ 10Kg ) – Fibrinogen < 100 mg/dl – 10u cryo Fibrinogen < 100 mg/dl – 10u cryo – Fibrinogen < 50 mg/dl – 20u cryoFibrinogen < 50 mg/dl – 20u cryo

Platelets Platelets – Platelet. count. < 100,000 – 1u plateletpheresisPlatelet. count. < 100,000 – 1u plateletpheresis– Platelet. count. < 50,000 – 2u plateletpheresisPlatelet. count. < 50,000 – 2u plateletpheresis

Blood Component Blood Component TherapyTherapy

Blood Comp Contents Volume(ml)

Effect

Packed RBCs RBC, Plasma 300 Inc. Hgb by 1 g/dl

Platelets Platelets, Plasma 250 Inc. count by 25,000

FFPFibrinogen, antithrombin III,

clotting factors, plasma250

Inc. Fibrinogen 10 mg/dl

Cryoprecipitate

Fibrinogen, VonWillebrand F, Factor V111, X111,

Fibronectin 40

Inc. Fibrinogen 10 mg/dl

Target ValuesTarget Values

• Maintain systolic BP>90 mmHgMaintain systolic BP>90 mmHg• Maintain urine output > 0.5 ml per kg Maintain urine output > 0.5 ml per kg

per hourper hour• Hct > 21%Hct > 21%• Platelets > 50,000/ulPlatelets > 50,000/ul• Fibrinogen > 100 mg/dlFibrinogen > 100 mg/dl• PT/PTT < 1.5 times controlPT/PTT < 1.5 times control• Repeat labs as needed – every 30 Repeat labs as needed – every 30

minutesminutes

Management of Major Obstetric Management of Major Obstetric Haemorrhage Haemorrhage

Recombinant factor VIIaRecombinant factor VIIa ((rFVIIa)rFVIIa)

rFVIIaXa

X

Va

Thrombin

Prothrombin

Fibrinogen

Fibrin

1. rFVIIa works at the site of vascular injury, where tissue factor (TF) is expressed and activated platelets aggregate.

In pharmacological doses rFVIIa binds directly to the activated platelet surface.

Here it enhances localized thrombin generation and the formation of a stable fibrin-based clot.

The fibrin clots formed in the presence of of a high thrombin concentration have a different architecture that is stronger and more resistant to degradation by fibrinolytic enzymes.

rFVIIa

Recombinant factor VIIaRecombinant factor VIIa • It is not licensed for use in obstetric haemorrhage and there have been no randomised contolled trials for its use in this situation

• The dose is approximately 90μg/kg.

• Its efficiacy is dependent on -normothermia,

-non-acidotic milieu-adequate levels of fibrinogen (> 1.0-1.5gr)

-platelets (> 50,000)

• A relatively early itervention to control PPH appears to be crucial for the success of rVIIa

Management of Major Obstetric Management of Major Obstetric Haemorrhage - Haemorrhage - rFVIIa rFVIIa

1. rFVIIa will not replace ligatures in controlling bleeding from damaged or torn vessels.

2. To be effective there must be adequate circulation delivering platelets and fibrinogen to the site of bleeding.

3. You should make your best efforts to correct acidosis and hypothermia.

TREATTREAT

THE ETIOLOGY ETIOLOGY

OF PPHOF PPH

TEAM - TEAM - Obstetrician, Obstetrician, - Anesthesiologist, - Anesthesiologist, - Haematologist and - Haematologist and - Blood Bank - Blood Bank

Correction of hypovolaemiaCorrection of hypovolaemia Ascertain origin of bleedingAscertain origin of bleeding Ensure uterine contractionEnsure uterine contraction Surgical managementSurgical management Management of special situatioManagement of special situationn

MANAGEMENT OF PPH

Massive Obstetric Massive Obstetric Haemorrhage TreatmentHaemorrhage Treatment

MedicalMedical SurgicalSurgical Blood Component TherapyBlood Component Therapy Post Treatment CarePost Treatment Care

Massive Obstetric HaemorrhageMassive Obstetric Haemorrhage MedicalMedical

Volume Replacement (Crystalloid,Colloid)Volume Replacement (Crystalloid,Colloid)

Blood (O –tive, Group Specific, X Matched)Blood (O –tive, Group Specific, X Matched)

Coagulation Support (FFP, Cryoprecipitate, Platelets)Coagulation Support (FFP, Cryoprecipitate, Platelets)

Inotropic SupportInotropic Support Uterine Massage / CompressionUterine Massage / Compression Uterotonic Agents (Syntocinon ,Ergotamine, Carboprost Uterotonic Agents (Syntocinon ,Ergotamine, Carboprost Misoprostol )Misoprostol )

Temperature Active WarmingTemperature Active Warming

Massive Obstetric HaemorrhageMassive Obstetric Haemorrhage

SurgicalSurgical• EUA RepairEUA Repair

• Uterine Tamponade (78%)Uterine Tamponade (78%)

• B-Lynch Suture (81%)B-Lynch Suture (81%)

• Arterial LigationArterial Ligation

• Radiological Arterial EmbolisationRadiological Arterial Embolisation

• Hysterectomy ( 12%)Hysterectomy ( 12%)

Treatment of PPH: Hysterectomy

A conservative option should be quickly efficacious

The addition of successive conservative approaches is hazardous

- Risk of delaying radical treatment

Placenta accreta is a frequent cause of failure of conservative Treatments

Hysterectomy may be a life-saving procedure in case of

- Failure of conservative approach

- Uterine rupture

- Placenta accreta

Early Decision

Selective Angiographic Selective Angiographic Embolization (SAE)Embolization (SAE)

Strategically difficult in many centers

Pulmonary Embolism

Pulmonary Embolism

Pulmonary embolism, along with amniotic fluid embolism, accounts for the leading cause of maternal mortality in the United States

(Koonin, et al; MMWR)

DVT: Key FactsDVT: Key Facts

• • 40% of asymptomatic patients with DVT have 40% of asymptomatic patients with DVT have radiographically documented pulmonary radiographically documented pulmonary embolismembolism

• • DVT of pelvic venous system is often an DVT of pelvic venous system is often an asymptomatic condition until clinical pulmonary asymptomatic condition until clinical pulmonary embolism developsembolism develops

• • Untreated pulmonary embolism mortality is up to Untreated pulmonary embolism mortality is up to 30%. Treated mortality is 3% 30%. Treated mortality is 3%

(Moser et al, 1994; Cunningham et al, 1997; Toglia (Moser et al, 1994; Cunningham et al, 1997; Toglia & & Weg, 1996)Weg, 1996)

The Wells scoreThe Wells score clinically suspected clinically suspected DVT - 3.0 points - 3.0 points alternative diagnosis is less likely than PE - 3.0 points alternative diagnosis is less likely than PE - 3.0 points Tachycardia - 1.5 points - 1.5 points immobilization/surgery in previous four weeks - 1.5 points immobilization/surgery in previous four weeks - 1.5 points history of history of DVT or PE - 1.5 points or PE - 1.5 points hemoptysis - 1.0 points - 1.0 points malignancy (treatment for within 6 months, palliative) - 1.0 pointsmalignancy (treatment for within 6 months, palliative) - 1.0 points

Traditional interpretationTraditional interpretation Score >6.0 - High Score >6.0 - High Score 2.0 to 6.0 - Moderate Score 2.0 to 6.0 - Moderate Score <2.0 - Low Score <2.0 - Low

Alternate interpretationAlternate interpretation Score > 4 - PE likely. Consider diagnostic imaging. Score > 4 - PE likely. Consider diagnostic imaging. Score 4 or less - PE unlikely. Consider Score 4 or less - PE unlikely. Consider D-dimer to rule out PE. to rule out PE.

Diagnosis of Pulmonary Diagnosis of Pulmonary EmbolismEmbolism

• • D-dimerD-dimer ( (0-300 ng/0-300 ng/ml as normal) as normal)

• • Chest X-rayChest X-ray

• • ECGECG

• • Arterial blood gasArterial blood gas

• • Ventilation-perfusion scintographyVentilation-perfusion scintography

• • AngiographyAngiography

• • Thoracic enhanced CT (64 slices MDCT)Thoracic enhanced CT (64 slices MDCT)

• • Extremity DopplerExtremity Doppler

Chest X-Ray Findings inChest X-Ray Findings inPE:PE:

• • Hampton’s HumpHampton’s Hump::

pleural based density at CPJpleural based density at CPJ

• • Westermark’s SignWestermark’s Sign::

peripheral aligemia with peripheral aligemia with

proximal vessel dilatationproximal vessel dilatation

• • Most common finding isMost common finding is

normal X-Ray (30%)!normal X-Ray (30%)!

ECG Changes in PE:ECG Changes in PE:

• • p-pulmonale, RBBB, RADp-pulmonale, RBBB, RAD

•• S1 Q3 T3 S1 Q3 T3 classic signs classic signs

-large S wave in lead I-large S wave in lead I

-a large Q wave in lead III and -a large Q wave in lead III and

-an inverted T wave in lead III -an inverted T wave in lead III

• • New Onset A-FibNew Onset A-Fib

• • Most common finding is normal (or sinus tach) ECGMost common finding is normal (or sinus tach) ECG

Radiographic Diagnosis Radiographic Diagnosis ofof

Pulmonary Embolism Pulmonary Embolism DuringDuring

Pregnancy:Pregnancy:• • Ventilation/Perfusion (V/Q) Ventilation/Perfusion (V/Q)

ScanningScanning

• • Pulmonary AngiographyPulmonary Angiography

• • Spiral/Helical CTSpiral/Helical CT

Treatment- PulmonaryTreatment- PulmonaryEmbolism in PregnancyEmbolism in Pregnancy

• • Anticoagulation is mainstay ofAnticoagulation is mainstay of

pharmacotherapypharmacotherapy

• • Supportive care should not be Supportive care should not be forgotten during the rush to forgotten during the rush to diagnose and treatdiagnose and treat

Venous Air EmbolismVenous Air Embolism

During the repair of hysterotomy woundExteriorization of the uterus and traction on

the wound edges increases the riskTrendelenburg position to be avoidedAbdominal and Uterine incision always below

heart CVP, High Uterine wound Air Embolism

Amniotic Fluid Amniotic Fluid EmbolismEmbolism

““Anaphylactoid syndrome of Anaphylactoid syndrome of pregnancy" pregnancy"

Amniotic Fluid EmbolismAmniotic Fluid Embolism

AFE is an - unpredictableAFE is an - unpredictable

- unpreventable and- unpreventable and

-an untreatable -an untreatable

(for the most part)(for the most part)

obstetric emergencyobstetric emergency

Amniotic Fluid EmbolismAmniotic Fluid Embolism

• • Frequency- 1/15,000 - 1/20,000Frequency- 1/15,000 - 1/20,000

PregnanciesPregnancies

• • Catastrophic ConsequencesCatastrophic Consequences

• • Multisystem CollapseMultisystem Collapse

• • Mortality Quoted as High as 80%Mortality Quoted as High as 80%

(Probably Lower Now)(Probably Lower Now)

First Victim of AFEFirst Victim of AFE 1817 an obstetrician1817 an obstetrician named named

Sir Richard CroftSir Richard Croft The patient was Princess CharlotteThe patient was Princess Charlotte

of Walesof Wales She died, presumably from an She died, presumably from an

undetected post-partum haemorrhage undetected post-partum haemorrhage CondemnationCondemnation and grief Croftand grief Croft

experienced led him to experienced led him to

commit suicidecommit suicide Charlotte's pregnancy is known Charlotte's pregnancy is known

in medical history as in medical history as

““the triple obstetrical tragedy”the triple obstetrical tragedy”..

Pathophysiology- AnimalPathophysiology- AnimalData:Data:

• • Amniotic fluid thought to be composed of Amniotic fluid thought to be composed of some abnormal factor or mediatorsome abnormal factor or mediator

• • Factor is heat stableFactor is heat stable

• • Factor is soluble?Factor is soluble?

• • Possible relationship with anaphylactoid Possible relationship with anaphylactoid phenomenonphenomenon

• Abnormal components suchAbnormal components such as meconium may as meconium may play a roleplay a role

(Hankins, 1995; Hankins, et al, 1993; Clark, (Hankins, 1995; Hankins, et al, 1993; Clark, 1995)1995)

Situations Related or Situations Related or NOTNOT

Related to AFE:Related to AFE:• • Uterine Hyperstimulation- AFE registry suggests Uterine Hyperstimulation- AFE registry suggests

that hyperstimulation is that hyperstimulation is EFFECTEFFECT rather than cause rather than cause of AFEof AFE

• • Oxytocin use- Oxytocin use- NOT RELATEDNOT RELATED

• • Drug Allergy and/or Atopy- Drug Allergy and/or Atopy- RELATEDRELATED, with, with

41% of patients in AFE registry with allergies41% of patients in AFE registry with allergies

• • Normal labor!!??Normal labor!!??

(Clark, 1997)(Clark, 1997)

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Mech

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Clinical presentationClinical presentation

The classic clinical presentation of the syndrome The classic clinical presentation of the syndrome has been described by five signs that often has been described by five signs that often

occur in the following sequenceoccur in the following sequence ::(1) Respiratory distress(1) Respiratory distress(2) Cyanosis(2) Cyanosis(3) Cardiovascular collapse (3) Cardiovascular collapse cardiogenic shockcardiogenic shock(4) Hemorrhage (4) Hemorrhage (5) Seizure & Coma. (5) Seizure & Coma.

DiagnosisDiagnosis

The presence of squamous cells in the pulmonary

arterial blood obtained from a Swan-Ganz catheter once considered pathognomonic for AFE is neither sensitive nor specific

The monoclonal antibody TKAH-2 may eventually prove more useful in the rapid diagnosis of AFE.

National registry’s criteria National registry’s criteria for diagnosis of amniotic for diagnosis of amniotic

fluid embolism fluid embolism

AFE- Differential Diagnosis AFE- Differential Diagnosis

• Pulmonary Embolism• Venous Air Embolism• Myocardial Infarction• Eclampsia• Anaphylaxis• Local Anesthetic Toxicity

ManagementManagement of AFEof AFE

IMMEDIATE MEASURES :IMMEDIATE MEASURES :

- Set up IV Infusion, - Set up IV Infusion,

-O-O22 administration. administration.

- Airway control - Airway control endotracheal intubation endotracheal intubation

maximal ventilation and oxygenation.maximal ventilation and oxygenation. LABS :LABS : CBC,ABG,PT,PTT,fibrinogen,FDP.CBC,ABG,PT,PTT,fibrinogen,FDP.

RECOGNITION FIRST STEP

ManagementManagement of AFEof AFE

Treat hypotensionTreat hypotension, increase the circulating volume and , increase the circulating volume and cardiac output with crystalloids.cardiac output with crystalloids.

After correction of hypotension, After correction of hypotension, restrict fluid therapy restrict fluid therapy to to maintenance levels since ARDS follows in up to 40% to 70% maintenance levels since ARDS follows in up to 40% to 70% of cases.of cases.

Steroids Steroids may be indicated (recommended but no evidence may be indicated (recommended but no evidence as to their value)as to their value)

DopamineDopamine infusion if patient remains hypotensive infusion if patient remains hypotensive (myocardial support).(myocardial support).

Other investigators have used Other investigators have used vasopressorvasopressor therapy such as therapy such as ephedrine or levarterenol with success (reduced systemic ephedrine or levarterenol with success (reduced systemic vascular resistance)vascular resistance)

Treat CoagulopathyTreat Coagulopathy

RESUSITATION RESUSITATION OF OF

CARDIAC ARRESTCARDIAC ARREST

CardiopulmonaryCardiopulmonaryResuscitation in Resuscitation in

PregnancyPregnancy

If you think that this will never happen to you, you are wrong!

Being an Obstetrics provider is no excuse not to be CPR literate.

Non-Obstetrics providers may know more than you do about CPR, but they may know little or nothing about pregnancy, fetal evaluation, etc.

Possible OutcomesPossible Outcomes

• Mother and babies die or brain-damagedMother and babies die or brain-damaged

• Mother and babies intactMother and babies intact

• Mother intact, babies die or impairedMother intact, babies die or impaired

• Mother brain damaged, babies intactMother brain damaged, babies intact

• Family takes legal action against hospital, Family takes legal action against hospital, anesthesiologist, obstetriciananesthesiologist, obstetrician

Cardiac Arrest in PregnancyCardiac Arrest in Pregnancy

Maternal diagnosisMaternal diagnosis

Fetal condition and maturityFetal condition and maturity

How rapidly and appropriately medical How rapidly and appropriately medical

and nursing personnel respondand nursing personnel respond

Resources available in hospitalResources available in hospital

What happens next depends on:What happens next depends on:

Cardiac Arrest in Pregnancy:Cardiac Arrest in Pregnancy:Complicated by Physiologic Complicated by Physiologic

ChangesChanges

Rapid development of hypoxia, Rapid development of hypoxia, hypercapnia, acidosis hypercapnia, acidosis

Risk of pulmonary aspirationRisk of pulmonary aspiration

Difficult intubationDifficult intubation

AORTO-CAVAL COMPRESSION AORTO-CAVAL COMPRESSION by by pregnant uterus when mother supinepregnant uterus when mother supine

Changes greater in multiple pregnancy, Changes greater in multiple pregnancy, obesityobesity

Cardiac Arrest in Pregnancy:Cardiac Arrest in Pregnancy:Special ProblemsSpecial Problems

• Cardiac output during closed chest massageCardiac output during closed chest massage

in CPR is only ~ 30% normalin CPR is only ~ 30% normal

• Cardiac output in the supine pregnant Cardiac output in the supine pregnant

woman is decreased 30-50% due to woman is decreased 30-50% due to

aortocaval compressionaortocaval compression

• Combined effect of above: There may be Combined effect of above: There may be

NO cardiac output!NO cardiac output!

MRI Scan• NORMAL • Aortocaval Compression-

occurs during second 1/2 of pregnancy

Cardiff Resusitation WedgeCardiff Resusitation Wedge

Guidelines 2000 for Cardiopulmonary Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiac Resuscitation and Emergency Cardiac

CareCare

Anticipatory treatment of cardiac arrestAnticipatory treatment of cardiac arrest

Emphasis on Automatic External Defibrillators (AEDs)Emphasis on Automatic External Defibrillators (AEDs)

Competent Competent bag-mask ventilation - may be better than bag-mask ventilation - may be better than intubation attemptsintubation attempts

Use of amiodarone 300 mg IV (in place of lidocaine*)Use of amiodarone 300 mg IV (in place of lidocaine*)

Vasopressin 40 mg x 1 (Vasopressin 40 mg x 1 (alternativealternative to repeated doses to repeated doses epinephrine 1 mg IV every 3-5 min*)epinephrine 1 mg IV every 3-5 min*)

Family presence during resuscitationFamily presence during resuscitation

American Heart Association, 2000American Heart Association, 2000

An international evidence and science-based consensus:An international evidence and science-based consensus:What’s new or different?What’s new or different?

*Insufficient evidence to support efficacy*Insufficient evidence to support efficacy

Why is Urgent Delivery Why is Urgent Delivery Indicated?Indicated?

Maternal brain damage may start at ~ 4-6 minMaternal brain damage may start at ~ 4-6 min

What is good for mother is usually good for babyWhat is good for mother is usually good for baby

Most intact newborns delivered within 5 minMost intact newborns delivered within 5 min

Closed chest massage is less effective with timeClosed chest massage is less effective with time

CPR may be totally ineffective before delivery:CPR may be totally ineffective before delivery:

Many reports of mother “coming back to life” after Many reports of mother “coming back to life” after

deliverydelivery

Advantages of Early Advantages of Early DeliveryDelivery

Aortocaval compression relieved:Aortocaval compression relieved:Venous return Venous return , Cardiac output , Cardiac output

Ventilation improved:Ventilation improved:-Functional Residual Capacity -Functional Residual Capacity

-Oxygenation improved-Oxygenation improved

Oxygen consumption Oxygen consumption , CO, CO2 2 production production

Improved maternal and newborn survivalImproved maternal and newborn survival

The Cesarean Delivery The Cesarean Delivery Decision - Not an Easy One!Decision - Not an Easy One!

• Has 3-4 min passed since cardiac arrest?Has 3-4 min passed since cardiac arrest?

• Has the mother responded to Has the mother responded to

resuscitation?resuscitation?

• Was resuscitation optimal - can it be Was resuscitation optimal - can it be

improved?improved?

““Perimortem” Cesarean Perimortem” Cesarean SectionSection

Start by 4 minutes, deliver by 5 Start by 4 minutes, deliver by 5 minutes (From the time of Arrest)minutes (From the time of Arrest)

Perform operation in patient’s room:Perform operation in patient’s room: Can move to OT Can move to OT afterafter delivery delivery

Don’t worry about sterilityDon’t worry about sterility

Vertical abdominal incision quickestVertical abdominal incision quickest

Prepare for uterine hypotonia and Prepare for uterine hypotonia and bleedingbleeding

Immediate CPR ACLSImmediate CPR ACLS

Early intubationEarly intubation

Start Cesarean by 4 min

Delivery by 5 min

Start Cesarean by 4 min

Delivery by 5 min

Left Uterine displacementLeft Uterine displacement

IS THIS REALISTIC

OUTSIDE THE OR?

Optimal OutcomeOptimal Outcome

Essential Equipment (Should be Essential Equipment (Should be available in Labour ward)available in Labour ward)

Pulse oximeterPulse oximeter

Cardiac arrest cart; defibrillatorCardiac arrest cart; defibrillator

Automatic Electric Defibrillator (AED)?Automatic Electric Defibrillator (AED)?

Cesarean section instrumentsCesarean section instruments

Difficult intubation equipment (including LMA, Difficult intubation equipment (including LMA,

jet ventilator, fiberoptic laryngoscope)jet ventilator, fiberoptic laryngoscope)

Thoracotomy instrumentsThoracotomy instruments

Blood warmer and rapid fluid infuserBlood warmer and rapid fluid infuser

Central venous and arterial line equipmentCentral venous and arterial line equipment

Common Problems in Common Problems in ObstetricsObstetrics

Denial of problem Denial of problem delay in response delay in response

Communication errorsCommunication errors

Obstetric staff not prepared for catastrophesObstetric staff not prepared for catastrophes

Inadequate response from transfusion or labsInadequate response from transfusion or labs

No specialty in-house surgeons (e.g., for No specialty in-house surgeons (e.g., for

airway, vascular, cardiac problems)airway, vascular, cardiac problems)

No OB-ICU facilitiesNo OB-ICU facilities

Family SupportFamily Support

When the mother and infant are gravely ill, When the mother and infant are gravely ill,

keep their familykeep their family members well informed. members well informed. Be cool and calm while communicating with the Be cool and calm while communicating with the

family membersfamily members Allow as much access to the lovedAllow as much access to the loved ones as ones as

possible.possible. Get informed consent at each stage.Get informed consent at each stage.

WORK FORCE & PROTOCALSWORK FORCE & PROTOCALS

• • In such emergency situationIn such emergency situation

It appears important to:It appears important to:

– – Streamline the Streamline the workflowworkflow

– – Co-ordinate the efforts Co-ordinate the efforts of different of different specialitiesspecialities

ІObstetrician• Assessment of patient condition– General condition, BP, pulse, revealed blood loss• Assessment of blood loss– Estimation of blood loss is notoriously difficult & inaccurate• Control bleeding–Manual pressure, oxytocic, operative procedures

ІІAnaesthetist• Resuscitation–Maintenance of haemodynaemic status of patient– Fluid & blood product replacement• Estimation of blood loss–More experienced in blood loss estimation• Anaesthesia– Induction a & maintenance of anaesthesia• Drug administration

ІІІOperating Theatre• Preparation for emergency operation• Assistance in operative procedures– Scrub nurse to conduct operation– Assist in administration of anaesthesia– Assist in fluid, blood product and drugadministration

ІV Radiologist• Control of haemorrhage– Cannulisation of pelvic vessels– Embolization of pelvic vessels to controlbleeding

VPaediatrican• Resuscitation of newborn– Stand by delivery– Immediate resuscitation of newborn– Escort newborn to NICU

5 Elements in management

Multidisciplinary Team Approach

• Protocal should be specific for your hospital (Hospital specific) • Protocal depends upon your hospital infra- structure

and the availability of Resource persons

•Determine the hemorrhage response team

•Determine team member responsibilities • Update and modify your Protocal periodically• Conduct periodic Emrgency drill

Hemorrhage protocol Logistics

Early Haemorrhage

Hypotention

Shock

Cardiac Arrest

Deliver the baby < 5mts

Early intervention

Late intervention

Early Recognition

Prevent shock

Resusitation

CPR

SummarySummary

Successful treatment requires:Successful treatment requires:

CommunicationCommunication PreparednessPreparedness Multidisciplinary Team ApproachMultidisciplinary Team Approach Hospital Hemorrhage ProtocolHospital Hemorrhage Protocol

A Good

understanding

between

MULTIDISCIPLINARY TEAM

IS A MUST

FOR THE SUCCESS

Intelligent anticipation, Intelligent anticipation,

skilled supervision, skilled supervision,

prompt detection and prompt detection and

effective institution of therapy effective institution of therapy

can prevent can prevent

disastrous consequences . disastrous consequences .