s udden m aternal c ollapse max brinsmead phd franzcog july 2011
TRANSCRIPT
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”