maternal collapse during pregnancy and puerperium

1. PROFESSOR SHABNAM NAZ SHAIKH
DEPARTMENT OF OBS/GYNAE
CMC,SMBBMU LARKANA
MATERNAL COLLAPSE IN PREGNANCY & PURPERIUM

2. • The outcome depends on
prompt and effective
resuscitation.
Incidence
• Unknown as morbidity data are
not routinely collected
• Incidence --------- 0.14- 6/1000
births
2
Maternal collapse is defined as; An acute event
Involving the cardiorespiratory systems + brain
 in a reduced or absent conscious level (and
potentially death).
At any stage in pregnancy and up to 6 wks after
delivery.
it is a rare but life-threatening event with a
wide-ranging etiology.
INTRODUCTION

3. Maternal resuscitation- Basic life support
Aims
'To understand the importance of maternal resuscitation
'To practice and develop the skills of cardiopulmonary resuscitation
'To achieve competence in those skills

4. Cardiopulmonary resuscitation
• This is the approach to an apparently lifeless patient
• it is a rapid assessment of –
• Airway and Breathing moving quickly to - Circulation
• then treatment
• 'Ensure you are not putting yourself at risk!

5. CASE.
• It’s 3:00 AM now and you are very tired after an exhausting shift
• Suddenly a pregnant patient is transferred in to E/R
• You evaluate the patient quickly
• you are shocked, the patient is collapsed
• Now
• What are you going to do?
5

6. Shake and shout
• Hello how are you?
• 'If no response, call for help

7. If breathing
• Turn into recovery position
• 'Call for help
• Check pulse, BP and FH
• 'Regularly reassess
• Assess and treat cause of collapse

8. If not breathing...
• This probably also means there is no
Circulation

9. 9
• call for help
• Activate maternal
resuscitation team
• Document time of
collapse
• Place patient in supine
position!!With manual Lt
uterine displacement for
uterus more than 20 wks
size

10. Start chest compressions
• place heel of first hand on lower part of sternum
• place heel of second hand on top of first interlock
fingers
• Keep arms straight and depress sternum 4-5 cm at a
rate of 100 compressions per minute
• Change the person delivering the compressions to
avoid getting tired
If your try is unsuccessful
Place patient in Lt lateral tilt position 27-30 degree
•

11. Give 30 compressions:2 breaths
• Give 2 slow breaths each lasting
about I second
• Watch for chest rise
• Give 100% oxygen if available

12. Defibrillation
• The Facts:
• It is safe
• Concern about arcing around external & internal fetal
monitors??
• There is no evidence
• But reasonable to remove them
• Defibrillation dose??
• An AED* should be apply as soon as possible
* Automated external defibrillator
12

14. SHOCKABLE
Ventricular Fibrillation
Ventricular Tachycardia

15. Non-Shockable
NON SHOCKABLE
Asystole
NON SHOCKABLE
PEA - Complete Heart Block
NON SHOCKABLE
PEA narrow complex Tachycardia

16. 16

17. 4 min after cardiac arrest
• ROSC* has not been achieved
• So what’s are you going to do?
* Return of spontaneous circulation
17

18. Perimortem c section
18
-RESUSCITATIVE HYSTEROTOMY

19. Decision to C/S Performance??
• Facts:
• The primary importance is mother life
• Aortocaval compression by gravid uterus relieved→↑return & CO
• Delivery→ improved ventilation, ↓O2 consumption & CO2
production
• No ROSC after 4 min of cardiac arrest
• Despite good BLS & ACLS an correction of reversible causes
• Delivery by 5 min
• PERIMORTEM INSTRUMENTAL DELIVERY
19

20. IS IT EFFECTIVE?
• Numerous case reports
• Several reviews of published cases
• Katz:20 (59%) of 34 cases had ROSC after CS
• In the Danish series, 67% of women experienced improved CO.
MATERNAL STATUS DON’T DETERIORATE WITH CESAREAN DELIVERY IN ANY CASES

21. LOGISTICS
• Scalpel
• Don’t worry about sterility or bleeding
• Vertical incision Vs pfannensteil
• Delivery within 5min is very challenging
• Einav review:
- only 4 of 21 women were delivered within 5 min
- CS within 10 min better maternal outcomes
A review of case reports of perimortem cesarean delivery from 1900 to 1985 suggested that
normal neonatal neurological outcome was most likely when delivery was completed within
five minutes of maternal cardiac arrest.
Evaluation of perimortem cesarean cases reported from 1985 to 2004 noted perimortem
cesarean was associated with spontaneous return of maternal circulation or improvement in
maternal hemodynamic status in 12 of 20 cases, particularly when the delivery was completed
within five minutes of maternal arrest

22. Do Not Forget!!
• BLS is cornerstone of ACLS
• All activities(CAB) should keep on
22

23. Airway
• You faced with an difficult airway
• You should insert an
advanced airway
• Experienced provider
23

24. Breathing
• Ventilation with O2 100%
• What is Compression/Ventilation ratio?
• 100 Compressions/ min / 8-10 breathes/min
without synchronization
• Do avoid hyperventilation plz!!!
• Continuous pulse oximetry
• Continuous wave capnography
24

25. Circulation
• Large bore IV lines
• Drugs??
• According to ACLS recommendations
• Defibrillation?
• According to ACLS protocol
25

26. POST RESUSCITATION CARE
• Arrange transfer of the patient to the intensive
care unit if appropriate.
• Re-evaluate for oxygenation and ventilation.
• Manage for temperature control.
• The patient should be examined for
resuscitation related injuries, e.g. rib fractures
26

27. RECAP
• CPR: The approach to an apparently lifeless patient
• Remember:
• CALL FOR HELP!
• #ABC approach
• Peri-mortem C/S

28. So what’s D??
• Differential Dx
• Recall:
• Hs & Ts
• BEAU-CHOPS
28

29. Differentials / causes of maternal collapse
29

30. BEAU-CHOPS
• Bleeding
• Embolism:
• Pulmonary
• Amniotic fluid
• Anesthetic
Complication
• Uterine Atony
• Cardiac disease
• HTN:
• Preeclampsia
• Eclampsia
• Other:
• Mg toxicity
• Placenta abruptio/previa
• Sepsis
30

31. Q: Can women at risk of impending collapse be identified early?
• Often there are clinical signs that precede collapse
• Deterioration in vital signs will precede significant clinical deterioration,
• Early intervention will reduce morbidity.
• In some cases maternal collapse occurs with no prior warning
• ANC for women with significant medical conditions
31

32. • An obstetric early warning score chart should be used routinely for
all women, to allow early recognition of the woman who is
becoming critically ill.
• The intention of the MEWS is to improve recognition of pregnant
women at risk of clinical deterioration and facilitate early
intervention.
•
32
The literature suggests potential benefit and supports the use of MEWS.
A prospective observational study published in 2016 evaluating a MEWS reported that
27% of women triggered a response, and 17% of women fulfilled criteria for obstetric
morbidity. The MEWS was found to be 86% sensitive and 85% specific for predicting
the presence of maternal morbidity.

33. 33

34. 34

35. What are physiological and anatomical changes in
pregnancy that affect resuscitation
• It is essential that anyone involved in the resuscitation of pregnant
women is aware of the physiological differences.
• The pregnant woman undergoes a variety of physiological changes
that accelerate the development of hypoxia and acidosis and make
ventilation more difficult.
35

36. 36

37. What are the outcomes for mother and baby?
• high maternal and neonatal fatality rates
• Maternal mortality rates of 30 to 80 percent and neonatal mortality
rates of 60 percent have been reported in large studies.
• Maternal and neonatal survival depends on several factors, including
 the underlying etiology for the arrest,
maternal location at the time of the arrest (out of hospital versus in
hospital),
speed of resuscitative efforts, and
the skills and resources of the healthcare providers
37

38. 38
Maternal collapse

39. Clinical governance
• Documentation
Accurate documentation in all cases of maternal collapse, whether or not resuscitation is
successful, is essential.
• • Poor documentation remains a problem in all aspects of medicine, and can have potential
medico-legal consequences.
• • note-keeping is difficult in a resuscitation situation. Those involved should write full notes as
soon as possible after the event.
• Incident reporting
All cases of maternal collapse should generate a clinical incident form and the care should be reviewed
through the clinical governance process.
• Debriefing
• Training
39

40. Training
• • All generic life support training courses should make mention of the
adaptation of CPR in the pregnant woman.
• • All front-line staff must be aware of the adaptations for CPR in
pregnancy.
• • This includes paramedics who will deal with collapse in the
community setting and accident and emergency department
personnel as well as staff within a maternity unit.
• • All maternity staff should have annual formal training in generic life
support and the management of maternal collapse.
• • Small-group interactive practical training is recommended.
40

41. 41

42. 42

43. • DEBRIEFING
• is recommended for the woman, her
family and the staff involved in the
event.
• Maternal collapse can be associated
with post- traumatic stress disorder,
postnatal depression and tocophobia.
• Family and staff members should not
be forgotten.
• Debriefing is an important part of
holistic maternity care and should be
offered by a competent professional.
43

44. 44

45. Take Home Message
• One of the biggest challenges with maternal collapse is the
unpredictability, and the need for constant vigilance.
• A logical structured approach using ABCDE should be used in
assessment and management of a collapsed patient
• CPR should be modified by securing the airway as early as possible
and displacing the uterus manually
• Perimortem caesarean section should be undertaken after 4 minutes
of unsuccessful CPR
• Obstetricians should lead a multidisciplinary team in the
management of critically ill pregnant women
• All staff should have annual drills and updates on obstetric
emergencies and resuscitation.
45

47. References
• RCOG, Maternal Collapse in Pregnancy and the Puerperium: Green-top Guideline No. 56
January 2019
• Amniotic Fluid EmbolismObstet Gynecol Clin N Am 34 (2007) 545–553:
• Cardiopulmonary Resuscitation in Pregnancy, Obstet Gynecol Clin N Am 34 (2007) 585–597
• BRITISH MEDICAL JOURNAL: EMERGENCIES IN GENERAL PRACTICE: POST-PARTUM MATERNAL
COLLAPSE, MAY 28, 1955
• Jonathan H. Skerman and Khalil E. Rajab Anesthetic and Obstetric Management of High-Risk
Pregnancy Third Edition
• M C Colquhoun ABC of Resuscitation 5th ed. 2016
• UpTodate 2018
47

48. 48