Maternal Collapse-Greentop Guideline 2019

1. Maternal Collapse in Pregnancy and
the Puerperium
Green-top Guideline No. 56

2. Purpose of the guideline
To discuss the identification of women at
increased risk of maternal collapse
To identify different causes of maternal collapse.
To delineate the initial and continuing
management of maternal collapse.
To review maternal and fetal outcomes.

3. • A-High-quality meta-analyses, systematic reviews
RCT or RCT.
• B-High-quality systematic reviews of case–control
or cohort studies.
• C-Well-conducted case–control or cohort studies
• D-Non-analytical studies/Expert opinion
- best practice based on the clinical experience.

4. Maternal collapse
An acute event involving the cardiorespiratory
systems and/or brain,
resulting in a reduced or absent conscious level
(and potentially death),
at any stage in pregnancy and up to six weeks after
delivery.

5. Can women at risk of impending collapse be identified
early?
An obstetric early warning score chart(EWS) should be
used routinely for all women, to allow early recognition
of the woman who is becoming critically ill. D
It depends on previous risk factors during pregnancy.

6. Causes of maternal collapse
-Result from a number of causes.
A systematic approach should be taken to identify the
cause. [New 2019] -----------B
Reversible
4H’s
• Hypovolemia
• Hypoxia
• Hypokalemia/Hyp
erkalemia
• Hypothermia
4T’s
Thromboembolism
Toxicity
Tension pneumothorax
Temponade (cardiac)

8. What are the physiological and anatomical changes in
pregnancy that affect resuscitation?
-anyone involved in the resuscitation of pregnant
women is aware of the physiological differences.

10. Aortocaval compression significantly reduces cardiac output
from 20 wks onwards and efficacy of chest compressions
during resuscitation.----------------------------C
Changes in lung function, diaphragmatic splinting and ↑O2
consumption make pregnant become hypoxic more readily
and make ventilation more difficult. -------------------------C
Difficult intubation is more likely in pregnancy. -----------C
Pregnant women are at an increased risk of aspiration.---C

11. What is the optimal initial management of
maternal collapse?
If maternal cardiac arrest occurs in the
community setting, basic life support should be
administered and rapid transfer arranged----- √
Maternal collapse resuscitation should follow standard
ABCDE approach, with some modifications for maternal
physiology, in particular relief of aortocaval
compression------------D

12. Manual displacement of uterus to left - effective in
relieving aortocaval compression in women >20 wks’
GA or where the uterus is palpable at or above the
level of the umbilicus.
This permits effective chest compressions in the supine
position in the event of cardiac arrest------D
A left lateral tilt of the woman from head to toe at
an angle of 15–30o on a firm surface will relieve
aortocaval compression and still allow effective
chest compressions to be performed in the event of
cardiac arrest----------------------C

14. • In major trauma, spine should be protected with
a spinal board before any tilt is applied.
• In absence of a spinal board, manual
displacement of the uterus should be used------
Intubation in unconscious woman with a cuffed
endotracheal tube should be performed
immediately by an experienced anesthetist--- 
Supplemental high flow oxygen should be
administered as soon as possible to counteract
rapid deoxygenation------- 

16. Bag and mask ventilation or insertion of a simple
supraglottic airway should be undertaken until
intubation achieved------ 
If airway is clear and there is no breathing, chest
compressions should be commenced immediately----B
Two wide-bore cannulae (minimum 16 gauge) should
be inserted as soon as possible.
If peripheral venous access is not possible, early
consideration of CV line should be considered------

18. There should be an aggressive approach to volume
replacement, Should cautious in pre-eclampsia or
eclampsia----------
Abdominal ultrasound by a skilled operator can assist in
the diagnosis of concealed Haemorrhage-------------- C
The same defibrillation energy levels should be used as
in a non-pregnant woman-------------B
There should be no alteration in algorithm drugs or
doses used in the Resuscitation protocols----------------- 

19. Common, reversible causes of maternal
cardiopulmonary arrest should be considered
throughout the resuscitation process-----D
Resuscitation efforts continued until a decision
is taken by consultant obstetrician and
anaesthetist to discontinue resuscitation efforts
--------

20. When, where and how should perimortem
caesarean section (PMCS) be performed?
In > 20 wks GA, if no response to correctly performed CPR
within 4 minutes of collapse or
if resuscitation is continued beyond this, then PMCS
should be undertaken to assist maternal resuscitation.
Ideally, this should be achieved within 5 minutes of the
collapse-------------------D
PMCS should not be delayed by moving the woman.
It should be performed where maternal collapse has
occurred and resuscitation is taking place-----

21. Postmortem caeserean section

22. A scalpel and umbilical cord clamps should be
available on the resuscitation trolley in all areas
where maternal collapse may occur, including the
accident and emergency department----------
The operator should use the incision, which will
facilitate the most rapid access.
This may be a midline vertical incision or a suprapubic
transverse incision------------ 

23. What does the ongoing management
consist of?
Senior staff with appropriate experience should
be involved at early stage-------------------------
Transfer should be supervised by an adequately
skilled team with appropriate equipment ----
In case of maternal collapse secondary to APH,
fetus & placenta delivered promptly to allow
control of haemorrhage --------------------

24. • In the case of massive placental abruption, CS
may occasionally indicated even if fetus is
dead to allow rapid control of haemorrhage---
----- 
• IV tranexamic acid significantly reduces
mortality due to PPH ---A

25. The management of amniotic fluid embolism (AFE)
is supportive rather than specific, as there is no
proven effective therapy--------------
Early involvement of senior experienced staff,
including midwives, obstetricians, anaesthetists,
haematologists and intensivists, is essential to
optimise outcome------ ----------------

26. • Coagulopathy needs early, aggressive treatment,
including the use of fresh frozen plasma------
• Recombinant factor VII should only be used if
coagulopathy cannot be corrected by massive blood
component replacement in AFE------------------C
• After successful resuscitation, cardiac cases should be
managed by an expert cardiology team--------- 
• Septic shock should be managed in accordance with
the Surviving Sepsis Campaign guidelines---------D

27. • The antidote to magnesium toxicity is 10 ml 10%
calcium gluconate or 10 ml 10% calcium chloride
given by slow IV inj.-----------
• If local anaesthetic toxicity is suspected, stop
injecting immediately------------------- 
• Lipid rescue should be used in cases of collapse
secondary to local anaesthetic toxicity-------C
• Intralipid 20% should be available in all hospitals
offering maternity services------------ 

29. • Manage arrhythmias as usual, recognizing that
they may be very refractory to treatment-------
-----
• Eclampsia should be managed in accordance
with the Guideline ------------D
• Neuroradiologists and neurosurgeons should
be involved in the care of pregnant women
with intracranial haemorrhage at the earliest
opportunity---- 

30. In cases of anaphylaxis,
all potential causative agents should be removed, and
ABCDE approach to assessment and resuscitation
followed -------
The treatment for anaphylaxis is 1:1000 adrenaline 500
mcg (0.5 ml) IM ------------- 

31. What are the outcomes for mother and baby after
maternal collapse?
• Outcomes for mothers and babies depend on
the cause of collapse, GA and access to
emergency care, with survival rates being
poorer if the collapse occurs out of hospital.
• In maternal cardiac arrest maternal survival
rates of over 50% have been reported-----C

32. Who should be on the team?
• In addition to team, there should be a senior midwife,
an obstetrician and an obstetric anaesthetist included
in cases of maternal collapse------------
• The most senior obstetrician and senior anaesthetist
should be called at the time of a cardiopulmonary
arrest ------------ 
• The neonatal team should be called early if delivery is
likely (antepartum collapse > 22+0 wks)------------- 

34. • https://journals.lww.com/ccmjournal
/Fulltext/2021/11000/Surviving_Seps
is_Campaign__International.21.aspx
https://www.rcog.org.uk/guidance/browse-all-
guidance/green-top-guidelines/reducing-the-
risk-of-thrombosis-and-embolism-during-
pregnancy-and-the-puerperium-green-top-
guideline-no-37a/
https://www.nice.org.uk/guidance/NG133

39. Thank You