1. A comatose pregnant patient presented to the hospital. Common causes of coma in pregnancy include preeclampsia, eclampsia, stroke, and infections. 2. An evaluation of the patient's vital signs, neurological exam, and diagnostic testing is needed to identify potential etiologies such as metabolic abnormalities, intracranial hemorrhage, or toxic ingestions. 3. Treatment depends on the underlying cause but initially involves stabilizing the patient's airway, breathing, and circulation. Supportive care including oxygen, intravenous fluids, anticonvulsants, and antibiotics may be needed while definitive diagnoses and therapies are pursued.

1. COMATOSE PATIENT IN PEGNANCY AND PUEPERIUM
PRESENTERS
Dr. ANZO WILLIAM ADIGA
Dr BAMEKA AGGREY
MAKERERE UNIVERSITY COLLEGE OF HEALTH SCIENCE,
OBGY DEPT
FACILITATOR: Dr KISEGERWA

2. OUTLINE
• BRIEF HISTORY
• INTRODUCTION
• PRIMARY SURVEY
• ETIOLOGY
• WORKOUT
• MGT
• PROGNOSIS
8/3/2021
Dr ANZO William Adiga 2

3. Brief History
• Gabelchoverus distinguished between four types of epilepsy in 1596, which
included epilepsy resulting from the head, stomach, the pregnant uterus, and
chilled extremities (Chesley, 1978). But it wasn’t until 1619 that the word
“eclampsia” first appeared in Varandaeus’ treatise on gynecology (Ong, 2004).
Blood Letting was very common.
• Hacienda HealthCare center, 29 years old who was14 years in comma gave
birth in ICU, 36years male nurse arrested in Arizona, CEO resigned….2019
• Massachusetts nursing home, 1998 24 years old in comma for 5 yeaars gave
birth to premature, in 1996 another similar case for 29years

4. Definition
• Coma is defined as a state of pathologic unconsciousness;
patients are unaware of their environment and are
unarousable.
• It is caused by either dysfunction of the reticular activating
system above the level of the mid-pons, or dysfunction of both
cerebral hemispheres.

5. Introduction
• Pregnant women may go into coma for the same reasons that face the
general population but also encounter conditions unique to or more
common in this state
• Gestational hypertension, eclampsia, and HELLP - Pregnancy related
organ failures including acute renal, hepatic, or pulmonary failure
• - Vascular risks include cerebral venous sinus thrombosis and pituitary
apoplexy

6. ETIOLOGIES OF COMMA IN PREGNANCY
• COVID-19
• MALARIA
• HYOGLYCEMIA
• ECLAMPSIA
• P.E
• CARDIAC ARREST
• ECTOPIC RUPTURE
• Thrombotic Thrombocytopenic Purpura
• Metabolic; DKA, HONK
• AMNIOTIC FLUID EMBOLISM
• TRUAMA
• AKI
• INFECTION
• RUPTURED UTERUS
• PLACENTA ABRUPTION
• HYPOGLYCEMIA
• HELLP Syndrome

7. PRIMARY SURVEY-ABCF

9. Helpful questions for relatives, friends, and witnesses include
• What was the time course of the loss of consciousness? Was it ABRUPT (eg,
subarachnoid hemorrhage, seizure), GRADUAL (eg, brain tumor), or
FLUNCTUATING (eg, recurring seizures, subdural hematoma, metabolic
encephalopathy)?
• Did focal signs or symptoms precede the loss of consciousness? As an
example, an initial hemiparesis suggests a structural lesion, likely with mass
effect.
• Transient visual symptoms, eg, diplopia or vertigo, suggest ischemia in the
posterior circulation.
• Previous neurologic episodes that suggest transient ischemic attacks or
seizures?

10. EVALUATION
• Recent illness, altered behaviour or function recently?
• Fever- suggests infection
• Increasing headache-expanding intracranial lesion, infection, or
venous sinus thrombosis;
• What prescription or non-prescription drugs are used?

11. Physical exam
Vital signs as |Primary survey goes on with resustation
• Extreme hypertension may suggest hypertensive encephalopathy, or hypertensive
intracerebral/cerebellar/brainstem hemorrhage.
• Hypotension may reflect circulatory failure from sepsis, hypovolemia, or cardiac
failure
• Hyperthermia usually signifies an infection; heat stroke, or anticholinergic
intoxication are other possibilities.

12. Physical exam
• Hypothermia could be accidental (cold exposure), primary (due to hypothalamic
dysfunction as in Wernicke's encephalopathy or tumor), or secondary (eg, adrenal
failure, hypothyroidism, sepsis, drug or alcohol intoxication).
• VENTILATION: count the respiratory rate and combined with blood gas or simple
pulseoximetry
• Bruises can indicate head trauma, especially "raccoon eye" (periorbital ecchymosis).
• Battle's sign (bruising over the mastoid) and hemotympanum (blood behind the
tympanic membrane) are signs of basal skull fracture.

13. Physical exam
• Petechiae and ecchymoses can be seen in bleeding diatheses (eg, thrombocytopenia,
disseminated intravascular coagulation), some infections (eg, meningococcal
septicemia
• Subungual (splinter) and conjunctival hemorrhages are sometimes seen in
endocarditis
• Petechiae confined to the head and neck may be found after convulsive seizures due
to acutely raised venous pressure.

14. Physical Exams cont…
• Perspiration is common in fevers, hypoglycemia, and
pheochromocytoma.
• Bullous lesions are characteristic of barbiturate
intoxication (coma blisters).
• Jaundice could indicate liver disease.
• A cherry red color, especially of the lips and mucous
membranes, suggests carbon monoxide intoxication.

15. Physical Exams
• Pallor, especially with a sallow appearance, may suggest uremia,
myxedema, or severe anemia as in profound pernicious anemia
• Needle tracks suggest intravenous drug abuse. A tongue bitten on the
lateral aspect suggests a recent convulsive seizure.
• Other — Most orthopedic injuries indicate trauma
• The neurologic examination in a comatose patient is necessarily brief and
is directed at determining whether the pathology is structural or due to
metabolic dysfunction (including drug effects and infection).

16. In Neurological Examination
The examiner assesses:
• Level of consciousness
• Motor responses
• Brainstem reflexes: pupillary light, extraocular, and corneal
reflexes
• Signs of meningeal irritation

17. DIAGNOSIS
• The goal of diagnostic testing in a patient in coma is to identify treatable
conditions (infection, metabolic abnormalities, seizures,
intoxications/overdose, surgical lesions).
Laboratory tests
Neuroimaging

18. DIAGNOSIS
Laboratory tests:
• Complete blood count
• COVID-19 test
• RFT with electrolytes
• LFT
• Malaria Rapid test/Blood Smear
• Random Blood Sugar
• Urinalysi
• Other like Adrenal and thyroid function test, Blood culture should be clinically
indicated

19. DIAGNOSIS
IMAGING STUDIES
• Ultrasound
• Chest Xray if indicated clinically
• CT- Scan
• MRI
• Electroencephalography

20. MANAGEMENT
• The primacy of ABC Fs (airway, breathing, and circulation) applies to cases of coma.
• Vital signs should be taken, an initial Glasgow Coma Scale score (GCS) established
and a set of arterial blood gases, along with the other blood and urine tests sent to
the laboratory.
• Patients with a GCS of 8 or less usually require endotracheal intubation to protect the
airway
• Oxygen supplementation is often needed, whether or not assisted ventilation is
required

24. MGT Cont…
• It is best to treat hypotension (mean arterial BP of <70 mmHg) with volume
expanders or vasopressors or both.
• With severe hypertension (mean arterial BP of >130 mmHg) repeated doses
of intravenous labetalol (5 to 20 mg boluses as needed) are often adequate
for initial stabilization.
• A 12-lead electrocardiogram should be done.

25. MGT CONT…
• It is recommended to give 25 g of dextrose (as 50 mL of a 50 percent dextrose
solution) while waiting for the blood tests, if the cause of coma is unknown.
• Thiamine, 100 mg, should be given with or preceding the glucose in any patient who
may be malnourished (to treat or to prevent precipitating acute Wernicke's
encephalopathy).
• Hyperthermia (T>38.5 degrees C) can contribute to brain damage in cases of
ischemia; efforts to lower fever with antipyretics and/or cooling blankets should be
administered immediately.
• Empiric antibiotic and antiviral therapy are recommended if bacterial meningitis

26. MGT CONT…
• Seizures treated with phenytoin
• Definitive therapy depends on establishing the precise diagnosis
• The prognosis depends on the underlying etiology, as well as the severity of the
insult and other premorbid factors, including age

27. 1. STROKE IN PREGNANCY
Ischemic Strokes
• incidence of 3.5 ischemic strokes per 100 000 population
• - it is recognized that there is an increased risk of stroke associated with pregnancy
– recent studies show similar incidence
• - considering stroke in the young as a broader group, strokes related to pregnancy
account for 12% to 35% of events
• - Based on the available evidence, the highest risk periods appear to be the delivery
period and up to 2 weeks postpartum.

28. Etiology
Similar to other causes of stroke in the young- Cardioembolic common
Physiologic and hemodynamic changes that occur --state of relative
hypercoaguability, Increased cardiac burden, and altered vascular
tone
• Preeclampsia, is associated with a 4-fold increase in stroke during
pregnancy
• Paradoxical embolism related to the presence of a patent foramen ovale
(PFO) may be facilitated by both the coagulation profile changes

29. Stroke In Pregnancy
Signs and symptoms
• acute onset of focal neurological changes
• headache and altered consciousness
• Seizures
Diagnosis
• Non-contrast head CT with appropriate fetal shielding
• MRI of the brain

30. Treatment
• TPA(Tissue Plasminogen Activator) - pregnant patients were excluded
from tPA clinical trials and there has been no systematic study
• Concerns regarding the risks of tPA on the pregnant patient and fetus (eg,
uterine hemorrhage, placental abruption, abortion, preterm delivery) have
been raised
• that maternal mortality (1%), fetal loss (6%), and preterm delivery (6%) are
all low
• Low-dose aspirin for secondary prevention is felt to be safe during
pregnancy
• unfractionated or low-molecular weight heparin as these do not cross the
placenta and confer no risk of teratogenicity or fetal hemorrhage

31. Antiphospholipid Antibody Syndrome
• Recurrent arterial and venous thromboses and can cause fetal death
• similarities to preeclampsia-eclampsia, with endothelial damage, platelet
activation, and thomboxane-mediated vasoconstriction
• Inhibition of protein C-protein S and antithrombin III activity
• Focal problems include cerebral infarction from thrombotic and venous
occlusion
• Antibodies contribute to the pathogenesis, and include the lupus
anticoagulant antibody, anticardiolipin antibody, and anti-B2 glycoprotein

32. CARDIAC CAUSES OF STROKE IN
PREGNANCY
• Peripartum Cardiomyopathy- defined as an unexplained cardiac failure
occurring during the last month of pregnancy to the first sixth postpartum
month.
• Viral and autoimmune causes of cardiomyopathy have been invoked
• Coma may occur from global cerebral hypoperfusion or by strokes

33. Heart Valve Abnormalities
• Prosthetic heart valves or chronic atrial fibrillation may induce stroke
• In normal childbirth and with Valsalva maneuvers, right atrial pressure rises
and the foramen ovale may open, enabling pelvic and peripheral vein emboli
to pass to the lung

34. Amniotic Fluid Embolism
• AFE occurs when amniotic fluid enters uterine veins and is forced into the
maternal circulation, causing hemodynamic collapse, disseminated
intravascular coagulopathy (DIC), focal cerebral hypoperfusion, thrombosis
or hemorrhage

35. Hemorrhagic stroke
• Occurs primarily in late pregnancy and in the puerperium
• Intracerebral hemorrhage has a higher maternal mortality rate -5% to 12%
of overall maternal mortality during pregnancy
• Primarily associated with preeclampsia / eclampsia, arteriovenous
malformations, and cerebral aneurysm rupture

36. Cerebral Venous Thrombosis
• CVT represents ≈0.5% to 1% of all strokes.
• Most pregnancy-related CVT occurs in the third trimester or puerperium.
• Risk factors are usually divided into acquired risks and genetic risks
Acquired risks- surgery, trauma, pregnancy, puerperium, antiphospholipid
syndrome, cancer, exogenous hormones)
Genetic risks - inherited thrombophilia

37. Pathophysiology
• Pregnancy induces several prothrombotic changes in the coagulation system
– fibrinogen activation with increased platelet adhesiveness
• Hypercoagulability worsens after delivery as a result of volume depletion
• Additional risk factors include infection and instrumental delivery or
cesarean section Increasing maternal age, as well as in the presence of
hypertension, infections, and excessive vomiting in pregnancy

38. Choriocarcinoma
• Metastatic choriocarcinoma rarely causes SAH, ICH, or subdural
hemorrhage
• Trophoblastic tissue may invade blood vessels and induce aneurysmal
dilatation, which may cause rupture

39. 3. Eclampsia
• PREECLAMPSIA - New onset of hypertension and proteinuria after 20 weeks of
gestation in a previously normotensive woman
• Criteria for the diagnosis of preeclampsia SBP ≥140 mmHg Or DBP ≥90
mmHg And Proteinuria ≥0.3 grams in a 24-hour urine specimen
• Eclampsia– Occurrence of one or more generalized convulsions and/or coma in the
setting of preeclampsia and in the absence of other neurologic conditions.
• Many patients have an incomplete clinical triad but a seizure or coma define eclampsia
• Eclampsia occurs in 0.05% to 0.20% of pregnancies
• Eclamptic seizure occurs in - 3% of severely preeclamptic women not receiving anti-
seizure prophylaxis

40. 4. Posterior Reversible Encephalopathy
Syndrome
Is a clinical radiologic syndrome of heterogeneous etiologies that are grouped together
because of similar findings on neuroimaging studies
• May occur in the setting of preeclampsia due to impaired cerebral autoregulation
from endothelial damage
• Most common clinical manifestations of PRES include headaches, confusion,
seizures, and visual changes.
• Confusion is common and may progress to more significant degrees of altered
awareness seizures may start focally but often generalize

41. 5. SEIZURES AND STATUS EPILEPTICUS
• Pregnancy may increase seizure frequency in women with epilepsy, but
produces no effect in most women; some have fewer seizures
• Pregnancy decreases the total blood levels of most antiepileptic drugs
(AEDs) by 50%
• Free valproate levels may increase. Lamotrigine levels may decrease
• Frequent causes of SE are a low level of AEDs, new strokes, infections,
abscesses, and vascular malformations
• Management is directed at seizure control and investigation of possible
underlying causes

42. 6. METABOLIC CAUSES OF COMA
Glucose Dysregulation
• Diabetes causing high or low blood sugar
• Morning sickness, may cause the mother to avoid glucose-lowering
medication and facilitate hyperglycemia.
• Vomiting with dehydration can cause hypernatremia Wernicke
Encephalopathy ,confusion, eye movement disorders and nystagmus,
ataxia, and rarely, coma
• Hyperemesis gravidarum may cause Wernicke encephalopathy by
depleting the body thiamine stores
• Treatment may require daily parenteral thiamine repletion for 7 to 10 days

43. ENDOCRINE DISTURBANCES IN
PREGNANCY
Pituitary apoplexy can arise from increased vascularity, and enlargement of the
pituitary
Result in antepartum infarction or hemorrhage
Acute pituitary apoplexy
• Emergency with high mortality, often from compression of the hypothalamus
• Consciousness is impaired and there is the danger of acute adrenal failure and
further hypotension
• Treatment is aimed at acute replacement of corticosteroids intravenously.
• Surgery to decompress the hypothalamus or optic nerve

44. Sheehan Syndrome
• Anterior pituitary necrosis after hypovolemia and hypotension in severe maternal
blood loss
• Pituitary, because of its pregnancy- associated hyperplasia and increased
vascularity, is particularly vulnerable to hypovolemia and hypotension
• Treatment – replacement of hormones

45. INFECTIONS
• Mild immunosuppression in pregnancy associated with alterations in
circulating maternal steroids
• Systemic infections and septicemia, but rarely coma.
• Herpes simplex virus encephalitis in pregnancy

46. ORGAN FAILURE OCCASIONALLY
LEADING TO COMA RENAL FAILURE
Acute renal failure
• ARF may be caused by hemorrhagic or septic shock, or severe preeclampsia.
• HELLP may lead to a decrease in glomerular filtration and renal failure, occasionally
with acute tubular necrosis- usually resolves
• DIC – causes ARF
• Other -malignant hypertension, infections, scleroderma, vasculitis, microangiopathic
• Hemolytic anemia transplant rejection, hemolytic uremic syndrome, malignancies, or
drug toxicity.

47. Acute Liver Failure
• Prepartum or postpartum with eclampsia, HELLP syndrome, or
acute viral hepatitis
• Acute fatty liver and HELLP syndrome occur most frequently in
the third trimester
• Presents with itching, diarrhea, and jaundice
• COMA- occurs in patients with hepatic encephalopathy,
coagulopathy, hypoglycemia

48. Acute Fatty liver of pregnancy
• Occurs 1 in 7000 to 16,000 pregnancies
• Maternal mortality is almost 20%
• Usually is seen in the third trimester of pregnancy
• Presents with hepatic failure, microvesicular fatty infiltration of the liver, and
encephalopathy
• Nausea and vomiting (75%), jaundice, or epigastric pain.
• There may be DIC, acute tubular necrosis, and pulmonary edema
• Treatment is with supportive measures
• On occasion, liver transplantation is recommended

49. PULMONARY DISEASE AND FAILURE IN
PREGNANCY
• Acute respiratory failure and ARDS, and all of the pulmonary disorders may cause
coma from hypoxia.
• Acute respiratory failure in pregnancy due to thromboembolism, AFE, venous air
embolism, or ARDS
Aspiration pneumonia may arise during ;
• Decreased consciousness in labor and delivery
• Increase in intragastric pressure by compression by the pregnant uterus
• Delayed gastric emptying

50. Venous Air Embolism
• Predominantly iatrogenic complication
• Is caused by air entry into the subplacental venous sinuses
• Occurs during abortion, delivery, labor, and other interventions
• Risk is higher in pregnant women, who may have a tear in their placentae.

51. Pathophysiology
• Complications have been reported with as little as 20 mL of air
• More than 5 mL/kg of air displaced into the intravenous space is required for
significant injury (shock or cardiac arrest)
• Air travels to the heart and prevents blood flow to the lungs, frequently causing a
blood-air interface, with microemboli, platelet injury, and inflammatory white cell
response leading to ARDS
Clinical features include shortness of breath, tachypnea and tachycardia, hypotension,
and sweating.
Clinical picture similar to that of pulmonary embolism, with hypoxia, decreased PCO 2
levels pulmonary veins
• In sitting position, gas will travel internal jugular vein to the cerebral circulation,
leading to neurologic symptoms.
• In a recumbent position, gas proceeds into the right ventricle and pulmonary
circulation

52. Investigations
• Lab tests not sensitive or specific CXR
• Transesophageal echocardiography (TEE) has the highest sensitivity for detecting the
presence of air in the right ventricular outflow tract
• CT scans can detect air emboli in the central venous system
Management
Identification of the source of air
Prevention of further air entry
Hemodynamic support.

53. References
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951301
• https://www.google.com/url?sa=t&rct
• https://www.rollingstone.com/culture/culture-news/coma-
birth-woman-arisona-hacienda-healthcare-776902/
• Dewhurst’s Textbook of Obstetrics & Gynaecology 9th edition
( PDFDrive.com ).pdf

54. 8/3/2021
Dr ANZO William Adiga 54