SlideShare a Scribd company logo
1 of 49
MATERNAL
COLLAPSE
Dr KTD Priyadarshani
Registrar- Emergency Medicine
National Hospital Kandy
2024/02/15
MATERNAL COLLAPSE
“an acute event involving the cardio-respiratory systems and/or brain ,
resulting in a reduced or absent conscious level (and potentially death),
at any stage in pregnancy and up to 6 weeks after delivery”.
-RCOG guideline -Maternal Collapse in Pregnancy and the Puerperium 2019-
• rare
• But a life-threatening event
• if maternal collapse which is not due to cardiac arrest is not treated
effectively, maternal cardiac arrest can then occur.
The incidence of cardiac arrest in pregnancy much rarer than maternal collapse.
1 :36 000 maternities.
Most common causes of maternal collapse
vasovagal attack
post-ictal state following epileptic seizure
CASE DISCUSSION
Sunday 1 AM
A 36 year, P3 C2, admitted at POA 31 weeks
Complain of severe abdominal pain
Triage parameters- PR 150 BP-unrecordable SpO2-poor
waveform Drowsy FHB+
CASE-ACUTE MANAGEMENT
Call for help
Take to resus bed- lateral position
Attach to mutipara monitor with ECG leads
Assess ABCDE and stabilise
CASE-ACUTE MANAGEMENT
A- Obstructed with secretion - open airway by maneuvers, suck out secretions, oropharyngeal airways
B- Dyspnic, RR 30, SpO2 96% on air, chest expansion and air entry- B/L equal - prop up, O2 via NRBM 15
L/min
C- CRFT- 5 sec, PR 150 bpm, thready peripheral pulse, BP- unrecordable- IV access with 2 16 G cannula at or
above diaphragm, Blood for IX- CBS, VBG, DT, FBC, RFT, SE, LFT, Left lateral tilt, Fast NS boluses
D- GCS- 12/15 ( E3V4M5), BL PERTL, CBS 130mg/dL-
E- T 37’C, pale +++, guarding, tender abdomen- CTG, Catheterisation
MEOWS chart
CASE-ACUTE MANAGEMENT
During transfer to USS bed- patient become
unresponsive….
MATERNAL CARDIAC ARREST
Cardiac arrest that occurs at any stage of pregnancy up to 6 weeks after birth
Maternal cardiac arrest 1:30,000
Maternal mortality (94%)high in low and lower-middle income countries
Start CPR according to standard ALS guideline
Identify and correct cause of arrest using 4 Ts and 4 Hs as appropriate.
PHYSIOLOGICAL CHANGES IN PREGNANCY
AND THE EFFECTS ON RESUSCITATION
SLCOG guideline 2021-
Immediate Resuscitation
Following Maternal Collapse
During Pregnancy
AORTOCAVAL COMPRESSION
20 weeks of gestation onwards
• Gravid uterus compress IVC
• reduces VR in the supine position
• CO reduced by up to 30–40%.
Supine hypotension itself can precipitate maternal collapse,
which is usually reversed by turning the woman into the left
lateral position.
‘up, off and over 'technique
• In trauma- spinal protective measures
CIRCULATION
• Uterus receives 10% of the CO at term.
• CO ( increased by 40%) and hyperdynamic circulation in pregnancy large
volumes of blood loss rapidly.
• So , healthy one tolerate up to 35% of blood loss before becoming symptomatic.(less
tolerated if anemia)
• Often maternal tachycardia may be the only sign of hypovolemia until very late in
the hemorrhage.
• Diaphragm and abdominal content are elevated by the gravid uterus
• Establish IV access as soon as possible , preferably at a level above diaphragm.
• if failed central venous access, venous cut down or intraosseous
• Aggressive volume replacement-
• Initial recommended volume replacement is 1 L over 20 min
• Caution in preeclampsia or eclampsia
• Hand position- slightly higher than normal (2-3 cm)
• Use defibrillator pads in standard position as far as possible. If left lateral tilt and large breasts
make placement of apical electrode difficult , place antero-posterior or bi-axillary electrode
position.
• Point of care ultrasound by a skilled operator can assist
• No alteration in algorithm drugs, doses or defibrillation energy (4J/kg)
ASPIRATION
Pregnant women are at higher risk of regurgitation and aspiration due to,
• progesterone effect relaxing the LES .
• raised intra-abd pressure secondary to the gravid uterus.
Cause Aspiration pneumonitis (Mendelson's syndrome)
The risks can be minimized by ,
• early intubation with effective cricoid pressure
• Use cuffed ET tube
• use of H2 antagonists and antacids
INTUBATION
Difficult intubation is more likely in pregnancy due to,
• Weight gain in pregnancy,
• large breasts inhibiting the working space
• laryngeal oedema
Consider early tracheal intubation (ET tubes 0.5-1 mm smaller than usual
because of oedema and swelling.)
Bag and mask ventilation or supraglottic airway should be
undertaken until intubation can be achieved.
RESPIRATORY CHANGES
progesterone in pregnancy  increased respiratory drive TV & MV
Splinting of the diaphragm by the enlarged uterus  decrease FRC and makes
ventilation more difficult.
O2 consumption of the fetoplacental unit become more hypoxic during
hypoventilation.
Supplemental high flow oxygen via nasal cannula should be administered as soon
as possible to counteract rapid deoxygenation. This should be maintained until
intubation
CAUSES-PREGNANCY RELATED OR ALREADY EXISTING
CASE CONTINUED…
Focused history
Previous delivery- twins- EM LSCS due to severe preeclampsia
Currently on Methyl dopa for PIH- on regular follow up
Had no PET symptoms prior to event, no seizure
CASE CONTINUED…
At 4th minute- No ROSC..
What is the next step in management?
PERIMORTEM CAESAREAN SECTION/
RESUSCITATIVE HYSTEROTOMY
primarily in the interests of maternal survival- improves maternal CO 25% by
Reduce uterine blood flow
Relieves diaphragmartic pressure and aortocaval compression
• prerequsites
Done without evaluating fetal wellbeing
Done without consent- The doctrine of ‘best interests of the patient’
When the CPR ongoing without moving- do not wait for seniors, USS or sterile prep
Indication for PMCS In women over 20 weeks of gestation,(fundal height above umbilicus) if
there is no response to correctly performed CPR within 4 minutes of maternal collapse / if
resuscitation is continued beyond this.
Decision by 4 minutes and aim for delivery within 5 minutes of cardiac arrest.
PMCS increases maternal cardiac output by
30%.
It also allows for internal chest compressions
by inserting the hand through the open
abdomen up to the diaphragm and
compressing the posterior aspect of the heart
against the chest wall.
Delivery of the fetus and placenta reduces
oxygen consumption, improves venous return
and cardiac output and makes ventilation
easier
a disposable scalpel
A bladder retractor
a pair of scissors
2 metal clamps
3 cord clamps
a kidney dish
a pack of antiseptic pour solution
abdominal pads
• Manual uterine displacement can be stopped immediately prior to incision.
• With no circulation, blood loss is minimal, and no anaesthesia or analgesia is required.
• Incision which facilitates the most rapid access- midline vertical incision ( from pubic symphysis to at least
umbilicus) or suprapubic transverse incision
• Retract abdominal wall laterally
• Reflect bladder inferiorly and empty by aspiration
• Make a small incision ( 5 cm) vertically in to the inferior presenting part of the uterus until amniotic fluid
comes or through endometrium
• Insert 2 fingers and lift up uterus from foetus
• Extend uterine incision up to fundus with safety scissors curved away from foetus
• Delivery of the foetus and placenta- clamp the cord twice and cut between clamps
• Give the neonate to neonatal team
• Control bleeding by packing, clamping bleeding vessels (Starts bleeding when ROSC achieved) & suture
uterine incision
• Give synthetic oxytocin 5 units IV
• Continue maternal resuscitation
If resuscitation is successful following birth,
prompt transfer to OT to control ensuing
haemorrhage and complete the operation
watch for bleeding, consider further
oxytocic drugs, TXA, antibiotic
prophylaxis
as well as anaesthesia and sedation at that
point.
If resuscitation failinform
coronerpostmotem
CASE CONTINUED…
During PMC
Large amount of free blood and placental tissue in the abdomen obstructing
vizualising the uterus
8th minute after arrest a live male infant was delivered with APGAR 1 and 6 at 1 & 5
min respectively
ALS continued
ROSC achieved at 13 min
COMMON CAUSES OF MATERNAL COLLAPSE
POST RESUSCITATION CARE
1. HAEMORRHAGE
• Commonest cause of maternal collapse
• Major obstetric hemorrhage incidence 3.7/1000 maternities
• Two major types
• APH ( placenta previa, placental abruption, placenta acreta/increta/percreta, uterine
rupture, ectopic pregnancy )
• PPH- Should not forget Concealed hemorrhage.
MX-
If APH delivery fetus and placenta promptly to control the haemorrhage.
IV Tranexamic acid significantly reduces mortality due to PPH.
If activate MTP box 3 comes before box 2(contain cryo)1,3,23,2
2.CARDIAC DISEASE
• Most common overall cause of indirect maternal death.
• 1/5 deaths in an ambulance or A&E department.
• So, paramedics and A&E staff must be familiar with the mx of maternal collapse.
• Main cardiac causes of maternal death
• -Myocardial infarction
• -Aortic root dissection
• -Cardiomyopathy
• Other cardiac causes include: Dissection of the coronary artery, Acute LVF,IE,MS
• Mx-After successful resuscitation, cardiac cases should be managed by an expert cardiology
team.
• Eg: Myocardial infarction PCI+/-Stenting
3. ECLAMPSIA
• Usually obvious in the inpatient setting.(diagnosis of preeclampsia already made ,
seizure witnessed)
• In the community setting, fitting after 20 weeks’ gestation may be attributable to
eclampsia, notably where there is no known history of epilepsy.
• But, consider epilepsy in maternal collapse associated with seizure.
Mx-
• Anticonvulsants – a loading dose of 4 g MgSO4 should be given IV over 5 min ,
followed by an infusion of 1 g/hour for 24 hours.
• If Recurrent fits a further dose of 2–4 g given IV 5 minutes.
2. Antihypertensives-
IV labetalol 20-50 g loading over two minutes Repeat every 10 mins maximum 4 doses (IV Total dose
up to 200 mg )
If still BP >160 /110 mmHg  IV labetalol infusion / IV Hydralazine.
(IV Labetalol infusion 20 mg/hr ,double rate at every 30 min until BP controlled)
3. Strict fluid balance- IP 80 ml/hr
4. Only cure is delivery of the baby  IV dexamethasone if preterm
5. Look for complications –HELLP/pulmonary oedema/cerebral hemorrhage/AKI
4.THROMBOEMBOLISM-PE
• Acute PE - one of the leading causes of maternal death in high-income countries
• Hx - Immobilization , dehydration, pre -eclampsia, sepsis
• p/c- SOB , pleuritic chest pain, cough, hemoptysis, tachypnoea, hypotension, tachycardia ,cardiac
arrest
• based on the assessment of clinical probability(pre-test), D-dimer measurement, CUS, and CTPA–may
safely exclude PE in pregnancy.
• Mx-LMWH is the treatment of choice for PE during pregnancy
• If life threatening PE with hemodynamic compromise
• Thrombolytic therapy ( rtPA)
• Embolectomy ( percutaneous catheter thrombus fragmentation/ surgical)
• ECMO
5. SEPSIS (CHORIOAMNIONITIS,UTI,CNS INFECTIONS ,
PNEUMONIA)
• A significant cause of maternal morbidity and mortality.
• Bacteraemia ( in the absence of pyrexia /raised WBC), can progress rapidly to severe
sepsis  septic shock collapse.
• The most common organisms implicated in obstetric sepsis
• -streptococcal groups A, B and D,
• -pneumococcus
• -Escherichia coli
Mx-
Septic shock mx according to Surviving Sepsis Campaign guidelines.
Hour -1 Bundle
Take 3-serum lactate, VBG, blood cultures
Administer 3-
1. broad spectrum antibiotic(s)
2. If hypotension or lactate > 4  fluid resuscitation(initial minimum of 30 ml/kg of crystalloid )
3. a vasopressor (noradrenaline , vasopressin or adrenaline ) and/or an inotrope (dobutamine) to
maintain MAP>65 mmHg.
Consider steroids if unresponsive to fluid resuscitation and vasopressor therapy.
6.ANAPHYLAXIS
A severe, life-threatening generalized or systemic hypersensitivity reaction, resulting in
respiratory, cutaneous and circulatory changes, and possibly GI disturbance and collapse.
Common triggers (drugs, latex, animal allergens ,foods )
Anaphylaxis is likely when all of the following three criteria are met:
-sudden onset and rapid progression of symptoms
-life-threatening airway / breathing / circulation problems
- skin and/or mucosal changes (flushing, urticaria, angioedema).
Mast cell tryptase levels can be useful in confirming the diagnosis.
Mx-
IM 1:1000 adrenaline 500 micrograms (0.5 ml)
can be repeated after 5 minutes if there is no effect.
In experienced hands, 50 microgram bolus (0.5 ml of 1:10 000 solution) can be
titrated intravenously.
Adjuvant therapy -chlorphenamine 10 mg and hydrocortisone 200 mg.( IM/IV)
7. INTRACRANIAL HEMORRHAGE
ICH is a significant complication of
Uncontrolled ( systolic ) hypertension
ruptured aneurysms
arteriovenous malformations.
p/c –seizures , maternal collapse, but often severe headache precedes this.
Mx-
Neuroradiologists and neurosurgeons should be involved in the care of pregnant women
with ICH at the earliest opportunity.
8. DRUG TOXICITY /OVERDOSE/POISONING
A cause of collapse especially outside of hospital. (OP/PCM/Kaneru)
MgSO4 in the presence of renal impairment/LA-in hospital
Signs of severe toxicity
-sudden LOC , convulsions, cardiovascular collapse, sinus bradycardia
conduction blocks , asystole ,ventricular tachyarrhythmias
Mx-
Mg toxicity 10 ml 10% (1g)calcium gluconate /calcium chloride slow IV injection
For cardiac arrest due to LAIV bolus injection 20% Intralipid 1.5 ml/kg over 1 min followed by
an IV infusion of Intralipid 20% 15 ml/kg/h. The bolus injection can be repeated twice at 5-
minute.
9.ENDOCRINE-HYPOGLYCAEMIA,DKA
Hypoglycemia-Blood glucose levels <70mg/dl
Causes-known DM/GDM on drugs, missed meals ,fasting ,exercise , sepsis
Diagnosis-Whipple’s triad
Clinical fx -Neurogenic/Neuroglycopenic
Mx-IV 50% Dextrose 50ml/IV 25% Dextrose 100ml
If IV access difficult-IM Glucogon1mg(takes 15-20 min to work)
IV Thiamine 100 mg stat(Wernicke's Korsakoff sx)
DKA
Definition -Blood glucose > 11.0mmol/L or known DM
Ketonemia > 3.0mmol/L or ketonuria (more than 2+ on standard urine sticks)
Bicarbonate (HCO3-) < 15.0mmol/L or venous pH < 7.3
Mx- IV fluid/ Potassium replacement /a fixed rate intravenous insulin infusion (FRIII)
10.ELECTROLYTES-NA+/K+
Hyponatremia-Na+<135 mmol/L
Mild 125-134 / Moderate 120-124 / Severe <120
Causes-Vomiting , diarrhoea , sweating , SIADH, pregnancy perse
speed of onset more important than level
Serious manifestations <115mmol/L
p/c-muscle weakness , confusion, seizures, coma, ICP
Mx-rapid correction 3% NaCl 3ml/kg over 30 min
(rise not more than 1-1.5 mmol/hr for 2-3 hrs,10-12 mmol/L over 12 hr)
Hyperkalemia
Mx- IV 10% Cal gluconate 30 ml over 10 min
Nebulize with salbutamol
10 U of S.insulin+50 ml of 50% Dextrose
CLINICAL GOVERNANCE
Documentation- accurate documentation in all cases of maternal
collapse, whether or not resuscitation is successful, is essential
Debriefing is recommended for the woman, her family and the staff
involved in the event
Incident reporting
WHAT ARE THE OUTCOMES FOR MOTHER
AND BABY AFTER MATERNAL COLLAPSE?
Outcomes for mothers and babies depend on
-the cause of collapse
-gestational age
-access to emergency care
Survival rates being poorer if the collapse occurs out of hospital.
In maternal cardiac arrest maternal survival rates of over 50% have been reported.
REFERENCES
1. RCOG guideline -Maternal Collapse in Pregnancy and the Puerperium 2019
2. SLCOG guideline -Immediate Resuscitation Following Maternal Collapse During
Pregnancy 2021
3. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism
4. Advanced Life Support-ERC guideline 2021 edition
5. Life in fast lane
6. Case report- Donnel NJ, Cardiopulmonary arrest in pregnancy: two case reports of
successful outcomes in association with perimortem cesarean delivery- BJA 2009
Approach to maternal collapse and cardiac arrest.pptx

More Related Content

Similar to Approach to maternal collapse and cardiac arrest.pptx

POST PARTUM HAEMORRHAGE (PPH).pptx
POST PARTUM HAEMORRHAGE (PPH).pptxPOST PARTUM HAEMORRHAGE (PPH).pptx
POST PARTUM HAEMORRHAGE (PPH).pptxdeepikaagarwal68
 
Obstetrical emergencies .
Obstetrical emergencies .Obstetrical emergencies .
Obstetrical emergencies .Pravin Ghodke
 
CPR in pregnant women anesthesia and ER.pptx
CPR in pregnant women anesthesia and ER.pptxCPR in pregnant women anesthesia and ER.pptx
CPR in pregnant women anesthesia and ER.pptxibrahimelkathiri1
 
COMPLICATED OBSTETRIC CONDITIONS.pptx
COMPLICATED OBSTETRIC CONDITIONS.pptxCOMPLICATED OBSTETRIC CONDITIONS.pptx
COMPLICATED OBSTETRIC CONDITIONS.pptxsruthireddy847506
 
Ectopic Pregnancy-1.pptx
Ectopic Pregnancy-1.pptxEctopic Pregnancy-1.pptx
Ectopic Pregnancy-1.pptxImranKhan127540
 
Bls pada ibu hamil
Bls pada ibu hamil Bls pada ibu hamil
Bls pada ibu hamil ssuserc74875
 
Peri arrest scenario in pregnancy
Peri arrest scenario in pregnancyPeri arrest scenario in pregnancy
Peri arrest scenario in pregnancyVaidyanathan R
 
Obstructed labor management
Obstructed labor managementObstructed labor management
Obstructed labor managementBeka Aberra
 
3rd stage of labour by dr shazia a khan 4 mar 19
3rd stage of labour by dr shazia a khan 4 mar 193rd stage of labour by dr shazia a khan 4 mar 19
3rd stage of labour by dr shazia a khan 4 mar 19mahmoodayub2
 
Maternal collapse
Maternal collapseMaternal collapse
Maternal collapseArsla Memon
 
Inversion, retained placenta , afe
Inversion, retained placenta , afeInversion, retained placenta , afe
Inversion, retained placenta , afeSushma Sharma
 
Valvular heart diseases in pregnancy
Valvular heart diseases in pregnancyValvular heart diseases in pregnancy
Valvular heart diseases in pregnancyKuntal Surana
 

Similar to Approach to maternal collapse and cardiac arrest.pptx (20)

POST PARTUM HAEMORRHAGE (PPH).pptx
POST PARTUM HAEMORRHAGE (PPH).pptxPOST PARTUM HAEMORRHAGE (PPH).pptx
POST PARTUM HAEMORRHAGE (PPH).pptx
 
Obstetric emergencies
Obstetric emergenciesObstetric emergencies
Obstetric emergencies
 
Obstetrical emergencies .
Obstetrical emergencies .Obstetrical emergencies .
Obstetrical emergencies .
 
CPR in pregnant women anesthesia and ER.pptx
CPR in pregnant women anesthesia and ER.pptxCPR in pregnant women anesthesia and ER.pptx
CPR in pregnant women anesthesia and ER.pptx
 
COMPLICATED OBSTETRIC CONDITIONS.pptx
COMPLICATED OBSTETRIC CONDITIONS.pptxCOMPLICATED OBSTETRIC CONDITIONS.pptx
COMPLICATED OBSTETRIC CONDITIONS.pptx
 
Cesarean section
Cesarean sectionCesarean section
Cesarean section
 
Ectopic Pregnancy-1.pptx
Ectopic Pregnancy-1.pptxEctopic Pregnancy-1.pptx
Ectopic Pregnancy-1.pptx
 
Maternal collapse in pregnancy
Maternal collapse in pregnancyMaternal collapse in pregnancy
Maternal collapse in pregnancy
 
Bls pada ibu hamil
Bls pada ibu hamil Bls pada ibu hamil
Bls pada ibu hamil
 
Peri arrest scenario in pregnancy
Peri arrest scenario in pregnancyPeri arrest scenario in pregnancy
Peri arrest scenario in pregnancy
 
Obstructed labor management
Obstructed labor managementObstructed labor management
Obstructed labor management
 
3rd stage of labour by dr shazia a khan 4 mar 19
3rd stage of labour by dr shazia a khan 4 mar 193rd stage of labour by dr shazia a khan 4 mar 19
3rd stage of labour by dr shazia a khan 4 mar 19
 
L28 Obstetric emergencies
L28 Obstetric emergenciesL28 Obstetric emergencies
L28 Obstetric emergencies
 
Pph1 [autosaved]
Pph1 [autosaved]Pph1 [autosaved]
Pph1 [autosaved]
 
Maternal collapse
Maternal collapseMaternal collapse
Maternal collapse
 
Obstetrical emergencies
Obstetrical emergenciesObstetrical emergencies
Obstetrical emergencies
 
Postpartum hemorrhage for undergraduate
Postpartum hemorrhage for undergraduatePostpartum hemorrhage for undergraduate
Postpartum hemorrhage for undergraduate
 
Inversion, retained placenta , afe
Inversion, retained placenta , afeInversion, retained placenta , afe
Inversion, retained placenta , afe
 
Valvular heart diseases in pregnancy
Valvular heart diseases in pregnancyValvular heart diseases in pregnancy
Valvular heart diseases in pregnancy
 
Pregnancy & cvd
Pregnancy & cvdPregnancy & cvd
Pregnancy & cvd
 

More from KTD Priyadarshani

Pelvic Fracture managemnt- Case based discussion .pptx
Pelvic Fracture managemnt- Case based discussion .pptxPelvic Fracture managemnt- Case based discussion .pptx
Pelvic Fracture managemnt- Case based discussion .pptxKTD Priyadarshani
 
Anti-arrhythmics pharmacology 2023.pptx
Anti-arrhythmics pharmacology  2023.pptxAnti-arrhythmics pharmacology  2023.pptx
Anti-arrhythmics pharmacology 2023.pptxKTD Priyadarshani
 
Thyroid Emergencies updated management .pptx
Thyroid Emergencies updated management .pptxThyroid Emergencies updated management .pptx
Thyroid Emergencies updated management .pptxKTD Priyadarshani
 
Diabetes Keto Acidosis management. .pptx
Diabetes Keto Acidosis management. .pptxDiabetes Keto Acidosis management. .pptx
Diabetes Keto Acidosis management. .pptxKTD Priyadarshani
 
ED approach to atrial fibrillation.pptx
ED approach to atrial fibrillation.pptxED approach to atrial fibrillation.pptx
ED approach to atrial fibrillation.pptxKTD Priyadarshani
 
Tri Cyclic Antidepressant Poisoning.pptx
Tri Cyclic Antidepressant Poisoning.pptxTri Cyclic Antidepressant Poisoning.pptx
Tri Cyclic Antidepressant Poisoning.pptxKTD Priyadarshani
 
Organo Phosphate Poisoning.pptx
Organo Phosphate Poisoning.pptxOrgano Phosphate Poisoning.pptx
Organo Phosphate Poisoning.pptxKTD Priyadarshani
 
Oral antidiabetics toxicity.pptx
Oral antidiabetics toxicity.pptxOral antidiabetics toxicity.pptx
Oral antidiabetics toxicity.pptxKTD Priyadarshani
 
Calcium channel blocker & Beta blocker Poisoning.pptx
Calcium channel blocker & Beta blocker Poisoning.pptxCalcium channel blocker & Beta blocker Poisoning.pptx
Calcium channel blocker & Beta blocker Poisoning.pptxKTD Priyadarshani
 
Use of bicarbonate in toxicology .pptx
Use of bicarbonate in toxicology .pptxUse of bicarbonate in toxicology .pptx
Use of bicarbonate in toxicology .pptxKTD Priyadarshani
 
Organo Phosphate Poisoning.pptx
Organo Phosphate Poisoning.pptxOrgano Phosphate Poisoning.pptx
Organo Phosphate Poisoning.pptxKTD Priyadarshani
 

More from KTD Priyadarshani (20)

Pelvic Fracture managemnt- Case based discussion .pptx
Pelvic Fracture managemnt- Case based discussion .pptxPelvic Fracture managemnt- Case based discussion .pptx
Pelvic Fracture managemnt- Case based discussion .pptx
 
Anti-arrhythmics pharmacology 2023.pptx
Anti-arrhythmics pharmacology  2023.pptxAnti-arrhythmics pharmacology  2023.pptx
Anti-arrhythmics pharmacology 2023.pptx
 
Thyroid Emergencies updated management .pptx
Thyroid Emergencies updated management .pptxThyroid Emergencies updated management .pptx
Thyroid Emergencies updated management .pptx
 
Diabetes Keto Acidosis management. .pptx
Diabetes Keto Acidosis management. .pptxDiabetes Keto Acidosis management. .pptx
Diabetes Keto Acidosis management. .pptx
 
Acute Hemolysis.pptx
Acute Hemolysis.pptxAcute Hemolysis.pptx
Acute Hemolysis.pptx
 
ED approach to atrial fibrillation.pptx
ED approach to atrial fibrillation.pptxED approach to atrial fibrillation.pptx
ED approach to atrial fibrillation.pptx
 
Toxidromes.pptx
Toxidromes.pptxToxidromes.pptx
Toxidromes.pptx
 
Toxic Alcohol.pptx
Toxic Alcohol.pptxToxic Alcohol.pptx
Toxic Alcohol.pptx
 
Tri Cyclic Antidepressant Poisoning.pptx
Tri Cyclic Antidepressant Poisoning.pptxTri Cyclic Antidepressant Poisoning.pptx
Tri Cyclic Antidepressant Poisoning.pptx
 
Snake Bite Management.pptx
Snake Bite Management.pptxSnake Bite Management.pptx
Snake Bite Management.pptx
 
Propanil Poisoning.pptx
Propanil Poisoning.pptxPropanil Poisoning.pptx
Propanil Poisoning.pptx
 
Poisonous Plants .pptx
Poisonous Plants .pptxPoisonous Plants .pptx
Poisonous Plants .pptx
 
Organo Phosphate Poisoning.pptx
Organo Phosphate Poisoning.pptxOrgano Phosphate Poisoning.pptx
Organo Phosphate Poisoning.pptx
 
ECG in Toxicology.potx
ECG in Toxicology.potxECG in Toxicology.potx
ECG in Toxicology.potx
 
Oral antidiabetics toxicity.pptx
Oral antidiabetics toxicity.pptxOral antidiabetics toxicity.pptx
Oral antidiabetics toxicity.pptx
 
Calcium channel blocker & Beta blocker Poisoning.pptx
Calcium channel blocker & Beta blocker Poisoning.pptxCalcium channel blocker & Beta blocker Poisoning.pptx
Calcium channel blocker & Beta blocker Poisoning.pptx
 
Use of bicarbonate in toxicology .pptx
Use of bicarbonate in toxicology .pptxUse of bicarbonate in toxicology .pptx
Use of bicarbonate in toxicology .pptx
 
Organo Phosphate Poisoning.pptx
Organo Phosphate Poisoning.pptxOrgano Phosphate Poisoning.pptx
Organo Phosphate Poisoning.pptx
 
Acute Pancreatitis.pptx
Acute Pancreatitis.pptxAcute Pancreatitis.pptx
Acute Pancreatitis.pptx
 
Biliary emergencies.pptx
Biliary emergencies.pptxBiliary emergencies.pptx
Biliary emergencies.pptx
 

Recently uploaded

Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.GawadHemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.GawadNephroTube - Dr.Gawad
 
Failure to thrive in neonates and infants + pediatric case.pptx
Failure to thrive in neonates and infants  + pediatric case.pptxFailure to thrive in neonates and infants  + pediatric case.pptx
Failure to thrive in neonates and infants + pediatric case.pptxclaviclebrown44
 
Young & Hot ℂall Girls Patna 8250077686 WhatsApp Number Best Rates of Patna ℂ...
Young & Hot ℂall Girls Patna 8250077686 WhatsApp Number Best Rates of Patna ℂ...Young & Hot ℂall Girls Patna 8250077686 WhatsApp Number Best Rates of Patna ℂ...
Young & Hot ℂall Girls Patna 8250077686 WhatsApp Number Best Rates of Patna ℂ...Model Neeha Mumbai
 
Signs It’s Time for Physiotherapy Sessions Prioritizing Wellness
Signs It’s Time for Physiotherapy Sessions Prioritizing WellnessSigns It’s Time for Physiotherapy Sessions Prioritizing Wellness
Signs It’s Time for Physiotherapy Sessions Prioritizing WellnessGokuldas Hospital
 
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptxGross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptxDr. Rabia Inam Gandapore
 
Treatment Choices for Slip Disc at Gokuldas Hospital
Treatment Choices for Slip Disc at Gokuldas HospitalTreatment Choices for Slip Disc at Gokuldas Hospital
Treatment Choices for Slip Disc at Gokuldas HospitalGokuldas Hospital
 
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose AcademicsCytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose AcademicsMedicoseAcademics
 
Mgr university bsc nursing adult health previous question paper with answers
Mgr university  bsc nursing adult health previous question paper with answersMgr university  bsc nursing adult health previous question paper with answers
Mgr university bsc nursing adult health previous question paper with answersShafnaP5
 
Sonia Journal club presentation (2).pptx
Sonia Journal club presentation (2).pptxSonia Journal club presentation (2).pptx
Sonia Journal club presentation (2).pptxpalsonia139
 
How to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw materialHow to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw materialSherrylee83
 
ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
ROSE  CASE SPINAL SBRT BY DR KANHU CHARAN PATROROSE  CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATROKanhu Charan
 
Sell 5cladba adbb JWH-018 5FADB in stock
Sell 5cladba adbb JWH-018 5FADB in stockSell 5cladba adbb JWH-018 5FADB in stock
Sell 5cladba adbb JWH-018 5FADB in stocktammysayles9
 
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...marcuskenyatta275
 
Tips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES examTips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES examJunhao Koh
 
Overview on the Automatic pill identifier
Overview on the Automatic pill identifierOverview on the Automatic pill identifier
Overview on the Automatic pill identifierNidhi Joshi
 
Drug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptxDrug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptxMohammadAbuzar19
 
Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?bkling
 
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...Health Kinesiology Natural Bioenergetics
 
Renal Replacement Therapy in Acute Kidney Injury -time modality -Dr Ayman Se...
Renal Replacement Therapy in Acute Kidney Injury -time  modality -Dr Ayman Se...Renal Replacement Therapy in Acute Kidney Injury -time  modality -Dr Ayman Se...
Renal Replacement Therapy in Acute Kidney Injury -time modality -Dr Ayman Se...Ayman Seddik
 
CAD CAM DENTURES IN PROSTHODONTICS : Dental advancements
CAD CAM DENTURES IN PROSTHODONTICS : Dental advancementsCAD CAM DENTURES IN PROSTHODONTICS : Dental advancements
CAD CAM DENTURES IN PROSTHODONTICS : Dental advancementsNaveen Gokul Dr
 

Recently uploaded (20)

Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.GawadHemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
 
Failure to thrive in neonates and infants + pediatric case.pptx
Failure to thrive in neonates and infants  + pediatric case.pptxFailure to thrive in neonates and infants  + pediatric case.pptx
Failure to thrive in neonates and infants + pediatric case.pptx
 
Young & Hot ℂall Girls Patna 8250077686 WhatsApp Number Best Rates of Patna ℂ...
Young & Hot ℂall Girls Patna 8250077686 WhatsApp Number Best Rates of Patna ℂ...Young & Hot ℂall Girls Patna 8250077686 WhatsApp Number Best Rates of Patna ℂ...
Young & Hot ℂall Girls Patna 8250077686 WhatsApp Number Best Rates of Patna ℂ...
 
Signs It’s Time for Physiotherapy Sessions Prioritizing Wellness
Signs It’s Time for Physiotherapy Sessions Prioritizing WellnessSigns It’s Time for Physiotherapy Sessions Prioritizing Wellness
Signs It’s Time for Physiotherapy Sessions Prioritizing Wellness
 
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptxGross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
 
Treatment Choices for Slip Disc at Gokuldas Hospital
Treatment Choices for Slip Disc at Gokuldas HospitalTreatment Choices for Slip Disc at Gokuldas Hospital
Treatment Choices for Slip Disc at Gokuldas Hospital
 
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose AcademicsCytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
 
Mgr university bsc nursing adult health previous question paper with answers
Mgr university  bsc nursing adult health previous question paper with answersMgr university  bsc nursing adult health previous question paper with answers
Mgr university bsc nursing adult health previous question paper with answers
 
Sonia Journal club presentation (2).pptx
Sonia Journal club presentation (2).pptxSonia Journal club presentation (2).pptx
Sonia Journal club presentation (2).pptx
 
How to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw materialHow to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw material
 
ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
ROSE  CASE SPINAL SBRT BY DR KANHU CHARAN PATROROSE  CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
 
Sell 5cladba adbb JWH-018 5FADB in stock
Sell 5cladba adbb JWH-018 5FADB in stockSell 5cladba adbb JWH-018 5FADB in stock
Sell 5cladba adbb JWH-018 5FADB in stock
 
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
 
Tips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES examTips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES exam
 
Overview on the Automatic pill identifier
Overview on the Automatic pill identifierOverview on the Automatic pill identifier
Overview on the Automatic pill identifier
 
Drug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptxDrug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptx
 
Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?
 
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
 
Renal Replacement Therapy in Acute Kidney Injury -time modality -Dr Ayman Se...
Renal Replacement Therapy in Acute Kidney Injury -time  modality -Dr Ayman Se...Renal Replacement Therapy in Acute Kidney Injury -time  modality -Dr Ayman Se...
Renal Replacement Therapy in Acute Kidney Injury -time modality -Dr Ayman Se...
 
CAD CAM DENTURES IN PROSTHODONTICS : Dental advancements
CAD CAM DENTURES IN PROSTHODONTICS : Dental advancementsCAD CAM DENTURES IN PROSTHODONTICS : Dental advancements
CAD CAM DENTURES IN PROSTHODONTICS : Dental advancements
 

Approach to maternal collapse and cardiac arrest.pptx

  • 1. MATERNAL COLLAPSE Dr KTD Priyadarshani Registrar- Emergency Medicine National Hospital Kandy 2024/02/15
  • 2. MATERNAL COLLAPSE “an acute event involving the cardio-respiratory systems and/or brain , resulting in a reduced or absent conscious level (and potentially death), at any stage in pregnancy and up to 6 weeks after delivery”. -RCOG guideline -Maternal Collapse in Pregnancy and the Puerperium 2019- • rare • But a life-threatening event • if maternal collapse which is not due to cardiac arrest is not treated effectively, maternal cardiac arrest can then occur.
  • 3. The incidence of cardiac arrest in pregnancy much rarer than maternal collapse. 1 :36 000 maternities. Most common causes of maternal collapse vasovagal attack post-ictal state following epileptic seizure
  • 4. CASE DISCUSSION Sunday 1 AM A 36 year, P3 C2, admitted at POA 31 weeks Complain of severe abdominal pain Triage parameters- PR 150 BP-unrecordable SpO2-poor waveform Drowsy FHB+
  • 5. CASE-ACUTE MANAGEMENT Call for help Take to resus bed- lateral position Attach to mutipara monitor with ECG leads Assess ABCDE and stabilise
  • 6. CASE-ACUTE MANAGEMENT A- Obstructed with secretion - open airway by maneuvers, suck out secretions, oropharyngeal airways B- Dyspnic, RR 30, SpO2 96% on air, chest expansion and air entry- B/L equal - prop up, O2 via NRBM 15 L/min C- CRFT- 5 sec, PR 150 bpm, thready peripheral pulse, BP- unrecordable- IV access with 2 16 G cannula at or above diaphragm, Blood for IX- CBS, VBG, DT, FBC, RFT, SE, LFT, Left lateral tilt, Fast NS boluses D- GCS- 12/15 ( E3V4M5), BL PERTL, CBS 130mg/dL- E- T 37’C, pale +++, guarding, tender abdomen- CTG, Catheterisation MEOWS chart
  • 7. CASE-ACUTE MANAGEMENT During transfer to USS bed- patient become unresponsive….
  • 8.
  • 9. MATERNAL CARDIAC ARREST Cardiac arrest that occurs at any stage of pregnancy up to 6 weeks after birth Maternal cardiac arrest 1:30,000 Maternal mortality (94%)high in low and lower-middle income countries Start CPR according to standard ALS guideline Identify and correct cause of arrest using 4 Ts and 4 Hs as appropriate.
  • 10.
  • 11.
  • 12. PHYSIOLOGICAL CHANGES IN PREGNANCY AND THE EFFECTS ON RESUSCITATION SLCOG guideline 2021- Immediate Resuscitation Following Maternal Collapse During Pregnancy
  • 13. AORTOCAVAL COMPRESSION 20 weeks of gestation onwards • Gravid uterus compress IVC • reduces VR in the supine position • CO reduced by up to 30–40%. Supine hypotension itself can precipitate maternal collapse, which is usually reversed by turning the woman into the left lateral position. ‘up, off and over 'technique • In trauma- spinal protective measures
  • 14. CIRCULATION • Uterus receives 10% of the CO at term. • CO ( increased by 40%) and hyperdynamic circulation in pregnancy large volumes of blood loss rapidly. • So , healthy one tolerate up to 35% of blood loss before becoming symptomatic.(less tolerated if anemia) • Often maternal tachycardia may be the only sign of hypovolemia until very late in the hemorrhage. • Diaphragm and abdominal content are elevated by the gravid uterus
  • 15. • Establish IV access as soon as possible , preferably at a level above diaphragm. • if failed central venous access, venous cut down or intraosseous • Aggressive volume replacement- • Initial recommended volume replacement is 1 L over 20 min • Caution in preeclampsia or eclampsia • Hand position- slightly higher than normal (2-3 cm) • Use defibrillator pads in standard position as far as possible. If left lateral tilt and large breasts make placement of apical electrode difficult , place antero-posterior or bi-axillary electrode position. • Point of care ultrasound by a skilled operator can assist • No alteration in algorithm drugs, doses or defibrillation energy (4J/kg)
  • 16. ASPIRATION Pregnant women are at higher risk of regurgitation and aspiration due to, • progesterone effect relaxing the LES . • raised intra-abd pressure secondary to the gravid uterus. Cause Aspiration pneumonitis (Mendelson's syndrome) The risks can be minimized by , • early intubation with effective cricoid pressure • Use cuffed ET tube • use of H2 antagonists and antacids
  • 17. INTUBATION Difficult intubation is more likely in pregnancy due to, • Weight gain in pregnancy, • large breasts inhibiting the working space • laryngeal oedema Consider early tracheal intubation (ET tubes 0.5-1 mm smaller than usual because of oedema and swelling.) Bag and mask ventilation or supraglottic airway should be undertaken until intubation can be achieved.
  • 18. RESPIRATORY CHANGES progesterone in pregnancy  increased respiratory drive TV & MV Splinting of the diaphragm by the enlarged uterus  decrease FRC and makes ventilation more difficult. O2 consumption of the fetoplacental unit become more hypoxic during hypoventilation. Supplemental high flow oxygen via nasal cannula should be administered as soon as possible to counteract rapid deoxygenation. This should be maintained until intubation
  • 19. CAUSES-PREGNANCY RELATED OR ALREADY EXISTING
  • 20. CASE CONTINUED… Focused history Previous delivery- twins- EM LSCS due to severe preeclampsia Currently on Methyl dopa for PIH- on regular follow up Had no PET symptoms prior to event, no seizure
  • 21. CASE CONTINUED… At 4th minute- No ROSC.. What is the next step in management?
  • 22. PERIMORTEM CAESAREAN SECTION/ RESUSCITATIVE HYSTEROTOMY primarily in the interests of maternal survival- improves maternal CO 25% by Reduce uterine blood flow Relieves diaphragmartic pressure and aortocaval compression • prerequsites Done without evaluating fetal wellbeing Done without consent- The doctrine of ‘best interests of the patient’ When the CPR ongoing without moving- do not wait for seniors, USS or sterile prep Indication for PMCS In women over 20 weeks of gestation,(fundal height above umbilicus) if there is no response to correctly performed CPR within 4 minutes of maternal collapse / if resuscitation is continued beyond this. Decision by 4 minutes and aim for delivery within 5 minutes of cardiac arrest.
  • 23. PMCS increases maternal cardiac output by 30%. It also allows for internal chest compressions by inserting the hand through the open abdomen up to the diaphragm and compressing the posterior aspect of the heart against the chest wall. Delivery of the fetus and placenta reduces oxygen consumption, improves venous return and cardiac output and makes ventilation easier
  • 24. a disposable scalpel A bladder retractor a pair of scissors 2 metal clamps 3 cord clamps a kidney dish a pack of antiseptic pour solution abdominal pads
  • 25. • Manual uterine displacement can be stopped immediately prior to incision. • With no circulation, blood loss is minimal, and no anaesthesia or analgesia is required. • Incision which facilitates the most rapid access- midline vertical incision ( from pubic symphysis to at least umbilicus) or suprapubic transverse incision • Retract abdominal wall laterally • Reflect bladder inferiorly and empty by aspiration • Make a small incision ( 5 cm) vertically in to the inferior presenting part of the uterus until amniotic fluid comes or through endometrium
  • 26. • Insert 2 fingers and lift up uterus from foetus • Extend uterine incision up to fundus with safety scissors curved away from foetus • Delivery of the foetus and placenta- clamp the cord twice and cut between clamps • Give the neonate to neonatal team • Control bleeding by packing, clamping bleeding vessels (Starts bleeding when ROSC achieved) & suture uterine incision • Give synthetic oxytocin 5 units IV • Continue maternal resuscitation
  • 27. If resuscitation is successful following birth, prompt transfer to OT to control ensuing haemorrhage and complete the operation watch for bleeding, consider further oxytocic drugs, TXA, antibiotic prophylaxis as well as anaesthesia and sedation at that point. If resuscitation failinform coronerpostmotem
  • 28. CASE CONTINUED… During PMC Large amount of free blood and placental tissue in the abdomen obstructing vizualising the uterus 8th minute after arrest a live male infant was delivered with APGAR 1 and 6 at 1 & 5 min respectively ALS continued ROSC achieved at 13 min
  • 29.
  • 30. COMMON CAUSES OF MATERNAL COLLAPSE
  • 32. 1. HAEMORRHAGE • Commonest cause of maternal collapse • Major obstetric hemorrhage incidence 3.7/1000 maternities • Two major types • APH ( placenta previa, placental abruption, placenta acreta/increta/percreta, uterine rupture, ectopic pregnancy ) • PPH- Should not forget Concealed hemorrhage. MX- If APH delivery fetus and placenta promptly to control the haemorrhage. IV Tranexamic acid significantly reduces mortality due to PPH. If activate MTP box 3 comes before box 2(contain cryo)1,3,23,2
  • 33. 2.CARDIAC DISEASE • Most common overall cause of indirect maternal death. • 1/5 deaths in an ambulance or A&E department. • So, paramedics and A&E staff must be familiar with the mx of maternal collapse. • Main cardiac causes of maternal death • -Myocardial infarction • -Aortic root dissection • -Cardiomyopathy • Other cardiac causes include: Dissection of the coronary artery, Acute LVF,IE,MS • Mx-After successful resuscitation, cardiac cases should be managed by an expert cardiology team. • Eg: Myocardial infarction PCI+/-Stenting
  • 34. 3. ECLAMPSIA • Usually obvious in the inpatient setting.(diagnosis of preeclampsia already made , seizure witnessed) • In the community setting, fitting after 20 weeks’ gestation may be attributable to eclampsia, notably where there is no known history of epilepsy. • But, consider epilepsy in maternal collapse associated with seizure. Mx- • Anticonvulsants – a loading dose of 4 g MgSO4 should be given IV over 5 min , followed by an infusion of 1 g/hour for 24 hours. • If Recurrent fits a further dose of 2–4 g given IV 5 minutes.
  • 35. 2. Antihypertensives- IV labetalol 20-50 g loading over two minutes Repeat every 10 mins maximum 4 doses (IV Total dose up to 200 mg ) If still BP >160 /110 mmHg  IV labetalol infusion / IV Hydralazine. (IV Labetalol infusion 20 mg/hr ,double rate at every 30 min until BP controlled) 3. Strict fluid balance- IP 80 ml/hr 4. Only cure is delivery of the baby  IV dexamethasone if preterm 5. Look for complications –HELLP/pulmonary oedema/cerebral hemorrhage/AKI
  • 36. 4.THROMBOEMBOLISM-PE • Acute PE - one of the leading causes of maternal death in high-income countries • Hx - Immobilization , dehydration, pre -eclampsia, sepsis • p/c- SOB , pleuritic chest pain, cough, hemoptysis, tachypnoea, hypotension, tachycardia ,cardiac arrest • based on the assessment of clinical probability(pre-test), D-dimer measurement, CUS, and CTPA–may safely exclude PE in pregnancy. • Mx-LMWH is the treatment of choice for PE during pregnancy • If life threatening PE with hemodynamic compromise • Thrombolytic therapy ( rtPA) • Embolectomy ( percutaneous catheter thrombus fragmentation/ surgical) • ECMO
  • 37. 5. SEPSIS (CHORIOAMNIONITIS,UTI,CNS INFECTIONS , PNEUMONIA) • A significant cause of maternal morbidity and mortality. • Bacteraemia ( in the absence of pyrexia /raised WBC), can progress rapidly to severe sepsis  septic shock collapse. • The most common organisms implicated in obstetric sepsis • -streptococcal groups A, B and D, • -pneumococcus • -Escherichia coli
  • 38. Mx- Septic shock mx according to Surviving Sepsis Campaign guidelines. Hour -1 Bundle Take 3-serum lactate, VBG, blood cultures Administer 3- 1. broad spectrum antibiotic(s) 2. If hypotension or lactate > 4  fluid resuscitation(initial minimum of 30 ml/kg of crystalloid ) 3. a vasopressor (noradrenaline , vasopressin or adrenaline ) and/or an inotrope (dobutamine) to maintain MAP>65 mmHg. Consider steroids if unresponsive to fluid resuscitation and vasopressor therapy.
  • 39. 6.ANAPHYLAXIS A severe, life-threatening generalized or systemic hypersensitivity reaction, resulting in respiratory, cutaneous and circulatory changes, and possibly GI disturbance and collapse. Common triggers (drugs, latex, animal allergens ,foods ) Anaphylaxis is likely when all of the following three criteria are met: -sudden onset and rapid progression of symptoms -life-threatening airway / breathing / circulation problems - skin and/or mucosal changes (flushing, urticaria, angioedema). Mast cell tryptase levels can be useful in confirming the diagnosis.
  • 40. Mx- IM 1:1000 adrenaline 500 micrograms (0.5 ml) can be repeated after 5 minutes if there is no effect. In experienced hands, 50 microgram bolus (0.5 ml of 1:10 000 solution) can be titrated intravenously. Adjuvant therapy -chlorphenamine 10 mg and hydrocortisone 200 mg.( IM/IV)
  • 41. 7. INTRACRANIAL HEMORRHAGE ICH is a significant complication of Uncontrolled ( systolic ) hypertension ruptured aneurysms arteriovenous malformations. p/c –seizures , maternal collapse, but often severe headache precedes this. Mx- Neuroradiologists and neurosurgeons should be involved in the care of pregnant women with ICH at the earliest opportunity.
  • 42. 8. DRUG TOXICITY /OVERDOSE/POISONING A cause of collapse especially outside of hospital. (OP/PCM/Kaneru) MgSO4 in the presence of renal impairment/LA-in hospital Signs of severe toxicity -sudden LOC , convulsions, cardiovascular collapse, sinus bradycardia conduction blocks , asystole ,ventricular tachyarrhythmias Mx- Mg toxicity 10 ml 10% (1g)calcium gluconate /calcium chloride slow IV injection For cardiac arrest due to LAIV bolus injection 20% Intralipid 1.5 ml/kg over 1 min followed by an IV infusion of Intralipid 20% 15 ml/kg/h. The bolus injection can be repeated twice at 5- minute.
  • 43. 9.ENDOCRINE-HYPOGLYCAEMIA,DKA Hypoglycemia-Blood glucose levels <70mg/dl Causes-known DM/GDM on drugs, missed meals ,fasting ,exercise , sepsis Diagnosis-Whipple’s triad Clinical fx -Neurogenic/Neuroglycopenic Mx-IV 50% Dextrose 50ml/IV 25% Dextrose 100ml If IV access difficult-IM Glucogon1mg(takes 15-20 min to work) IV Thiamine 100 mg stat(Wernicke's Korsakoff sx) DKA Definition -Blood glucose > 11.0mmol/L or known DM Ketonemia > 3.0mmol/L or ketonuria (more than 2+ on standard urine sticks) Bicarbonate (HCO3-) < 15.0mmol/L or venous pH < 7.3 Mx- IV fluid/ Potassium replacement /a fixed rate intravenous insulin infusion (FRIII)
  • 44. 10.ELECTROLYTES-NA+/K+ Hyponatremia-Na+<135 mmol/L Mild 125-134 / Moderate 120-124 / Severe <120 Causes-Vomiting , diarrhoea , sweating , SIADH, pregnancy perse speed of onset more important than level Serious manifestations <115mmol/L p/c-muscle weakness , confusion, seizures, coma, ICP Mx-rapid correction 3% NaCl 3ml/kg over 30 min (rise not more than 1-1.5 mmol/hr for 2-3 hrs,10-12 mmol/L over 12 hr) Hyperkalemia Mx- IV 10% Cal gluconate 30 ml over 10 min Nebulize with salbutamol 10 U of S.insulin+50 ml of 50% Dextrose
  • 45. CLINICAL GOVERNANCE Documentation- accurate documentation in all cases of maternal collapse, whether or not resuscitation is successful, is essential Debriefing is recommended for the woman, her family and the staff involved in the event Incident reporting
  • 46. WHAT ARE THE OUTCOMES FOR MOTHER AND BABY AFTER MATERNAL COLLAPSE? Outcomes for mothers and babies depend on -the cause of collapse -gestational age -access to emergency care Survival rates being poorer if the collapse occurs out of hospital. In maternal cardiac arrest maternal survival rates of over 50% have been reported.
  • 47.
  • 48. REFERENCES 1. RCOG guideline -Maternal Collapse in Pregnancy and the Puerperium 2019 2. SLCOG guideline -Immediate Resuscitation Following Maternal Collapse During Pregnancy 2021 3. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism 4. Advanced Life Support-ERC guideline 2021 edition 5. Life in fast lane 6. Case report- Donnel NJ, Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem cesarean delivery- BJA 2009

Editor's Notes

  1. Concealed hemorrhage (difficult to estimate blood loss, slow, steady bleeding and fit, healthy women can tolerate significant loss prior to showing signs of decompensation) Eg:-following caesarean section and ruptured ectopic pregnancy - splenic artery rupture and hepatic rupture(rare) PPH-(4 Ts -Tone,Trauma,Tissue,Thrombin) 1-2RCC+2ffp 2-4RCC+4FFP+1 adult dose ofPLT(6 UNITS) 3-4 RCC+4FFP+1 adult dose ofCRYO
  2. Aortic root dissection(Central chest/interscapular pain,wide pulse pressure,new murmur
  3. If fitting---need to exclude ICH Monitor-PR,BP,RR,SPO2,deep tendon reflexes,UO MG toxicity-cardio resp arrest 1g Cal gluconate
  4. Virchow’s triad-venous stasis , endothelial damage,hypercoagulability Clinical judgment(CXR,ECHO),Using prediction rule(Geneva & wells rule) Diaggnostic-Ddimers,CTPA,v/q scan
  5. 1.broad spectrum antibiotic(s) within the first hour according to local protocol. 2.In hypotension or lactate more than 4 mmol/làfluid resuscitation(initial minimum of 30 ml/kg of crystalloid with assessment of fluid status ) 3.a vasopressor (noradrenaline, with vasopressin or adrenaline in addition, if required) and/or an inotrope (dobutamine) may be used to maintain MAP>65 mmHg. Dynamic variables of fluid status(IVC ) preferred over static variables like CVP. Maintain SPO2 > 94% (88%–92% in hypercapnic respiratory failure) with facial oxygen. Consider transfusion if Hb<7 g/dl. Ongoing management – continued supportive therapy, removing the septic focus, administration of blood products if required, thromboprophylaxis.
  6. Vasodilatationà Intravascular volume redistributiondecreased CO -angioedema, bronchospasm and mucous plugging of smaller airwaysUpper airway occlusionhypoxia ,difficulties with ventilation. -Exposure to a known allergen for the woman supports the diagnosis, but many cases occur with no previous history.
  7. Whipple’s triade- 1.presence of symptoms of hypoglycaemia 2.low serum glucose levels 3.resolution of signs & symptoms with administration of glucose Clinical fx Neurogenic-sweating,palpitation,tachycardia,treomrs,anxiety Neuroglycopenic-dizzinesss,headache,blurred vision,confusion,convulsion Mx-IV 50% Dextrose 50ml+Normal saline flush/IV 25% Dexrtose 100ml If IV access difficult-IM Glucogon1mg(takes 15-20 min to work) IV Thiamine 100 mg stat(Wernikes korsokoff sx) DKA P/C-polyuria , Polydipsia, weight loss, Malaise, Fatigability, Nausea , Vomiting, Abd. Pain , LOA, Altered consciousness ,Confusion, Coma, Fever Signs-ill , Kussmaul breathing ,dry mucous membranes, decreased skin turgor, decreased reflexes, Ketotic breath odor, tachycardia ,hypotension, tachypnea, hypothermia, fever, Confusion , coma, abdominal tenderness