1. 1 MATERNAL COLLAPSE Berrin Gunaydin, MD, PhD Department of Anesthesiology Gazi University School of Medicine Ankara, Turkey

2. 2 OBJECTIVES Discuss the incidence and causes of cardiac arrest/maternal collapse in pregnancy the physiological changes in pregnancy that make women susceptible resusciation techniques and management of cardiac arrest in pregnancy amniotic fluid embolism perimortem cesarean section

3. 3 Maternal mortality Cardiac arrest is a very rare maternity emergency (1/30000 pregnancy) It usually occurs as a result of other maternity emergencies If managed well, up to 50% of maternal deaths are preventable Many maternal deaths occur from potentially treatable causes

4. 4 Physiology of Pregnancy I Increased plasma volume (50%) Increased cardiac output (40%) Increased heart rate (15-20 bpm) Increased respiratory rate Increased oxygen consumption (20%) Decreased blood pressure Decreased residual lung capacity Laryngeal oedema Aoto-caval compression

5. 5 Physiology of Pregnancy II Increased clotting factors Increased breast tissue Diaphragm rises by about 7 cm and the organs move for growing uterus Gut peristaltis slows

6. 6 Major body changes for the pregnant woman Improve blood supply for fetal nutrition Promote breast development in preparation for neonatal feeding Alter the internal organ displacement to make room for the growing fetus and uterus

7. 7 Hormonal influences Oestrogen Increased excitability in uterine muscle fibers Increased susceptibility to catecholamines Progesterone İncreased tidal volume and respiratory rate Hyperventilation causes decreased CO 2 and compansated respiratory alkalosis

8. 8 Pregnant CPR TILT 27º angle - Left side - Human wedge compression of the aorta by the gravid uterus causes 30% of cardiac output sequestered chest compressions need to be stronger due to the increased breast size and chest wall resistance intubation is difficult due to the pharyngeal and nasal oedema

9. 9 CPR Danger: safety for self, others and woman Response: level of consciousness Airway: open the airway Breathing: 2 initial breaths provide positive-pressure ventilations Circulation:30 chest compressions to 2 breaths Defibrillation: assess and shock VF or pulseless VT

10. 10 CPR Airway Ensure airway is patent and protected from aspiration Consider early intubation Breathing Confirm placement of tube Secure device Confirm adequate oxygenation

11. 11 CPR Circulation Establish IV access Identify rhythm and monitor Administer appropriate drugs Differential diagnosis Search for identified reversible causes

12. 12 Drugs for resuscitation Adrenaline 1 mg IV bolus repeat every 3-5 min Be aware of all the drugs are on the emergency trolley

13. 13 4 minute rule 4 minute after arrest Maternal apnoea occurs associated with rapid declines in arterial pH and PO 2 Fetus of an apnoeic and asystolic mother has ≤2 minutes of oxygen reserve After 4 minutes without restoration of circulation, dramatic action must occur

14. 14 Pre-requisite for perimortem caserean The arrest must be witnessed Skilled personnel and equipment available No spontaneous maternal circulation for 4 min Potential viability: singleton at 23-24 weeks or greater A perimortem caserean section can save two lives

15. 15 Amniotic fluid embolism (AFE) Occurs when there is an opening between the amniotic sac and the uterine veins in approximately 1:20 000 births Risk factors include –Abruption –Intrauterine fetal demise –Tumultuous labor –Oxytocin hyperstimulation

16. 16 AFE Amniotic fluid may enter maternal circulation passes through the maternal heart and becomes trapped in maternal pulmonary circulation causing L sided heart failure and bronchospasm These lead to localised DIC which then spreads quickly throughout the mother Anaphylactic reaction associated with amniotic fluid in the maternal circulation may occur

17. 17 AFE Symptoms occur very rapidly –Sudden dyspnoea and respiratory distress –Shock without obvious blood loss –Maternal collapse –Seizures (30%) –DIC Diagnosis is usually made postmortem

18. 18 Management Call for help Supportive and resuscitative ABC 2 large bore cannulae Consider X-ray and ECG Immediate delivery

19. 19 Summary of AFE Rare obstetric emergency with very poor prognosis for maternal-fetal outcome Historically high maternal mortality rate of 85% declined to  27% with better diagnosis and ICU treatment

20. 20 CONCLUSION Cardiac arrest is a rare event 44-50% of maternal deaths are preventable by improving management strategies –Remember 27ºº tilt and working around the increased breast tissue –Perimortem C/S can save 2 lives –TEAM WORK can help to improve outcomes –Documentation and Debriefing are of utmost importance

21. 21 Scenario 38 year-old parturient at 34 weeks’ gestation suffering from dyspnea and chest pain is admitted to the ER Vital signs AConscious BSianosis, RR 40 breath min -1, SpO 2 85% during 15 L/min oxygen via reservuar mask CHR140 beat min -1 sinus tachycardia, BP 70/40 mmHg DAnxious and restless EGravid uterus Differential diagnosis?

22. 22 Scenario continued All of a sudden she became unconscious and apnoeic ECG monitor displays wide complexes, HR 20 beat min -1. No pulse What do you do right now?