1. Sudden Maternal Collapse
Max Brinsmead MB BS PhD
May 2015

2. Introduction Rare – but serious (life threatening)
14 – 600 per 100,000 births
Once every 8 weeks in Port Moresby
Once every 7 years in a unit delivering 1000/year
Has a diverse range of causes
Fetal survival depends primarily on effective maternal resuscitation
Maternal survival depends on...
Aetiology
Facilities available
The training and expertise of those on the spot

3. Differential Diagnosis
Shock syndromes
Vasovagal*
Haemorrhage (see below)
Anaphylaxis
Sepsis
Uterine inversion (3rd stage labour)
Cardiac
Arrhythmia
Acute heart failure
Cerebral
Post ictal (epilepsy)*
Eclampsia
Cerebrovascular accident
*Spontaneous recovery likely

4. Differential Diagnosis - 2
Drugs & Metabolism
Prescribed e.g. MgSO4
Illicit drugs and toxins
Hypoglycaemia
Concealed Haemorrhage
Blood in the uterus (APH or PPH)
Or vagina/paravaginal space
Blood in the abdominal cavity
Ruptured liver, spleen or splenic artery
Post Caesarean
Blood in the chest
Aortic dissection
Pulmonary
Thromboembolism
Amniotic fluid embolism
Pneumothorax
Aspiration syndrome

6. Treatable Causes of Collapse
4 H’s and 4 T’s plus E
Hypovolaemia
Hypoxia
Hypo or Hyperkalaemia
Hypothermia
Thromboembolism
Toxins
Tension Pneumothorax
Tamponade (cardiac)
Eclampsia

7. Obstetric Physiology impacts on Resuscitation
Aortocaval compression
Also known as supine hypotension
Progressively increases from 20w
May reduce cardiac output by up to 40%
Always use a 15 degree tilt position
Pregnant uterus compromises external cardiac massage (ECM)
By up to 90%
Also compromises chest ventilation
So hypoxaemia occurs more rapidly
Empty the uterus if mother is not responding to ECM within 4 – 5 minutes
Blood volume is increased
By up to 50%
But mother may tolerate blood volume loss up to 30%
Increased risk of stomach regurgitation and aspiration

8. Emergency Management - 1
Does the mother respond?
To verbal commands
To stimulation
Is she breathing?
Is she cyanosed
Is there a heartbeat?
Capillary filling
Clear the airway
Coma position or prepare for CPR
Always with left lateral tilt
Attempt diagnosis
But proceed with basic life support
Always check that the environment is safe

9. Emergency Management - 2
If the mother is not breathing (but a pulse is present)...
Provide oxygen
Assess over 10 sec
Artificially ventilate with a face mask/airway
Early intubation is desirable
If there is no carotid pulse...
Proceed immediately with ECM
30 compressions, mid chest and vertical
With >4 cm chest movement
At 100 per minute
Then give 2 “breaths” (the 30:2 rhythm)
When intubated 100 ECM/min and 10 breaths/min
Get an ECG connected ASAP
Is it arrhythmia or asystole?

10. Emergency Management - 3
The treatment for ventricular fibrillation is...
External Defibrillation
Establish IV lines
Repeat if necessary
The treatment for asystole is...
IV adrenaline 1 mg
Correct reversible causes i.e.
Hypoxia
Hypvolaemia
Hypo or hyperkalaemia
Hypothermia
Repeat adrenaline every 5 min if necessary
Empty the uterus if not responding after 4 min

11. Emergency Uterine Evacuation
The aim is to facilitate maternal resuscitation
Not to save a baby
To be done even if the baby is already dead
This is the responsibility of the most obstetrically competent person present
Who may be anyone
Should be done “on the spot”
Anaesthesia not required
Only a scalpel and two clamps for the cord required
Incise the abdomen and uterus in any way you like
Can facilitate cardiac compression
Through the diaphragm and against the sternum
If the mother responds to resuscitation then transfer to theatre for anaesthesia and haemostasis

12. Vasovagal Syndrome
Now after all that excitement let us consider the most common cause of maternal collapse...

13. Vasovagal syndrome
Typically occurs when mother gets up too soon after her delivery
Make sure that she is not shocked from blood loss
Check PR, BP, Fundus and PV loss
If the mother has a slow but good volume pulse
And she is pink and breathing...
Put her in the coma position and monitor recovery
If she is hypovolaemic get in 1 – 2 IV cannulae ASAP and commence resuscitation with fluids

14. Acute uterine inversion
Typically occurs with cord traction and the uterus disappears from the abdomen...
Because it is inside out & in the vagina
Degree of shock is out of proportion to blood loss
Resuscitate with IV Fluids
Analgesia if necessary
Attempt manual replacement of the uterus followed by manual removal placenta
O’Sullivans hydrostatic replacement

15. May present without fever or a raised white cell count (WCC)
SEPSIS
May present without fever or a raised white cell count (WCC)
Beware the patient with low WCC
Can progress very rapidly
Principal obstetric organisms...
Streptococci A, B and D
Pneumococci
E Coli

16. Septic Shock Requires multidisciplinary care
Take blood culture before giving antibiotics
Antibiotics as per local agreed protocol or as advised by a microbiologist
Measure Serum lactate
For hypotension and/or lactate >4 mmol/L
Give IV crystalloids 20 ml/Kg
Then pressor agents to maintain BP >65 systolic
If not responding...
Insert CVP and intubate for IPPV
Maintain CVP 8 – 12 mm Hg
Consider steroids

17. Acute Pulmonary Oedema (CCF)
Typically occurs in the known cardiac patient in the third stage of labour
But can occur in the profoundly anaemic patient who is given too much fluid (blood) too quickly
Nurse upright
Give oxygen
Give IV Frusemide
Consider rotating limb cuffs to reduce venous return

18. Drug Reactions The maximum dose of Lignocaine is 4mg/Kg
Or 6 mg/Kg for Lignocaine with adrenaline
That is 28 ml 1% Lignocaine in a 70 Kg woman
First sign of overdose is numbness tongue and mouth, slurred speech
Then convulsions and arrest
Treat with CPR, ventilation, sedation and 20% Intralipid (100 ml stat and 400 ml in 20 min)
Penicillin or other antibiotic anaphylaxis
Adrenaline may be life saving
The dose is 0.5 mg maximum and intramuscular
(IV adrenaline 1.0 mg is only for cardiac asystole)
Add IV antihistamine and hydrocortisone 200 mg

19. Cardiac Arrhythmia There may be a history of palpitations or PAT
Diagnose by ECG
Carotid massage may work
IV Atropine 0.6 mg sometimes
Best managed by consultation with a cardiologist

20. Cerebrovascular Accident
Typically occurs with a hypertensive crisis
Maybe after ergometrine given to a preeclamptic patient
There may be localising CNS signs
Check pupils, DTJ’s and Plantars
Look for neck stiffness
A sign of meningeal irritation
May require perimortem Caesarean section
NB Hypertension and bradycardia are signs of cerebral coning

21. Improving outcomes after maternal collapse
Be Ready
Trained staff
Have emergency equipment assembled & quarantined for emergency use
Have systems that assemble more staff
Practice drills
Be Forewarned
Needs an obstetric early warning system to identify...
The patient at risk
When she is on the slippery slope
Review and Revise
After each event
And each “near miss”

22. Patients at risk Increasing maternal age Obesity
Maternal mortality rises 5-fold between age 20 – 40
Obesity
The modern epidemic
Social Class and Ethnicity
Aboriginal
Black
Pre existing Maternal Disease
One of the main reasons for antenatal care

23. Any Questions or Comments?
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