University of Mosul�College of Medicine
Lecture:7
Subject/year : Maternal collapse 2022-2023
Lecturer: Dr. Saja Al-Jawady
Department: Gynecology & obstetrics
Date:
The AIM of this lecture is
To understand
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Maternal collapse
Maternal collapse
is defined as an acute event involving the cardiorespiratory systems and/or
central nervous system resulting in a reduced or absent conscious level (and potentially cardiac
arrest and death), at any stage in pregnancy and up to 6 weeks after birth
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Causes of Maternal Collapse
Consider
1-4 ‘H’s and
2-4 ‘T’s and in the pregnant woman add
3-clampsia and
4-intracranial haemorrhage
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*4 H’s
1=Hypovolaemia
A- Bleeding (obstetric/other; may be concealed) or
B- relative hypo-volaemia due to dense spinal block, septic or neurogenic shock
2=Hypoxia
Cardiac events – peri-partum cardiomyopathy, myocardial infarction,
aortic dissection, large vessel aneurysms
3=Hypo/hyper-kalaemia
No more likely; severe hyperemesis
4=Hypo/hyper-natraemia
May be caused by oxytocin use
Iatrogenic administration of fluids in labour
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4 T’s
5-Thromboembolism Amniotic fluid embolism, pulmonary embolus, air embolus,
Myocardial infarction
6-Toxicity Local anaesthetic, magnesium
7-Tension pneumothorax Following trauma/suicide attempts
8-Tamponade Following trauma/suicide attempts
9-Eclampsia and pre-eclampsia
10-Intracranial Haemorrhage
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HAEMORRHAGE
Massive obstetric haemorrhage
refers to the loss of 30–40%
(generally about 2L) of the patient’s blood volume
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-
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Thrombo-embolism
is the leading cause of direct maternal death during or up to 6 weeks after the
end of the pregnancy
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Cardiac disease
remains the commonest cause of indirect maternal
death.
TYPES
1-ischaemia and sudden arrhythmic cardiac death with a structurally normal heart.
2-Aortic root dissection, although usually associated with an inherited aorto-pathy can present in otherwise healthy women
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3-The incidence of congenital and rheumatic heart disease in pregnancy is increasing, secondary to increased survival rates and with improved management of congenital heart disease
4-women with mechanical prosthetic heart valves are at particularly increased risk of complications
in pregnancy.
5-Other cardiac causes include: cardiomyopathy; dissection of the coronary artery; acute left ventricular failure; infective endocarditis; and pulmonary oedema.
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Sepsis
is a significant cause of maternal morbidity and mortality
the most common organisms implicated in obstetrics are
1=the streptococcal groups A, B and D,
2=pneumococcus
3= Escherichia coli
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Amniotic fluid Embolism (AFE)
presents as a collapse during labour or birth, or within (usually) 30 minutes of birth in the form of
1-hypotension
2-respiratory distress and
3-acute hypoxia.
4-Seizures and cardiac arrest may also occur.
5-This is followed by acute coagulopathy in those women who survive the initial event
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Drug toxicity and overdose
Therapeutic drug toxicity is possible with commonly used drugs in obstetric practice such as
1-magnesium sulphate
in the presence of renal impairment
2-local anaesthetic agents.
Presented as
*cardiac dysrhythmias,
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Eclampsia
Fitting after 20 weeks gestation may be attributed to eclampsia , notably where there is no known history of epilepsy.
However, epilepsy should always be considered in cases of maternal collapse
associated with seizure activity
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Anaphylaxis
is a severe, life threatening systemic hypersensitivity reaction, resulting in respiratory,
cutaneous and circulatory changes, and collapse.
There is significant intravascular volume redistribution, which can lead to decreased cardiac output.
Acute ventricular failure and myocardial
ischaemia may occur
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Management of maternal
Collapse
Maternal collapse resuscitation should follow the Resuscitation Council guidelines
using the standard ABCDE approach
Commence MEOWS chart (Modified Obstetric Warning System )if not already in use and escalate as appropriate
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Specific treatment
depends on the cause.
Important to ensure
multidisciplinary input
early to optimize outcome.
Anaesthetic and ICU
assistance urgently required.
If focal neurological signs
are present, early
neurosurgical input may save
lives
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1/Massive obstetric hemorrhage
Do not delay fluid resuscitation and blood transfusion because of false reassurance from a single haemoglobin result , treat the patient, not the
Result
Consider the administration of blood components before coagulation indices deteriorate if a woman is bleeding and is likely to develop a coagulopathy.
Consider early recourse to hysterectomy if simpler medical and surgical interventions prove ineffective.
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Peri-mortem Caesarean Section (PMCS)
Is surgical delivery of alive fetus during or near the time of cardiac arrest of the mother
PMCS should be seen as a resuscitative procedure to be performed primarily in the interests of maternal survival.
1=In women over 20 weeks of gestation,
2=if there is no response to correctly performed
CPR within 4 minutes of maternal collapse
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2/sepsis
1. Measure serum lactate.
2. Obtain blood cultures/culture swabs
3. Administer broad-spectrum antibiotic(s) within the first hour of recognition of severe sepsis and septic shock according to local protocol
4. In hypotension and/or lactate >4 mmol/l:
a-deliver crystalloid/ colloid
b-vasopressor (norepinephrine, epinephrine) and/or an inotrope (e.g. dobutamine) may be used
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Drug toxicity/overdose
should be considered in all cases of collapse.
Therapeutic drug toxicity:
Magnesium sulphate : The antidot is 10 ml 10% calcium gluconate given by slow intravenous injection.
Local anaesthetic : agents toxicity if suspected, stop injecting immediately, Intralipid 20% should be available in all maternity units
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4/Anaphylaxis
The definitive treatment for anaphylaxis is
1-500 mcg (0.5 ml) of 1:1000 adrenaline intramuscularly.
THIS DOSE IS FOR INTRAMUSCULAR USE ONLY.
Adrenaline treatment can be repeated after 5 minutes if there is no effect.
2-Adjuvant therapy consists of
chlopheniramine 10 mg
hydrocortisone 200 mg.
Both are given intramuscularly or by slow intravenous injection.
To summarize:
Lets check our knowlege
MCQ
Q- most common causes of maternal sepsis are EXCEPT:
a- streptococcal group A
b-Escherichia coli
c-pneumococcus
d-streptococcus group B
e-clamydia
References and recommended further readings:
Obstetrics by Ten Teachers, 19E - Kenny, Louise, Baker, Philip N.
Dewhurst's Textbook of Obstetrics and Gynaecology,Eighth Edition- D.
Keith Edmonds
UNICEF-Sd-Neonatal-Guidelines-report-2018
The end