2019 56 Maternal Collapse

Question 1

What are the physiological & anatomical changes in pregnancy that affect resuscitation?

Answer 1

1. Aortocaval compression, reducing cardiac output from 20/40
2. Hypoxia, due to changes in lung function, increased O2 use & diaphragmatic splinting
3. Difficult intubation
4. Increased risk of aspiration

Question 2

How should aortocaval compression be relieved for resuscitation?

Answer 2

1. Manual displacement to the left
2. Left lateral tilt 15-30•
3. Spinal board before tilting in major trauma

Question 3

What should remain the same in the life support algorithm?

Answer 3

ABCDE approach
Defibrillation energy levels
Drugs & doses

Question 4

Who should decide when to discontinue resuscitation efforts?

Answer 4

Consultant obstetrician
Consultant anaesthetist
With cardiac arrest team consensus

Question 5

When, where & how should perimortem CS be carried out?

Answer 5

1. In women over 20/40
2. If no ROSC within 4 mins of correct CPR
3. Where collapse has occurred
4. Via midline vertical or suprapubic transverse incision
5. Scalpel & cord clamps from resus trolley

Question 6

What is the antidote to magnesium toxicity?

Answer 6

10ml 10% calcium gluconate or
10ml 10% calcium chloride
Slow IV injection

Question 7

What is the antidote to local anaesthetic toxicity?

Answer 7

Intralipid 20%
NB report to NHS Improvement & Lipid Rescue site

Question 8

How should anaphylaxis be treated?

Answer 8

1) 1:1000 adrenaline 500 micrograms (0.5ml) IM
2) Repeat after 5 mins if no effect
3) Hydrocortisone 200mg
4) Chlorphenamine 10mg
5) Take mast cell triptase

Question 9

What are the survival rates for in-hospital maternal cardiac arrest?

Answer 9

50%

Question 10

How should maternal collapse be reported?

Answer 10

1. Clinical incidence form for all collapse
2. MBRRACE for all deaths

Question 11

What is the incidence of cardiac arrest in pregnancy?

Answer 11

1:36,000

Question 12

How are the 4Hs affected in pregnancy?

Answer 12

Hypovolaemia
Bleeding, spinal, septic or neurogenic
Hypoxia
Breathing, cardiac: cardiomyopathy, MI, aortic dissection, aneurysms
Hypo/hyperkalaemia, hyponatraemia
K no more likely, Na oxytocin use
Hypothermia
No more likely

Question 13

How are the 4Ts affected in pregnancy?

Answer 13

Thromboembolism
AFE, PE, air embolus, MI
Toxicity
Local anaesthetic, Mg, other
Tension pneumothorax
Following trauma/suicide attempt
Tamponade
Following trauma/suicide attempt

Question 14

What should be added to the 4Hs & 4Ts?

Answer 14

Eclampsia
Pre-eclampsia
Intracranial haemorrhage

Question 15

How does the plasma volume change in pregnancy & impact on resus?

Answer 15

⬆️ up to 50%
Dilutional anaemia
Reduced oxygen carrying capacity

Question 16

How does the heart rate change in pregnancy?

Answer 16

⬆️ 15-30 BPM

Question 17

How does the cardiac output change in pregnancy?

Answer 17

⬆️ by 40%
Significantly reduced by pressure of gravid uterus on IVC

Question 18

How much of the cardiac output is directed to the uterus at term?

Answer 18

10%

Question 19

How does arterial blood pressure change in pregnancy?

Answer 19

⬇️ by 10-15 mmHg

Question 20

How does the oxygen consumption change in pregnancy?

Answer 20

⬆️ by 20%

Question 21

How does the residual capacity change in pregnancy?

Answer 21

⬇️ by 25%

Question 22

What are the GI changes in pregnancy?

Answer 22

⬇️ gastric motility
Relaxed oesophageal sphincter
⬆️ weight

Question 23

What is the incidence of major obstetric haemorrhage?

Answer 23

6:1000

Question 24

What are the causes of major obstetric haemorrhage?

Answer 24

1. PPH
2. Placenta praevia
3. Placental abruption
4. Uterine rupture
5. Ectopic pregnancy

Question 25

What is the incidence of amniotic fluid embolism?

Answer 25

1.7 per 100,000

Question 26

How does amniotic fluid embolism present?

Answer 26

During or within 30 mins of birth Acute hypotension Respiratory distress Acute hypoxia May progress to seizures & cardiac arrest

Question 27

How does amniotic fluid embolism progress?

Answer 27

1. Vascular occlusion 2. Pulmonary hypertension 3. LV dysfunction or failure 4. Coagulopathy 5. Massive PPH

Question 28

What is the major cardiac cause of maternal death?

Answer 28

1. Ischaemia 2. Sudden arrhythmia with structurally normal heart

Question 29

What are the cardiac causes of maternal death?

Answer 29

1. Ischaemia 2. Arrhythmia 3. Aortic root dissection 4. Congenital & rheumatic heart disease 5. Cardiomyopathy 6. Coronary artery dissection 7. Acute LV failure 8. Infective endocarditis 9. Pulmonary oedema

Question 30

What are the most common causative organisms of maternal sepsis?

Answer 30

1. Group A Strep 2. Group B Strep 3. Group D Strep 4. Pneumococcus 5. E. Coli

Question 31

What are the signs of local anaesthetic toxicity?

Answer 31

1. Feeling inebriated & light-headed 2. Sedation 3. Circumoral paraesthesia & twitching 4. Convulsions 5. Cardiovascular collapse 6. Arrhythmia: sinus bradycardia, conduction blocks, asystole, VT

Question 32

How should mast tryptase levels be taken?

Answer 32

3 timed samples: 1. ASAP after resus started 2. 1-2 hours after symptom onset 3. 24 hours later

Question 33

What proportion of cardiac output can be provided by chest compressions?

Answer 33

30% if not pregnant 10% if pregnant

Question 34

What proportion of circulating volume can be lost before becoming symptomatic?

Answer 34

Up to 35%

Question 35

What are the rates for CPR?

Answer 35

2 ventilation breaths 10/min 30 chest compressions 100-120/min

Question 36

How often should adrenaline be given in resus algorithm?

Answer 36

Every 3-5 mins

Question 37

What are the shockable rhythms?

Answer 37

VF Pulseless VT

Question 38

What are the non-shockable rhythms?

Answer 38

Asystole PEA

Question 39

What are the energy values for defibrillation?

Answer 39

200J biphasic 360J monophasic

Question 40

What drugs are considered in the resus algorithm?

Answer 40

Amiodarone Atropine Magnesium