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24-Obstetric Emergencies > Collapse > Flashcards

Collapse Flashcards

1
Q

What is the definition of maternal collapse?

A

Acute event involving cardiorespiratory system and/ or brain : causing reduced or absent conscious level at any point during pregnancy and up to 6 weeks postpartum

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2
Q

What is the incidence of cardiac arrest in pregnancy?

A

1 / 36,000 maternities
Fatality rate 42 %

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3
Q

What is the proportion of maternal cardiac arrest is secondary to anaesthesia? What is the survival rate in this proportion?

A

25% of cardiac arrest is secondary to anaesthesia
100 % is the survival rate

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4
Q

What are the most common causes of maternal collapse?

A

1- vasovagal attacks
2- epileptic seizures

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5
Q

Can women at risk of impending collapse be identified early?

A

Yes : using an obstetric modified early warning score chart for all women undergoing observation
MEWS system

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6
Q

What are the main physiological changes in pregnancy?

A

1- plasma volume ⬆️ 50 %
2- heart rate ⬆️ 15 - 20 / bpm
3- cardiac output ⬆️ 40 %
4- uterine blood: 10 % of cardiac output at term
5- arterial blood ⬇️ 10 - 15 mmhg
6- residual pulmonary capacity:
⬇️ 25 %
7- lower oesophagus sphincter: relaxed
8- oxygen consumption ⬆️ 20 %

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7
Q

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

A

1- increased CPR demands
- dilutational anaemia
- reduced o2 carrying capacity
2- reduced cardiac output due to compression after 20 w ➡️ reduce the efficiency of chest compression
3- become hypoxic more rapidly & ventilation more difficult ( ⬆️ o2 consumption & diaphragmatic splinting)
4- difficult intubation ( laryngeal oedema)
5- increased risk of aspiration ( relaxed lower oesophagus sphincter)
6- potential for rapid massive haemorrhage ( ⬆️ uterine blood flow)

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8
Q

What makes intubation more difficult in pregnancy?

A

1- weight gain
2- large breasts inhibits the working space
3- laryngeal oedema

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9
Q

What makes pregnant women at higher risk of aspiration?

A

1- relaxed lower oesophagus sphincter
2- raised intra abdominal pressure
3- opioid administration during labour

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10
Q

What is Mandelson’s syndrome? How minimize the risk of this syndrome?

A

Aspiration pneumonitis in pregnant women
To minimize the risk:
1- early intubation with effective cricoid pressure
2- use of H2 antagonists & antacids prophylactically in all women at high risk of obstetric interventions during labour

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11
Q

How much blood loss volume a healthy pregnant woman can tolerate without showing symptoms?

A

35 %

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12
Q

What are the reversible causes of maternal collapse?

A

🚩4Hs:
1- hypovolaemia
2- hypoxia
3- hypo/hyperkalaemia &
hyponatremia ( oxytocin use)
4- hypothermia
🚩4Ts :
1- thromboembolism
2- toxicity ( Mg- local anaesthesia)
3- tension pneumothorax (trauma)
4- tamponade ( trauma)
🚩Eclampsia & preeclampsia + ICH

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13
Q

What are the causes of hypovolaemia as a reversible cause of maternal collapse?

A

1- bleeding
2- relative hypovolaemia of dense spinal block
3- septic block
3- neurogenic block

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14
Q

What are the causes of hypoxia as a reversible cause of maternal collapse?

A

Mainly cardiac events: peripartum cardiomyopathy/ myocardial infarction/ aortic dissection/ large vessels aneurysms

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15
Q

What is the main cause of hyponatremia in labour?

A

Oxytocin use

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16
Q

What are the causes of maternal collapse ( imagine the human body 🤺)?

A

1- eclampsia & preeclampsia
2- anaphylaxis
3- aortic dissection
4- myocardial infarction + cardiomyopathy
5- hypoglycemia
6- sepsis
7- drugs: Mg / local anaesthesia / illicit drugs
8- pulmonary embolism / amniotic fluid embolism
9- hepatic rupture/ splenic artery rupture
10 - uterine haemorrhage

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17
Q

What is the definition of amniotic fluid embolism?

A

Clinical syndrome of hypoxia + hypotension + coagulopathy
Results from entry of fetal antigens into maternal circulation

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18
Q

What are the risk factors of AFE ?

A

1- CS
2- advanced maternal age
3- multifetal pregnancy
4- placental abruption
5- abdominal trauma
6- placenta praevia
7- uterine rupture
8- cervical lacerations
9- forceps delivery
10- polyhydramnios
11- induction of labour

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19
Q

When does amniotic fluid embolism usually manifest ?

A

During and shortly after labour
Within 30 minutes of delivery

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20
Q

What are the symptoms of amniotic fluid embolism?

A

1- respiratory: dyspnoea + tachypnoea + cyanosis + hypoxia + pulmonary crackles
2- cardiac: tachycardia + hypotension + cardiac arrest
3- coagulopathy: bleeding from the uterus or sites of incisions and venepuncture
4- fetal distress

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21
Q

What is the treatment of amniotic fluid embolism?

A

Supportive treatment
No proven effective treatment
- if undelivered delivery of the fetus should be performed as soon as possible
- arrhythmias will require standard treatment
- inotropic support: after estimating cardiac output
- avoid fluid overload: may exacerbate pulmonary edema
- recombinant factor 7 : after failure to stop haemorrhage by massive blood component replacement
- various therapies: steroids, heparin, plasmapheresis, hemofiltration

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22
Q

Is detecting fetal squamous cells and hair in the pulmonary circulation by autopsy diagnostic for AFE ?

A

No , because sometimes they are detected in patients who don’t have AFE

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23
Q

What is the most common overall cause of INDIRECT maternal death?

A

Cardiac disease
Main causes:
Ischemia + sudden arrhythmic cardiac death
With a structurally normal heart

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24
Q

What is the main cause of aortic dissection?

A

Inherited aortopathy eg: Marfan syndrome + Ehler danlos syndrome

25
Q

What are the symptoms of aortic dissection?

A

1- tearing chest pain ( central chest or inter scapular)
2- wide pulse pressure ( systolic hypertension)
3- New cardiac murmur
4- different or absent peripheral pulses
5- variations in BP between the limbs

26
Q

How is aortic dissection diagnosed?
What is the management?

A
  • By Echocardiogram
  • surgical correction
    🎗 each hour delay increases the mortality by 1 %
27
Q

How to diagnose acute coronary syndrome?

A

ECG + TROPONIN I or T levels

28
Q

What is the initial management of acute coronary syndrome?

A

1- analgesia: morphine
2- o2
3- aspirin 300 mg
4- GTN : glyceryl trinitrate

29
Q

What is the first line treatment for acute coronary syndrome?

A

Percutaneous intervention

30
Q

If the cause of maternal collapse is cardiomyopathy,
how to diagnose , what is the main risk ,what is the preferable mode of delivery?

A
  • Echocardiogram + chest X ray to identify pulmonary edema
  • main risk : thromboembolism
    ➡️ prophylaxis is required
  • vaginal delivery with good analgesia & passive delivery ( without pushing)
31
Q

In a case of maternal collapse caused by sepsis, what are the most common organisms implicated?

A

Streptococcus A , B , D
Pneumococcus
E coli

32
Q

In the event of hypotension despite fluid resuscitation ( septic shock) or lactate > 4 , how to guide fluid resuscitation?

A

CVP & BP are not enough
* Transoesophageal Doppler & Lithium dilution cardiac output LIDCO are preferred

33
Q

In the event of hypotension ,Once adequate volume replacement has been achieved during septic shock, what is next ?

A

1-Vasopressor ( noradrenaline + vasopressin)
2- inotrope ( dobutamine)
* to maintain arterial BP > 65 mmhg

34
Q

What is the maximum dose of (lidocaine plain & lidocaine with epinephrine) injected to avoid toxicity & collapse?

A

Lidocaine plain 4,5 mg / kg not to exceed 300 mg
Lidocaine with epinephrine 7 mg / kg

35
Q

What are the signs & symptoms of local anaesthesia toxicity? ( spinal / epidural top up )?

A

1- light headedness followed by sedation confusion
2- circumoral ot tongue numbness
3- hallucinations
4- metallic taste
5- muscle twitching
* signs of severe toxicity:
Loss of consciousness with ot without tonicclonic seizures & cardiovascular collapse ( sinus bradycardia + ventricular tachy arrhythmias

36
Q

How to treat local anaesthesia toxicity leading to cardiac arrest?

A

Lipid emulsion ( intralipid 20%)
IV 20 % 1.5 ml / kg over 1 min
( 100 ml for a woman weighing 70 kg)
Followed by 15 ml/ kg / h
( 1000 ml for a woman weighing 70 kg)
The bolus injection can be repeated after 5 minutes
The infusion rate should be increased to 30 ml/ kg / h if an adequate circulation hasn’t been restored
This work by forming LIPID SINK

37
Q

When is anaphylaxis likely a cause of maternal collapse?

A

1- sudden onset & rapid progress
2- life threatening airway and/ or breathing and / or circulation problems
3- skin/ mucosal changes

38
Q

What is the best validated marker of mast cell activation ( anaphylaxis)?

A

Tryptase
should be checked
* at baseline and
* within 1-2 hours of a suspected mast cell activation event.
* 24 hours later
A formula of20% of baseline plus 2 ng/mLis used to calculate the minimal increase required to diagnose mast cell activation

39
Q

What is the management of anaphylaxis causing maternal collapse?

A

Should follow the ABCDE
1- stop the trigger
2- lay the patient flat with their legs raised
3- administer :
* adrenaline 1/1000:
500 mcg ( 0.5 ml ) IM
* CHLORPHENAMINE: 10 mg
* hydrocortisone 200 mg IM or IV
🔮 adrenaline can be given at 5 minutes intervals
🔮 give O2
🔮administer IV crystalloid 500-1000
Avoid colloid ( dextran)
🔮monitor at least 6 hours

40
Q

What are the shockable heart rhythm?

A

1- ventricular tachycardia
2- ventricular fibrillation

41
Q

What is the maternal survival rate in maternal cardiac arrest?

A

Over 50 %

42
Q

Case : 42 years woman delivered 1,5 kg baby using forceps at 36 w , she had active 3rd stage, forty minutes later she falls to one side and becomes unresponsive?

A

ICH

43
Q

What is the optimal initial management of maternal collapse?

A

1- standard ABCDE approach
2- in the community ➡️ basic life support & transfer arranged
3- manual displacement of the uterus to the left if > 20 w
4- left lateral tilt of the woman from head to toe at angle of 15 - 30 degree
5- unconscious woman ➡️ intubation with a cuffed endotracheal tube
6- supplemental high flow O2
7- bag & mask ventilation or supraglottic airway until intubation
8- if airway is clear & no breathing ➡️ chest compression
9- 2 wide bore cannula ( 16 gauge)
10 - volume replacement with caution in case of preeclampsia
11- abdominal US to diagnose concealed haemorrhage

44
Q

In the resuscitation of maternal collapse, is there any change in defibrillation energy or algorithm drugs?

A

No changes

45
Q

When should perimortem CS ( PMCS) be performed?

A

In women > 20 w if there is no response to CPR within 4 minutes, or if the resuscitation is continued beyond this
* ideally within 5 minutes of collapse

46
Q

Where should PMCS be performed?

A

Where maternal collapse has occurred & resuscitation is taking place

47
Q

How should PMCS be performed?

A

Rapid access:
Midline vertical incision
Or suprapubic transverse incision
Using : scalpel + umbilical cord clamp

48
Q

What is the role of tranexamic acid in the management of maternal collapse due to postpartum hemorrhage?

A

Reduces the mortality

49
Q

Why should recombinant factor 7 ONLY be used if coagulopathy cannot bee corrected by massive blood component replacement in women with AFE ?

A

It causes poorer outcome

50
Q

What is the antidote to Mg toxicity?

A

10 ml calcium gluconate 10 %
Or 10 ml calcium chloride 10 %
Slowly IV injection

51
Q

When should neonatal team be called if delivery is likely in women with collapse?

A

Over 22 weeks

52
Q

What is the incidence of major obstetric haemorrhage?

A

6 / 1000 maternities

53
Q

What is the most common cause of direct maternal death?

A

Thromboembolism

54
Q

What is the incidence of AFE ?
What is the survival rate?

A

Incidence 1.7 / 100,000 maternities
Survival rate 81 %

55
Q

How to diagnose AFE ?

A

Clinically

56
Q

What are the main cardiac causes of maternal death?

A

Ischemia
Sudden arrhythmic cardiac death

57
Q

How to perform chest compression in maternal collapse?

A

30 chest compression ( 100- 120 / min) for every 2 ventilation breaths

58
Q

What is the infant survival rate when PMCS is preformed?

A

69 % if PMCS is preformed within 5 minutes

24-Obstetric Emergencies (6 decks)

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