Maternal collapse Flashcards
What system is recommended to earlier identify women at risk of impending collapse?
Maternal early warning score
Causes of maternal collapse?
4H’s and 4Ts + Eclampsia/PET
- Hypovolaemia: Haemorrhage, dense spinal block, sepsis
- Hypoxia: pregnant pts become hypoxic faster. Causes: cardiac events e.g. peripartum cardiomyopathy/MI/aortic dissection
- Hypo/hyperkalaemia and other electrolyte disturbances
- Hypothermia
Ts:
- Thromboembolism: PE/AFE/MI/air embolud
- Toxicity :Local anaesthetic, other drugs
- Tension pneumothorax: e.g. trauma/suicide
- Tamponade: e.g. trauma/suicide
Eclampsia and PET- including intracranial haemorrhage
Estimated incidence of AFE
2 per 100,000 maternities
Typical presentation of AFE
- During labour or within 30 minutes of delivery
- Acute hypotension, respiratory distress and acute hypoxia
- May develop seizures and cardiac arrest
Disease progression of AFE
- Pulmonary hypertension secondary to vascular occlusion (by debris or vasoconstriction)
- LV dysfunction or failure
- Coagulopathy - leading to massive obstetric haemorrhage
- If prior to delivery may see profound fetal distress
Pathophysiology thought to be similar to anaphylaxis/severe sepsis
What are the physiological and anatomical changes in pregnancy that affect resuscitation?
- Aortocaval compression
- Cardiovascular changes
- Increased respiratory demand
What is the effectiveness of CPR in the absence of left lateral tilt?
10% of that in non-pregnant women (30%)
What cardiovascular changes in pregnancy affect the effectiveness of CPR?
Increased:
- plasma volume
- HR
- Cardiac output
- Uterine blood flow
Decreased:
- SVR
- BP
- Venous return (due to enlarged uterus)
Leads to: reduced O2 carrying capacity, decreased effectiveness of CPR, increased circulatory demands
What respiratory changes in pregnancy affect the effectiveness of CPR?
Increased:
- RR
- O2 consumption
- Laryngeal oedema
Decreased:
- Residual capacity (due to enlarged uterus)
- arterial PCO2
Leads to: Decreased buffering capacity- acidosis more likely, Hypoxia develops more quickly, difficult intubation
What gastrointestinal changes in pregnancy affect the effectiveness of CPR?
DECREASED gastric motility
RELAXED oesophageal sphincter
lead to increased aspiration risk
What is the optimal initial management of maternal collapse?
A, B, C
+ modifications:
- left lateral tilt when >20/40
- early, secure airway with ET tube
- Ensure O2 administered as soon as possible
- Perimortem CS after 4 minutes and within 5
Defib the same and no alteration in drug doses in ALS algorithm
Sepsis 6 bundle
- Measure serum lactate.
- Obtain blood cultures/culture swabs prior to antibiotic administration.
- Administer broad-spectrum antibiotic(s) within the first hour of recognition of severe sepsis and
septic shock according to local protocol - In the event of hypotension and/or lactate >4 mmol/l:
a) deliver an initial minimum of 20 ml/kg of crystalloid/ colloid
b) once adequate volume replacement has been achieved, a vasopressor (norepinephrine,
epinephrine) and/or an inotrope (e.g. dobutamine) may be used to maintain mean arterial
pressure over 65 mmHg
Further management consists of:
5. In the event of hypotension despite fluid resuscitation (septic shock) and/or lactate over 4 mmol/l:
a) achieve a central venous pressure of at least 8 mmHg (or over 12 mmHg if the woman is
mechanically ventilated) with aggressive fluid replacement
b) consider steroids.
6. Maintain oxygen saturation with facial oxygen. Consider transfusion if haemoglobin is below 7g/dl.
What is the antidote to MgSO4 toxicity?
10 ml 10% calcium gluconate given by slow intravenous injection
What drug should be given in LA toxicity?
Intralipid 20%
What is the dose of Adrenaline that should be given in anaphylaxis?
500 micrograms (0.5 ml) of 1:1000 adrenaline intramuscularly.
PLEASE NOTE THIS DOSE IS FOR INTRAMUSCULAR USE ONLY.
