Maternal Collapse

Question 1

leading cause of maternal mortality in labour and 6 weeks following?

Answer 1

cardiac (indirect)

Question 2

main direct cause of maternal death?

Answer 2

venous thromboembolism

Question 3

general principles of management of emergency?

Answer 3

anticipation and preparation are essential (prevent collapse/arrest etc)
two lives at stake but mum is 1st
get help early
ABCDE
human factors and communication training essential
counselling and debrief for patient and staff

Question 4

MEWS?

Answer 4

maternal early warning score

1 red or 2 amber scores = medical review

Question 5

what can cause collapse (5 Hs)?

Answer 5

head
- eclampsia, epilepsy, cerebrovascular accident
heart
- MI, arrhythmia, paripartum cardiomyopathy
hypoxia
- asthma, PE, pulmonary oedema, anaphylaxis
haemorrhage
- abruption, atony, trauma, uterine rupture, uterine inversion, ruptured aneurysm
whole body and hazzards
- hypoglycaemia, septicaemia, trauma, anaesthetic complications, drug overdose

Question 6

emergency bloods?

Answer 6

FBC
cross match
coagulation
U&Es
lactate
glucose
......

Question 7

risks to be aware of when resuscitating pregnant woman?

Answer 7

gravid uterus
- can cause aortocaval compression and can also make ventilation difficult due to pressure on diaphragm
foetus and placenta steal oxygen and circulation from mother (20% decrease in pulmonary functional residual capacity and 20% increase in oxygen consumption increasing risk of hypoxia)
more likely to aspirate (increased prostaglandins loosen muscles/sphincters including oesophageal
more difficult to intubate

Question 8

what is aortocaval compression?

Answer 8

from 20 weeks gestation (or as soon as visibly pregnant), the uterus can compress IVC and aorta when lying on back reducing venous return
decreases cardiac output up to 40% causing supine hypotension

Question 9

how is

Answer 9

mrs MUD

- manual uterine displacement (push the bump over to the left hand side)

Question 10

causes of cardiac arrest (4 Hs and 4 Ts)?

Answer 10

hypothermia
hypotension
hypokalaemia
hypoxia

thrombosis
tamponade
toxins
tension pneumothorax

Pre-eclampsia in pregnancy

Question 11

how long should CPR be continued before emergency (peri-mortem) C section is performed?

Answer 11

4 mins

Question 12

how is a perimortem C section performed?

Answer 12

very basic, fast, non-sterile C section done in emergency
basically just slice open with a scalpel
CPR continued throughout

Question 13

which rhythms are shockable?

Answer 13

VF

VT

Question 14

specific drug treatment for collapse in pregnancy?

Answer 14

cardiac arrest = 1mg adrenaline every 2 mins
VF/VT = 300mg amiodarone
opiate overdose = 0.4-0.8mg naloxone
magnesium toxicity = 1g calcium gluconate
local anaesthetic toxicity = 1.5ml 20% intralipid

Question 15

when is magneisum sulphate given?

Answer 15

pre-term delivery = to foetus

seizure (eclampsia) = to mum

Question 16

management of seizure?

Answer 16

call for help
make patient safe
note time and length of seizure
give high flow oxygen
don't restrain patient
get IV access
move patient into left lateral position and open airway
monitor baby
declare status if >5 mins
give magnesium sulphate

Question 17

how is anaphylaxis managed?

Answer 17

remove allergen
sit up
high flow oxygen
IM adrenaline 500mcg every 5 mins and IV crystalloid bolus (main initial management)
chlorpheniramine 20mg IV
hydrocortisone 200mg IV
salbutamol neb

Question 18

how is hypoglycaemia managed?

Answer 18

<3mmol = 50ml of 10% dextrose ivor 1mg glucagon IM or glucogel
stop insulin

Question 19

diagnostic criteria for DKA?

Answer 19

ketones > 3mmol/L
blood glucose > 11mmol/L
venous bicarbonate <15mmol/L or venous pH <7.3

Question 20

how is DKA managed?

Answer 20

fluid replacement saline
insulin therapy
locate and treat cause
monitor ABGs and baby
- deliver if mum is stable

Question 21

what is an amniotic fluid embolism?

Answer 21

amniotic fluid enters maternal circulation causing collapse +/- arrest

Question 22

how does amniotic fluid embolism present?

Answer 22

profound foetal distress 
sudden resp distress
seizure
DIC
increased zinc coproporphyrin levels
squames seen on right sided circulation

Question 23

how is amniotic fluid embolism managed?

Answer 23

supportive ITU

Question 24

can you thrombolyse in pregnancy?

Answer 24

yes

only if necessary as can cause risk to foetus and increased risk of PPH

Question 25

what is cord prolapse and what are the risks?

Answer 25

prolapse of the umbilical cord out of the uterus (can even protrude out of the vagina)
can cause direct compression and cord spasm leading to decreased flow to foetus resulting in hypoxia and death

Question 26

how can cord prolapse be prevented?

Answer 26

ensure head is engaged before rupturing amniotic membranes

Question 27

management of cord prolapse?

Answer 27

obstetric emergency
immediate delivery (category 1)
tocolytic and maternal positions to relieve pressure

Question 28

what is shoulder dystocia?

Answer 28

any cephalic delivery where manoeuvres other than gentle traction are required to deliver baby after the head has been delivered
bony impaction of the foetal anterior shoulder on the maternal symphysis

Question 29

risk factors for shoulder dystocia?

Answer 29

obesity
diabetes
macrosomnia
prolonged labour
instrumental delivery

Question 30

signs of shoulder dystocia?

Answer 30

slow delivery of the head, face and chin
turtling of the head against perineum
lack of restitution
head bobbing (head retracts back inside between contractions)