Maternal Collapse Flashcards
what groups of women are most at risk of maternal death
black women
asian women
older women
women from deprived areas
what is the leading cause of death up to six weeks after pregnancy
thromboembolism and cardiac disease
what is the leading cause of maternal death from six week to a year after pregnancy
cancer and suicide
whos life comes first- the mothers or the babies
mum
define maternal collapse
respiratory or cardiac distress that may lead to cardiac arrest (range of causes from syncope to cardiac arrest)
what are the 6 H’s for causes of maternal collapse
Head- eclampsia, epilespy, cerebrovascular accident, vasovagal response
Heart- MI, arrythmias, peripartum cardiomyopathy
Hypoxia- asthma, PE, pulmonary oedema, ananphylaxis
Haemorrage- abruption, atony, trauma, uterine rupture, uterine invesion, ruptured aneurysm
wHole body and Hazards- hypoglycaemia, amniotic fluid embolism, septicaemia, trauma, anaesthetic complications, drug overdose
why shouldnt pregnant women lie of their backs
causes vasovagal- pressure on aorta, Aortocaval compression
if they collapse roll them on their side
should you be cautious given pregnant women oxygen
wont do any harm giving 15 L
what should you consider before giving a rapid fluid bolus
other co morbidities e.g. PET
what position should unconscious pregnant women be in
left lateral position
at what blood glucose level should you give glucose
<4
why are pregnant women harder to resuscitate
Gravid uterus
-Aortocaval compression
-Ventilation difficult – pressure on diaphragm
Fetus/placenta
-‘Steals’ oxygen and circulation from mother
-20% decrease in pulmonary functional residual capacity and a 20%
increase in oxygen consumption – more risk of hypoxia
More likely to aspirate (hormonal relaxation of the oesophageal sphincter and delayed gastric emptying)
More difficult to intubate (oedema and the larger tongue and breasts of pregnancy)
what is aortocaval compression
From 20 weeks gestation, in the supine position the gravid uterus can compress IVC and aorta reducing venous return
Decreasing cardiac output by up to 40%, causing supine hypotension
As soon as infant is delivered vena cava returns to normal and cardiac output is restored
what is MUD
manual uterine displacement
how is aortocaval compression prevented
Displace uterus to relieve pressure on aorta and vena cava and improve venous return to the heart:
Keep mother supine and apply left manual uterine displacement or 30-degree tilt if on theatre table
when should a perimortem C section be done
do at 5 minutes, prepare at 4
If there is no response to correctly performed CPR within 4 minutes of maternal collapse delivery should be undertaken to assist maternal resuscitation (aortocaval compression reduces CO from chest compressions from 30% to 10%)
what is needed for a perimortem C section
A limited amount of equipment is required
Sterile preparation and drapes are unlikely to improve survival
Moving to an operating theatre is not necessary
CPR should continue throughout
Diathermy will not be needed as there is little blood loss if there is no cardiac output
If the mother is successfully resuscitated she can be moved to theatre to complete the operation
when should adrenaline and amiodarone be given in resus
given after the third shock and then every other cycle (i.e. every 4 minutes)
Amiodarone 300 mg should be given after the third shock.
what are the 4H’s and 4T’s of reversible causes of cardiac arrest
Hypoxia
Hypovolaemia
Hypo/hyper metabolic
Hypothermia
Thrombosis
Tamponade
Toxins
Tension pneumothorax
Pre eclampsia
what drug for cardiac arrest
1 mg adrenaline (epinephrine) every 2minutes
what drug for VF/VT
300 mg amiodarone
what drug for opiate overdose
0.4–0.8 mg naloxone
what drug for magnesium toxicity
1 g calcium gluconate
what drug for local anaesthetic toxicity
1.5 ml 20% Intralipid
what management for eclampsia/ seizure in pregnancy
cCall for help Make patient safe Note time and length of seizure Give high flow oxygen Don’t restrain patient during fit Get iv access Move patient into left lateral and open airway Monitor baby
what treatment for anaphylaxis
Remove allergen High flow oxygen IM adrenaline 500mcg every 5 mins and IV Crystalloid bolus Chlorpheniramine 20mg IV Hydrocortisone 200mg IV Salbutamol neb
what treatment for hypoglycaemia
Glucose, <3mmol/l- 50ml of 10% dextrose Ivor 1mg glucagon IM or glucogel (stop insulin!)
what is the diagnostic criteria for DKA
ketonaemia 3 mmol /l and over or significant ketonuria
blood glucose over 11 mmol /l or known diabetes mellitus
venous bicarbonate (HCO3 ) below 15 mmol /l or venous pH less than 7.3
what is an amniotic fluid embolism
Amniotic fluid enters maternal circulation- collapse+/- arrest
Rare 1/8000
Mortality 30%
Not predictable or preventable, usually in labour
Diagnosis can be confirmed on post-mortem by squames on right sided circulation
what is the presentation of an amniotic fluid embolism
Acute presentation: profound fetal distress, sudden resp distress, seizure & DIC
what is the treatment for an amniotic fluid embolism
support ITU
when are women most at risk of a PE
postnatally
what are the features of a massive PE
Cyanosis, shock, collapse (tachy, dyspnoea, pain, apprehension, cough, haemoptysis, temp>37)
JVP raised, enlarged liver, parasternal heave, fixed splitting of 2nd heart sound
15% have a DVT evident
ECG tachy and right sided strain
what Ix for a PE
ECG tachy and right sided strain, rarely S1Q3T3
CXR to exclude pneumothorax and pneumonia, may see pleural effusion, raised hemidiaphragm and wedge collapse
ABG- may show hypoxia and a normal or low CO2
Echo- rule out dissection and tamponade
Consider pulmonary angiography
Consider CTPA
treatment for a PE
Therapeutic Tx with heparin
Thrombolysis
what CVAs can happen in pregnancy
PET Thrombosis/embolus AFE Haemorrhagic- AV malformation or aneurysm Infarct- infection, cocaine, vasculitis
how might a CVA present
headache, vomiting, hypertension, seizure, collapse
Can have focal signs, neck stiffness, papilloedema
what Ix for a CVA
Head CT/MRI
Echo, coag, thrombophilia screen, carotid Doppler, lumbar puncture, cerebral angiography
what is cord prolapse associated with
malpresentation, preterm labour, 2nd twin, artificial membrane rupture
what is the risk of cord prolapse
Direct compression and cord spasm = decreased flow- hypoxia- death
is an emergency
what is the management for cord prolapse
Scan for fetal cardiac activity
Immediate delivery – Cat 1 (CS or forceps)
Tocolytic and maternal positions to relieve pressure
(cont ve/ knee- chest position)
what is shoulder dystocia
is any cephalic delivery where manoeuvres other than gentle traction are required to deliver the baby after the head has delivered
=bony impaction of fetal anterior shoulder on the maternal symphysis
what are the risk factors for shoulder dystocia
obesity, diabetes, macrosomia, prolonged 1st & 2nd stage, instrumental delivery
what are the signs of shoulder dystocia
slow delivery of the head, face and chin, ‘turtling’ of head against perineum, lack of restitution
‘head bobbing’ – this is when the head consistently retracts back between contractions during the active second stage
‘turtle-sign’ – the delivered head becomes tightly pulled back against the perineum and there is difficulty delivering the chin
what are the risks of shoulder dystocia
stillbirth, Hypoxic brain injury, brachial plexus injury, fractures, PPH, 3rd & 4th degree distress
Hypoxic ischaemic damage risk is low if delivery is achieved within 5 minutes from the time of delivery of the head.
what is the management of a shoulder dystocia
HELPER (call for) Help Evaluate for episiotomy Legs (McRoberts' manoeuvre) Pressure (suprapubic) Enter (rotational manoeuvre) Remove the posterior arm Roll the patient onto her hands and knees
what is the role of the maneouvers used to treat a shoulder dystocia
Increase the functional size of the bony pelvis
Narrow the bisacromial diameter of the fetus
Change the position of the bisacromial diameter within the bony pelvis
what should you assume a fitting pregnant women has
eclampsia
when should you declare status epilepticus
after 5 mins
what is disseminated intravascular coagulation
when blots clots form throughout the body, hyperactive clotting due to infection/ other disease
what can cause a cord prolapse
rupturing membranes before babies head in engaged in pelvis
