Maternal Collapse and Obstetric Emergencies Flashcards
In developed countries, what is the maternal death rate?
10 per 100,000
In developing countries, what is the maternal death rate and what are the causes?
462 per 100,000 PPH Infections Labour complications Unsafe abortion
What is MBRACE?
Examines all UK maternal deaths within a year of delivery
What are the commonest causes of maternal death in the UK?
Cardiac disease Thrombosis and VTE Neurological Psychiatric Sepsis Haemorrhage Amniotic fluid embolism
What are the 5Hs of maternal collapse?
Head; eclampsia, epilepsy, CVA, vasovagal
Heart; MI, arrhythmia, peripartum cardiomyopathy
Hypoxia; asthma, PE, pulmonary oedema, anaphylaxis
Haemorrhage; abruption, atony, uterine rupture, uterine inversion, ruptured aneurysm
wHole body and Hazards: hypoglycaemia, amniotic fluid embolism, sepsis, trauma, anaesthetic cx, drug overdose
Why is resuscitating a pregnant woman difficulty?
Gravid uterus; aortocaval compression, ventilation difficult due to pressure on diaphragm
Fetus steals oxygen (reduces pulmonary function by 20%, 20% decrease in oxygen consumption)
More likely to aspirate
More difficult to intubate
When will aortocaval compression begin?
From 20 weeks gestation, in supine position the gravid uterus can compress IVC and aorta reducing venous return
What is a very important manoeuvre whilst resuscitating a pregnant woman?
Manual uterine displacement
In what position should a collapsed pregnant woman be put in?
Left lateral
In non-pregnant woman what percentage of normal cardiac output will chest compressions achieve?
30%
In pregnant woman, what percentage of normal cardiac output will chest compressions achieve?
Aortocaval compression reduces CO to around 10%
When should a perimortem c-section be performed in pregnant women who are in cardiac arrest?
If no response to correctly performed CRP within 4 mins of maternal collapse, delivery should be undertaken
What are shockable rhythms?
VF
Pulseless VT
When should adrenaline and amiodarone be given in cardiac arrest?
Adrenaline after 3rd shock then every other cycle
Amiodarone 300mg given after 3rd shock
How is tube placement in intubation confirmed?
Capnography
What are the 4Hs and 4Ts of cardiac arrest?
Hypoxia Hypovolemia Hypo/hyper metabolic Hypothermia Thrombosis Tamponade Toxins Tension pneumo In pregnant woman; add PET
What drug should be considered in opiate overdose?
0.4-0.8 mg naloxone
What drug should be considered in magnesium toxicity?
1g calcium gluconate; 10ml of 10%
What drug should be considered in LA toxicity?
1.5 ml 20% intralipid
Drug treatment for anaphylaxis?
IM adrenaline 500 mcg every 5 mins and IV crystalloid bolus
Chlorpheniramine 20mg IV
Hydrocortisone 200mg IV
Salbutamol neb
Treatment for hypoglycemia?
If under 4 mmol/l give 50ml of 10% dextrose
OR
1mg glucagon IM
DKA criteria?
Ketonaemia 3 mmol/l
BG > 11 mmol/l
Venous bicarb <15 mmol/l or venous pH <7.3
Presentation of amniotic fluid embolism
Profound foetal distress
Sudden resp distress
Seizure
DIC
What is the treatment of amniotic fluid embolism?
Supportive in ICU
How can amniotic fluid embolism be confirmed?
Zine coproporphyrin levels increased
Post-mortem via squames on right side of circulation
Investigations for massive PE?
ECG; tachy, right side strain, S1Q3T3 CXR to exclude pneumothorax or pneumonia. May see wedge collapse ABG; hypoxia Echo; rule out dissection and tamponade Consider CTPA or V/Q scan
Signs of a massive PE?
JVP raised
Enlarged liver
Parasternal heave
Fixed splitting of 2nd heart sound
Ix for stroke
Heat CT/ MRI Echo Coag Thrombophilia screen Carotid doppler LP Cerebral angiography
What is cord prolapse associated with?
Malpresentation
Preterm labour
2nd twin
Artificial membrane rupture
Why will cord prolapse lead to foetal death?
Direct compression and cord spasm resulting in decreased flow and hypoxia
What are the ix for cord prolapse?
Scan for foetal cardiac activity
What is the management for cord prolapse?
Immediate delivery; cat 1 (c/s or forceps)
Tocolytic and maternal position to relive pressure
What is shoulder dystocia?
Any cephalic presentation where maneuvers other than gentle traction are required to delivery the baby after the head has delivered
Bony impaction of foetal anterior shoulder on maternal pubic symphysis
What are risk factors for shoulder dystocia?
Obesity Diabetes Macrosomia Prolonged 1st or 2nd stage Instrumental delivery
What are the signs of shoulder dystocia?
Slow delivery of head
Turtling of head
Lack of restitution
What is the head bobbing sign in terms of shoulder dystocia?
Head consistently retracts back between contractions during the active second stage
What is the turtle sign in shoulder dystocia?
Delivered head becomes tightly pulled back against the perineum and there is difficulty delivering the chin
What are the risks associated with shoulder dystocia?
Stillbirth Hypoxic brain injury Brachial plexus injury Fractures PPH 3rd and 4th degree tears
What reduces the risk of hypoxic ischaemic damage in shoulder dystocia?
If delivery is achieved within 5 mins from time of delivery of head
What is the management of shoulder dystocia?
HELPERR Help Evaluate for episiotomy Legs (McRoberts manoeuvre) Pressure (suprapubic) Enter (rotational maneouvre) Remove posterior arm Roll patient onto hands and knees
What are the manouvres in shoulder dystocia designed to do?
Increase functional size of bony pelvis
Narrow bisacromial diameter of foetus
Change position of bisacromial diameter within bony pelvis
