Maternal Collapse + Trauma

Question 1

Antenatal/intrapartum collapse mx

Scenario 1 - after epidural intrapartum

Answer 1

DDx
- LA toxicity
- epilepsy, eclampsia, electrolytes
- cerebral vein throm/stroke/SAH/mass
- cardioresp - PE/APO/AMI/cardmyo/dis
- sepsis, anaphylaxis, vasovagal
- withdrawal/pseudo-seizure
- haemorrhage

• Call for Help
• ABC +/- CPR
• Left lateral with wedge
• Hudson mask 10L
• x2 wb IVC -> bloods/fluid bolus/ECG
• IV intralipid 20% (bolus - infusion)
• Stop Synt, monitor CTG closely

Question 2

Postpartum collapse mx

Scenario 1 - postpartum, grand mal seizure at home on bkg of PET in preg

Scenario 2 - postpartum, 34yo, collapse on ward after emCS for suspected chorioamnionitis at 29/40

Scenario 3 - cyanosed/unconscious post CS for FDIU in the setting APO/PET - failed medical mx (miso) - tachycardic/hypotensive, high RR, saturating 70% (dx of PE)

Answer 2

DDx
- epilepsy, eclampsia, electrolytes
- cerebral vein throm/stroke/SAH/mass
- cardioresp - PE/APO/AMI/cardmyo/dis
- sepsis, anaphylaxis, vasovagal
- withdrawal/pseudo-seizure
- haemorrhage - PPH

Emergency -> MDI
Simultaneous tasks
Priorities are resuscitation/stabilization

Hx
- preceding events/sx
- Trigger - sleep/fluid…
- ?T&C, duration, postictal, injury
- AN course/PN PET mx
- PHx/Med/SHx - D&A use…

Exam
- Vitals, pupils
- Cardio-resp
- Abdo-pelvic
- Clonus/Hyperreflexia

Ix
- FBE/UEC/CMP/LFT/CRP
- Lactate/LDH/Coag/G&S/BSL
- CTB +/- MRI/ECG

Mx
- Maternal collapse = emergency
- Resuscitation - DR ABC
(IVC/IVT/O2/septic screen…)
- MDI (Obs/Obs Med/Ano/HDU/ICU
- Stabilization - resp/vascular sup -> ICU
- +/- seizure prevention - MgSo4 24/24
- +/- VQ or CTPA to exclude PE
- +/- vascular team ?thrombolectomy
- BP control - PO regimen =<150/100
- VTE prophylaxis +/- therapeutic LMWH
- Support care - baby safety
- Postpartum seizure clinic F/U - EEG
- Postpartum Obs OPC in 6/52

Saddle embolus

Question 3

Abdominal trauma mx

Scenario 1 - 40/40, rural hospital, major MVA, abdo-trauma, semi-conscious -> initial ax

Scenario 2 - major MVA, abdo-trauma, unknown gestation - arrested during initial resus

Answer 3

• Obs emerg - ?abruption/rupture
• Activate Obs emergency code
• MDI - Obs/ED/Trauma/MW/Paeds/Rad
• Simultaneous resus/stabilization/Ix
• ABC - NBM/left lat/O2/IVCx2/IVT
• FBE/UEC/LFT/Coag/G&S/FMH
• Abdo palp + RTS +/- CTG
• Targeted HEI - gestation/APH
  Once stabilized
• Admission +/- CTG
  +/- steroid +/- MgSo4
• Formal obstetric USS
• Chase Kleihauer +/- anti-D
• Debrief/Psychosocial support

In case of cardiac arrest
- +/- perimortem CS (reduce mat M&M)
- kit by 3min of CPR, CS by 4, del by 5
- single layer closure
- pack abdomen
- prep for OT for def closure if ROC
- broad spec IV ABx
- postop- debrief/M&M/VBAC discussion

Question 4

Uterine rupture mx

Scenario 1 - as a result of MVA trauma identified during perimortem CS

Answer 4

• recognize
• inform team - esp EBL
• continue resus +/- MTP
• deliver fetus
• repair vs hyster (req GONC assist)
• ROS/success -> urgent OT for mx
• postop - routine/preg interval/elCS/F/U