Sudden Maternal Collapse Flashcards
What are the common obstetric causes of sudden maternal collapse?
Obstetric
• Massive haemorrhage – placenta praevia, abruption, PPH, supralevator haematoma following genital tract trauma and uterine rupture
• Severe Pre-eclampsia with intracranial bleed
• Eclampsia
• Amniotic fluid embolism
• Severe sepsis from chorioamnionitis
• Cardiac failure e.g. peripartum cardiomyopathy
What are the common medical/surgical causes of sudden maternal collapse?
- Massive PE
- Cardiac failure or MI
- Shock – anaphylactic or septic
- Intrabdominal bleeding – hepatic, splenic or aortic rupture
- Intracerebral bleed
- Overdose
- Diabetic coma
- Cerebral infection
Why are pregnant women at a higher risk of PE/VTE?
Pregnancy itself – venous stasis, change in blood content and coagulation
What pre-exisiting factors increase the risk of obstetric PE/VTE
- 1 previous unprovoked VTE
- Congenital thrombophilia’s
- Age > 35
- Obesity
- Smoking
- Varicose veins
- Paraplegia
- Cancer
- Inflammatory disease
- Significant cardiac or respiratory disease
What obstetric factors increase the risk of obstetric PE/VTE?
- Multiple pregnancy
- PET
- C section or any other surgical procedure
- Prolonged labour
- Stillbirth
- Preterm birth
- PPH
- Parity > 4
What transient factors can increase the risk of obstetric PE/VTE?
- Dehydration and hyperemesis
- Ovarian hyperstimulation syndrome
- Admission or immobility
- Systemic infection
- Long distance travel
Describe the clinical features of a PE/VTE?
DVT or swollen legs (left leg most common)
Sudden onset dyspnoea, pleuritic chest pain, cough and haemoptysis
May become unstable – tachycardic, tachypnoeic and raised JVP
When does a mother require antenatal thromboprophylaxis?
LMW Heparins is the drug of choice for antenatal thromboprophylaxis.
Pregnant women offered prophylaxis if
>/= 4 risk factors in 1st and 2nd trimester
>/= 3 in the 3rd trimester
>/= 2 in the post-partum period
If >1 previous VTE whether unprovoked or provoked or 1 VTE with any thrombophilia, then LMWH throughout pregnancy and 6-week post-partum.
How long should thromboprophylaxis be given for?
If receiving thromboprophylaxis antenatally then continue 6 weeks post-partum
Do you require thromboprophylaxis after a Cesarean section?
7 days course of LMWH should be considered in all women who have had a CS post-partum
How should a suspected obstetric PE be investigated
FBC, Us and Es and LFTs
ECG and Chest X-ray
ABG
Duplex USS of the leg – if positive no need for anything further
CTPA
Ventilation/perfusion lung scan
MRI scan
Coagulation screen
Thrombophilia screen
How should a confirmed PE/VTE be treated in the obstetric setting?
LMWH, alternatives include unfractionated heparin or NOAC such as rivaroxaban. Treatment continued for the duration of pregnancy and continue for 6 weeks after delivery.
Warfarin can be used postnatally and is safe in breast feeding.
For those receiving thromboprophylaxis or treatment for PE/VTE, who should have their Anti-Xa levels measured?
Anti-Xa activity should be monitored in those at the extremes of weight (<50kg and >90kg) or renal impairment or recurrent VTE.
Should thromboprophylaxis or PE/VTE treatment continue through a CS or other intervention in labour?
Once in labour – no more injection of heparin. Omit dose 24hours before any planned IOL or CS. Also, to avoid risk of epidural haematoma regional blocks should wait until at least 12 hours after last dose. No dose should be given for 4 hours after catheter removed and catheter should not be removed within 10-12 hours of a heparin dose.
Are NOACs ever used in a pregnancy?
Note NOACS are contraindicated in pregnancy due to the risk of placental haemorrhage, prematurity and foetal demise.
