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MATERNAL COLLAPSE

Berrin Gunaydin, MD, PhDDepartment of Anesthesiology

Gazi University School of Medicine

Ankara, Turkey

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OBJECTIVES

Discuss • the incidence and causes of cardiac

arrest/maternal collapse in pregnancy• the physiological changes in pregnancy

that make women susceptible• resusciation techniques and

management of cardiac arrest in pregnancy

• amniotic fluid embolism• perimortem cesarean section

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Maternal mortality

• Cardiac arrest is a very rare maternity emergency (1/30000 pregnancy)

• It usually occurs as a result of other maternity emergencies

• If managed well, up to 50% of maternal deaths are preventable

• Many maternal deaths occur from potentially treatable causes

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Physiology of Pregnancy I

• Increased plasma volume (50%)• Increased cardiac output (40%)• Increased heart rate (15-20 bpm)• Increased respiratory rate • Increased oxygen consumption (20%)• Decreased blood pressure • Decreased residual lung capacity • Laryngeal oedema• Aoto-caval compression

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Physiology of Pregnancy II

• Increased clotting factors• Increased breast tissue• Diaphragm rises by about 7 cm and

the organs move for growing uterus • Gut peristaltis slows

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Major body changes for the pregnant woman

• Improve blood supply for fetal nutrition

• Promote breast development in preparation for neonatal feeding

• Alter the internal organ displacement to make room for the growing fetus and uterus

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Hormonal influences

Oestrogen • Increased

excitability in uterine muscle fibers

• Increased susceptibility to catecholamines

Progesterone• İncreased tidal

volume and respiratory rate

• Hyperventilation causes decreased CO2 and compansated respiratory alkalosis

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Pregnant CPR

• TILT 27º angle - Left side - Human wedge

• compression of the aorta by the gravid uterus causes 30% of cardiac output sequestered

• chest compressions need to be stronger due to the increased breast size and chest wall resistance

• intubation is difficult due to the pharyngeal and nasal oedema

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CPR

• Danger: safety for self, others and woman• Response: level of consciousness• Airway: open the airway• Breathing: 2 initial breaths

provide positive-pressure ventilations • Circulation:30 chest compressions to 2

breaths• Defibrillation: assess and shock VF or

pulseless VT

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CPR

Airway• Ensure airway is

patent and protected from aspiration

• Consider early intubation

Breathing • Confirm placement of

tube• Secure device• Confirm adequate

oxygenation

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CPR

Circulation• Establish IV access• Identify rhythm and monitor• Administer appropriate drugsDifferential diagnosis • Search for identified reversible

causes

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Drugs for resuscitation

• Adrenaline 1 mg IV bolus repeat every 3-5 min

• Be aware of all the drugs are on the emergency trolley

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4 minute rule

4 minute after arrest• Maternal apnoea occurs associated with

rapid declines in arterial pH and PO2

• Fetus of an apnoeic and asystolic mother has ≤2 minutes of oxygen reserve

• After 4 minutes without restoration of circulation, dramatic action must occur

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Pre-requisite for perimortem caserean

• The arrest must be witnessed• Skilled personnel and equipment

available • No spontaneous maternal circulation

for 4 min• Potential viability: singleton at 23-24

weeks or greater• A perimortem caserean section can

save two lives

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Amniotic fluid embolism (AFE)

• Occurs when there is an opening between the amniotic sac and the uterine veins in approximately 1:20 000 births

• Risk factors include– Abruption– Intrauterine fetal demise– Tumultuous labor– Oxytocin hyperstimulation

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AFE

Amniotic fluid • may enter maternal circulation• passes through the maternal heart and

becomes trapped in maternal pulmonary circulation causing L sided heart failure and bronchospasm

• These lead to localised DIC which thenspreads quickly throughout the mother• Anaphylactic reaction associated with amniotic

fluid in the maternal circulation may occur

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AFE

• Symptoms occur very rapidly– Sudden dyspnoea and respiratory

distress– Shock without obvious blood loss– Maternal collapse– Seizures (30%)– DIC

• Diagnosis is usually made postmortem

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Management

• Call for help

• Supportive and resuscitative ABC

• 2 large bore cannulae

• Consider X-ray and ECG

• Immediate delivery

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Summary of AFE

• Rare obstetric emergency with very poor prognosis for maternal-fetal outcome

• Historically high maternal mortality rate of 85% declined to 27% with better diagnosis and ICU treatment

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CONCLUSION

• Cardiac arrest is a rare event• 44-50% of maternal deaths are

preventable by improving management strategies– Remember 27ºº tilt and working around the

increased breast tissue– Perimortem C/S can save 2 lives– TEAM WORK can help to improve outcomes – Documentation and Debriefing are of utmost

importance

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Scenario

• 38 year-old parturient at 34 weeks’ gestation suffering from dyspnea and chest pain is admitted to the ER

Vital signs

A ConsciousB Sianosis, RR 40 breath min-1, SpO2 85% during 15

L/min oxygen via reservuar mask C HR140 beat min-1 sinus tachycardia, BP 70/40

mmHgD Anxious and restlessE Gravid uterus

Differential diagnosis?

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Scenario continued

All of a sudden she became unconscious and apnoeic

ECG monitor displays wide complexes, HR 20 beat min-1.

No pulse

What do you do right now?