Maternal collapse and maternal cardiac arrest · 2018-10-04 · Maternal cardiac arrest •Cardiac arrest during pregnancy carries a very high maternal and fetal mortality rate •Very
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Maternal collapse andmaternal cardiac arrest
Maternal collapse
• What is it?
• Causes
• Early recognition and treatment
• Maternal cardiac arrest
AIRWAY o Obstructed or noisy
BREATHING o Respiratory rate < 5 or > 35 breaths per minute
CIRCULATIONo Pulse rate < 40 or > 140 bpm
o Systolic BP < 80 mmHg or > 180 mmHg
NEUROLOGYo Sudden decrease in level of consciousness
o Unresponsive/only responsive to painful stimuli
APPEARANCE o Woman who ‘looks’ collapsed
What is maternal collapse?
Maternal Cardiac Arrest –MBRRACE 2009-2012
• Maternal death rate UK 2009-2012 : 10 per 100,000 maternities
• Significant decrease in death rates over time
• Primarily due to significant halving in direct maternal deaths (2003-5 to now)
• Despite women with higher care needs (advanced maternal age, obesity, greater proportion of women born outside UK)
MBRRACE – UK 2010-2012Causes – direct
Direct causes of maternal deaths (78 deaths)
Rates per 100 000 maternities
Thrombosis and thromboembolism 1.08
Genital tract sepsis 0.50
Haemorrhage 0.46
Pre-eclampsia & eclampsia 0.38
Early pregnancy deaths 0.33
Amniotic fluid embolism 0.33
Anaesthesia 0.17
Total 3.25
MBRRACE 2010–2012Causes – indirect
Indirect causes of maternal deaths (Deaths 165)
Rates per 100 000 maternities
Other Indirect Causes (sepsis) 2.54
Cardiac disease 2.25
Indirect Neurological conditions 1.29
Psychiatric 0.67
Indirect malignancies 0.13
Total 6.87
Key MBRRACE Messages
• 2/3 of mothers died from medical and mental health problems in pregnancy and only 1/3 from direct causes such as thromboembolism
• ¾ of women who died had medical or mental health problems before they became pregnant
• Women with pre-existing medical and mental health problems need pre-pregnancy advice and joint specialist and maternity care.
Key MBRRACE Messages
• Think Sepsis
– ¼ of women who died had sepsis
– Women with sepsis need
1. Early diagnosis
2. Rapid antibiotics
3. Review by senior doctors and midwives
• Prevent Influenza
– 1 in 11 of deaths were due to influenza
– More than half these deaths were preventable by the flu jab!
Recognition
• Heart rate
• BP
• Respiratory rate
• Temperature
• Simple observation of the woman
• Enables
recognition of
unwell patients
• Provides prompts
for medical review
Early warning chart
Causes of collapse
Action
Structured plan:
1. Initial supportive treatment: ABC
2. Do a ‘primary obstetric survey’
3. Decide ongoing treatment
4. Do a ‘secondary obstetric survey’
5. Decide further investigation and treatment
Initial supportive treatment: ABC
GET HELP
• Airway
o Open airway
• Breathing
o Check for breathing
oBLS protocol if no signs of life
o High-flow oxygen
o Check respiratory rate
o Pulse oximetry
• Circulationo Assess pulse, BP, capillary refill
oBLS protocol if no signs of life
o IV access
o Bloods as appropriate including cross-match
o Consider fluid resuscitation
• Consider patient’s positiono Left lateral
o Sitting if short of breath
o Recovery position
Initial supportive treatment ABC
Primary obstetric survey
Secondary obstetric survey
Decide ongoing treatment
• Fluid resuscitation
– Priority or contraindicated?
• Expedite birth of baby
• Antibiotics
• Further supportive treatment
• Laparotomy
Don’t panic!
Maternal cardiac arrest
• Cardiac arrest during pregnancy carries a very
high maternal and fetal mortality rate
• Very uncommon:
– 1 in 30 000 ongoing pregnancies
• Most staff involved will have no, or very little, experience of a maternal arrest
• Very stressful situation
Resuscitating a pregnant woman is difficult
• Gravid uterus
– Aortocaval compression
– Ventilation difficult – pressure on diaphragm
• Fetus/placenta
– ‘Steals’ oxygen and circulation from mother
• More likely to aspirate
• More difficult to intubate
Extra actions• 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
• Perimortem caesarean section/assisted vaginal birth
Basic life support
Manual displacement of uterus (left tilt only if on firm tilting
surface)
2010 guidelines
During CPR
• Ensure high-quality CPR: rate, depth, recoil
• Plan actions before interrupting CPR
• Give oxygen
• Consider advanced airway and capnography
• Continuous chest compressions when advanced
airway in place
• Vascular access (IV, intraosseous – not tracheal)
• Give adrenaline every 3–5 minutes
• Correct reversible causes : 4Hs and 4Ts
Attach defibrillator
NON-SHOCKABLE
Adrenaline every 3–5 mins
Perimortem birth: startat 4 mins
CPR 30:2 with mother supine and manual LEFT uterine
displacement Laerdel mask
+/- Ambu bag (2 hands)Oxygen
CPR x 2 mins
Reassess rhythm
Think of 4Hs and 4Ts
Post-resuscitation care
Non-shockable rhythms
Pulseless electrical
activity
Asystole
4 Hs
HypoxiaAsthmaPE
Hypovolaemia Massive haemorrhage
Hypo/hyper/metabolic
Hypoglycaemia
Hyperkalaemia
Hypermagnesimaemia
Hypocalaemia (overdose of nifedipine)
Hypothermia
4 Ts
ThrombosisPEMyocardial infarction
Tamponade Usually following trauma
Toxins
Inadvertent IV local anaesthetic(‘epidural in the arm’)
Opioid overdose
Magnesium toxicity
IV insulin
Anaphylaxis/drug reaction
Tension pneumothorax Following insertion of CVP line
Attach defibrillator
SHOCKABLE: VF or VT
Adrenaline 1 mg after 2nd shock and then every other cycle (every 4 mins)
Perimortembirth: startat 4 mins
CPR 30:2 with mother supine and manual LEFT uterine displacement
Laerdel mask +/- Ambu bag (2 hands)
Oxygen
CPR x 2 mins
Reassess rhythm
Amiodarone 300 mg after 3rd shock
Defibrillate(200 J biphasphic, 360 J monophasic)
Shockable rhythms
Pulseless ventricular tachycardia
Ventricular fibrillation
Advanced
life
support
Cardiac arrest 1 mg adrenaline (epinephrine)every 3minutes
VF/VT 300 mg amiodarone
Opiate overdose 0.4–0.8 mg naloxone
Magnesium toxicity 1 g calcium gluconate
Local anaesthetic toxicity 1.5 ml/kg 20% Intralipid
Drug treatment
Where is it kept? How does it work?
Know your own equipment
Maternal cardiac arrest:top five tips
1. If there are no signs of life, call for help and immediately start basic life support
2. Manual left uterine displacement (30-degree left tilt if on a firm tilting surface)
3. State maternal cardiac arrest
4. Don’t stop basic life support when the anaesthetist arrives
5. Deliver baby within 5 minutes to save the mother
Perimortem Caesarean
• From MBRRACE 30% of women who died (321) were still pregnant at the time of death, 1/3 of these women were less than 20 wks gestation.
• 46 perimortem caesareans were performed
• 50% were stillborn and 20% died in the neonatal period.
• 75% of babies born at less than 37 weeks died.
Cardiac Arrest during hospitalization for delivery in the United States 1998-2011
• 8.5 per 100,000 hospitalizations for delivery
• 1 in 12,000
• Demographic factors (35yrs plus, black, Medicaid)
• Maternal medical conditions (pulmonary HTN, malignancy, CVS disease, liver disease, SLE
• Obstetric conditions (stillbirth, caesarean delivery, severe preeclampsia/eclampsia and placenta previa
Cardiac Arrest during hospitalization for delivery in the United States 1998-2011
Etiology of Cardiac Arrest % of total cardiac arrests
Survival to discharge %
Postpartum Haemorrhage 27.9 55.1
Antepartum Haemorrhage 16.8 53.2
Heart Failure 13.3 71.1
Amniotic Fluid embolism 13.3 52.5
Sepsis 11.2 46.9
Anaesthesia complication 7.8 81.9
Aspiration pneumonitis 7.1 82.9
Venous thromboembolism 7.1 41.5
Eclampsia 6.1 76.5
Puerperal Cerebrovasc disease 4.4 40
Trauma 2.6 23.3
Pulmonary oedema 2.4 70.9
AMI 3.1 56.3
Magnesium toxicity 1.4 85.9
Status Asthmaticus 1.1 53.7
Anaphylaxis 0.3 100
Aortic dissection/rupture 0.3 0
Cardiac Arrest during hospitalization for delivery in the United States 1998-2011
Cause Cause-specific cardiac Arrest Frequency per 1000 women with each condition
Amniotic fluid embolism 252.7
AMI 89.8
Venous thromboembolism 43.9
Aortic dissection/rupture 31
Anaesthesia complication 29.5
Aspiration pneumonitis 20.3
Heart Failure 15.6
Puerperal cerebrovascular disorder 13.6
Status asthmaticus 12.6
Pulmonary oedema 11.2
Anaphylaxis 10.8
Eclampsia 6.2
Magnesium toxicity 5.2
Trauma 3.9
Sepsis 2.1
Antepartum haemorrhage 0.9
Postpartum haemorrhage 0.8
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