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NWAC. MATERNAL COLLAPSE. Berrin Gunaydin, MD, PhD Department of Anesthesiology Gazi University School of Medicine Ankara, Turkey. Discuss the incidence and causes of cardiac arrest/maternal collapse in pregnancy the physiological changes in pregnancy that make women susceptible - PowerPoint PPT Presentation
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1
MATERNAL COLLAPSE
Berrin Gunaydin, MD, PhDDepartment of Anesthesiology
Gazi University School of Medicine
Ankara, Turkey
2
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
3
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?