Sudden Maternal Collapse - Understanding Causes and Emergency Management

 Immediate Past Chairperson –Indian College of
OB/GY-ICOG
 National Corresponding Editor-Journal of OB/GY of
India JOGI
 National Corresponding Secretary- Association of
Medical Women, India
 Joint Secretary-Indian Menopause Society
 President –ISOPARB Vidarbha Chapter 2019-21
 Chairperson-IMS Education Committee 2021-23
 Chairperson-fertility enhancement Committee-
ISOPARB
 Member-SAFOG Education Committee
 President-Association of Medical Women, Nagpur
AMWN 2021-24
 Senior Vice President FOGSI 2012
 President Menopause Society, Nagpur 2016-18
 President Nagpur OB/GY Society 2005-06
Dr. Laxmi Shrikhande
MBBS; MD(OB/GY);
FICOG; FICMU; FICMCH
Medical Director-
Shrikhande Fertility Clinic
Nagpur, Maharashtra
 Nagpur Ratan Award @hands of
Union Minister Shri Nitinji
Gadkari
 Received Bharat excellence Award
for women’s health
 Received Mehroo Dara Hansotia
Best Committee Award for her
work as Chairperson HIV/AIDS
Committee, FOGSI 2007-2009
 Received appreciation letter from
Maharashtra Government for her
work in the field of SAVE THE
GIRL CHILD
 Delivered 22 orations and
450 guest lectures
 Publications- 42 National &
21 International
 Sensitized 2 lakh boys and
girls on adolescent health
issues
Awards
Positions

Sudden Maternal Collapse
Dr Laxmi Shrikhande
Consultant-Shrikhande Hospital & Research Centre Pvt Ltd
NAGPUR

Sudden Maternal Collapse
Maternal collapse is a rare but life-threatening event that can
occur in a variety of circumstances.
It is likely to present in an environment of predominately young
healthy women looked after by staff who have little experience
of cardiac arrest in pregnancy.
Maternal collapse is defined as an acute event involving the
cardiorespiratory systems and/or brain, resulting in a reduced or
absent conscious level (and potentially death), at any stage in
pregnancy and up to six weeks after delivery.

Incidence
The true rate of maternal collapse lies somewhere between
0.14 and 6/1000 (14 and 600/100 000) births.
As it is such a rare event, with potentially devastating
consequences, it is essential that caregivers are skilled in initial
effective resuscitation techniques and are able to investigate
and diagnose the cause of the collapse to allow appropriate,
directed continuing management.
It should be noted that vasovagal attacks and the postictal state
following an epileptic seizure are the most common causes of
‘maternal collapse’ and are not covered here.

Causes of Sudden Maternal Collapse
There are many causes; however
not all are obvious.
Though some may be related to
pregnancy, the increasing numbers
of pregnant women of advanced age
means cardiac arrest may present
secondary to co-existing medical
conditions.
Evaluate the causes of maternal
collapse after initial resuscitation.

Sudden Maternal Collapse - Understanding Causes and Emergency Management

How is resuscitation different in pregnant women?
Chest compressions are performed in the
same way as in a non pregnant person
EXCEPT that if the pregnant uterus is above
the umbilicus, it should be tilted towards the
left side with one hand or both hands by the
assisting personnel.
This is to relieve the aortocaval compression
effect of the uterus so as to increase the
cardiac output and make the compressions
more effective
The 15 degree tilt of the patient which was
practiced earlier is not recommended any
more as it hampers effective compressions

Physiological changes that impede
resuscitation
Cardiovascular: Aorto-caval compression by the gravid uterus.
• This results in reduced venous return and obstruction to forward flow of
blood into the aorta
• The gravid uterus accounts for 10% of cardiac output, resulting in a
significant shunt that further impairs effective cardiopulmonary
resuscitation (CPR).
Respiratory: Reduced functional residual capacity (FRC) and increased
oxygen consumption increase rates of desaturation and greatly hinder
adequate oxygenation during CPR.
In addition, patients are at increased risk of difficult and failed intubation.
Gastrointestinal: Increased risk of aspiration due to delayed gastric
emptying

Airway-
The airway should be protected as soon as possible by intubation with a cuffed endotracheal
tube.
In pregnancy, the airway is more vulnerable because of the increased risk of regurgitation
and aspiration.
 Intubation should be performed as soon as possible.
This will protect the airway, ensure good oxygen delivery and facilitate more efficient
ventilation.
Intubation can be more difficult in pregnancy, so this should be undertaken by someone
with the appropriate skills.
During cardiac arrest in the nonpregnant patient it is acceptable to use a supraglottic
device such as the laryngeal mask airway as an alternative to the tracheal tube.
 However, it should be emphasised that the pregnant woman is more likely to regurgitate
and aspirate in the absence of a secured airway (tracheal tube) than the nonpregnant
patient, and that the early involvement of an appropriately skilled anaesthetist remains
best practice.

Breathing
Supplemental oxygen should be administered as soon as possible.
• Because of the increased oxygen requirements and rapid onset
of hypoxia in pregnancy, it is important to ensure optimal oxygen
delivery by adding high-flow 100% oxygen to whatever method of
ventilation is being employed.
Bag and mask ventilation should be undertaken until intubation can
be achieved.

Circulation
In the absence of breathing despite a clear airway, chest compressions should be
commenced immediately.
Chest compressions should not be delayed by palpating for a pulse, but should be
commenced immediately in the absence of breathing and continued until the cardiac rhythm
can be checked and cardiac output confirmed.
Hand position should be over the centre of the chest, and it is important to ensure that the
direction of compression is perpendicular to the chest wall, thus the angle of tilt must be taken
into account.
Compressions should be performed at a ratio of 30:2 ventilations unless the woman is
intubated, in which case chest compressions and ventilations should be desynchronised, with
compressions being performed at a rate of 100/minute and ventilations at a rate of 10/minute.
 Because chest compressions are not as effective after 20 weeks of gestation, there should be
early recourse to delivery of the foetus and placenta if CPR is not effective.

Circulation
Two wide-bore cannulae should be inserted as soon as possible.
There should be an aggressive approach to volume.
Haemorrhage is the most common cause of maternal collapse and a
consequence of other causes of collapse.
There must be a high index of suspicion for bleeding and awareness of the
limitations of clinical signs.
Caution must be exercised in the presence of severe pre-eclampsia and
eclampsia, where fluid overload can contribute to poor outcome.
In the case where both significant haemorrhage and pre-
eclampsia/eclampsia exist, careful fluid management is essential.

Algorithm : CPR in pregnant women

When, where and how should perimortem
caesarean section be performed?
If there is no response to correctly performed CPR within 4 minutes of maternal collapse or if
resuscitation is continued beyond this in women beyond 20 weeks of gestation, delivery
should be undertaken to assist maternal resuscitation. This should be achieved within 5
minutes of the collapse.
The rationale for this timescale is that the pregnant woman becomes hypoxic more quickly
than the nonpregnant woman, and irreversible brain damage can ensue within 4–6 minutes.
The gravid uterus impairs venous return and reduces cardiac output secondary to aortocaval
compression.
Delivery of the foetus and placenta reduces oxygen consumption, improves venous return
and cardiac output, facilitates chest compressions and makes ventilation easier.
It also allows the heart to be compressed easily through the diaphragm against the chest wall
by placing the hand behind the heart (with the diaphragm closed) and compressing it against
the posterior aspect of the anterior chest wall.
This improves cardiac output beyond that achieved with closed chest compressions.
Before 20 weeks of gestation there is no proven benefit from delivery of the foetus and
placenta.

Perimortem caesarean section should be considered a resuscitative
procedure to be performed primarily in the interests of maternal, not foetal,
survival.
Delivery within 5 minutes of maternal collapse improves the chances of
survival for the baby, but this is not the reason for delivery.
If maternal resuscitation continues beyond 4 minutes of the collapse,
delivery of the fetus and placenta should be performed as soon as possible
to aid this, even if the fetus is already dead.
There is, of course, the possibility that the outcome could be that of a
severely damaged surviving child, but the interests of the mother must
come first.

Perimortem caesarean section should not be delayed by moving the
woman – it should be performed where resuscitation is taking place.
Time should not be wasted by moving the woman to an operating theatre;
a perimortem caesarean section can be performed anywhere, with a
scalpel being the only essential equipment required.
With no circulation, blood loss is minimal and no anaesthetic is required.
If resuscitation is successful following delivery, there should be prompt
transfer to an appropriate environment at that point, as well as anaesthesia
and sedation, to control ensuing haemorrhage and complete the operation.
The doctrine of ‘the best interests of the patient’ would apply to conduct of
this procedure being carried out without consent.

The operator should use the incision that will facilitate the most rapid
access.
In terms of the best incision to use, a midline abdominal incision and a
classic uterine incision will give the most rapid access, but many will be
unfamiliar with this approach and, as delivery can be achieved rapidly with
a transverse approach, the operator should use the approach they are
most comfortable with.
 If resuscitation is successful, the uterus and abdomen should be closed in
the usual way to control blood loss and minimise the risk of infection.
Where the outcome is not successful, the case should be discussed with
the coroner/ procurator fiscal to determine whether a postmortem is
required before any medical devices such as lines and endotracheal tubes
are removed, as per the Royal College of Pathologists recommendations.

A perimortem caesarean section tray should be available on the
resuscitation trolley in all areas where maternal collapse may occur,
including the accident and emergency department.
To ensure there are no delays in executing a perimortem caesarean
section when indicated, the equipment necessary should be
immediately available on the resuscitation trolley.
 All that is required is a fixed blade scalpel and two clamps for the
cord.
In the absence of a specific tray, a scalpel alone will enable delivery
of the foetus and placenta and cutting the cord, which can then be
manually compressed until a clamp is found if the baby is alive.

Outcomes
Mother recovers completely
Mother dies (inform police & insist for post
mortem)
Mother brain damaged,
Family takes legal action against hospital,
obstetrician and anesthetist

Documentation
Accurate documentation in all cases of maternal collapse,
whether or not resuscitation is successful, is essential.
Poor documentation remains a problem in all aspects of
medicine, and can have potential medico-legal consequences.
Contemporaneous note-keeping is difficult in a resuscitation
situation, unless someone is scribing.
Those involved should then write full notes as soon as possible
after the event.

Documentation
Documentation of the CPR intervention should be included in the Patient Care
Report (PCR).
For a cardiac event ensure the following are included:
Patient data: age, gender, and any comorbid conditions.
Event data: was collapse witnessed or unwitnessed, location of event, time from
collapse to the beginning of cardiopulmonary resuscitation (CPR) if known.
Observations and interventions: initial rhythm if known, essential interventions
(how long CPR was performed, AED application, number of shocks delivered) with
times recorded. Note time from collapse to first defibrillation when the initial
rhythm is ventricular fibrillation or pulseless ventricular tachycardia.
Outcomes: return of spontaneous circulation (for at least 20 minutes), transport,
or discontinuation of CPR

Communication
A scribe should be allocated to ensure that all events are
recorded as contemporaneously as possible.

Debriefing
Debriefing is recommended for the woman, her family and the
staff involved in the event.
Maternal collapse can be associated with post-traumatic stress
disorder, postnatal depression and tocophobia.
Family and staff members should not be forgotten.
Debriefing is an important part of holistic maternity care and
should be offered by a competent professional.

Training
All members of the team looking after pregnant women should
undertake regular resuscitation training on mannequins and be
aware of the most current resuscitation guidelines.
More usefully, cardiac arrest scenarios should be set up where
the whole team can participate within their own specialities.
The use of high fidelity simulation may be useful in encouraging
familiarity with the management of this rare event.

Training
All generic life support training should make mention of the adaptation of
CPR in the pregnant woman.
All front-line staff must be aware of the adaptations for CPR in pregnancy.
This includes paramedics who will deal with collapse in the community
setting and accident and emergency department personnel as well as staff
within a maternity unit.
All maternity staff should have annual formal training in generic life support
and the management of maternal collapse.
Life support training reduces morbidity and mortality.
Small-group interactive practical training is recommended.
Despite all this evidence in support of training, it cannot be assumed that
the presence of training equates to the receipt of training, and this remains
a challenge.

Who should be on the team?
In addition to the general arrest team, there should be a senior midwife, an
obstetrician and an obstetric anaesthetist included in the team in cases of
maternal collapse.
While managing the arrest, there must be dialogue between the team
leader, the obstetrician and the obstetric anaesthetist as to how best to
manage the pregnant woman.
In stand-alone consultant-led maternity units, or those that are
geographically distant from the main general hospital, the entire arrest
team is often made up of staff from within the maternity unit.
In this case, the team is usually made up of senior midwifery staff,
operating department practitioners, resident obstetric staff andthe resident
obstetric anaesthetist.

Use of early warning scores to identify
maternal collapse - MOEWS
To help with early recognition and intervention in an unwell patient before maternal
collapse, the MBRRACE reports recommended using the modified obstetric early warning
scoring (MOEWS) system (Lewis et al, 2007), taking into account the physiological
changes of pregnancy.
These incorporate measurement of vital parameters like –
Abnormal parameters trigger a colour-coded or a weighted-score system that guides the
frequency of monitoring and urgency of review by specialists.

Use of early warning scores to identify
maternal collapse-MOEWS
These scoring systems provide a visual aid of individual physiology, can
predict critical care admission and maternal morbidity and have high
negative predictive values.
A lack of a single universal validated MOEWS, variation in scoring,
differing escalation protocols, parameters not recognising the physiological
adaptations across different trimesters of pregnancy, staff shortages, staff
training and the limited usefulness of MOEWS in those with low-risk
pregnancies are factors that undermine confidence in the validity of
MOEWS for predicting maternal collapse (Robbins et al, 2019).
Clinicians need to be aware that maternal collapse may occur without
warning and with a normal MOEWS.
 Clinical judgement should be incorporated, especially in patients who look
unwell or have specific risk factors.

Summary
Maternal collapse is a rare life-threatening event that can occur at any stage of
pregnancy or up to 6 weeks postpartum.
Prompt identification and timely intervention by a multidisciplinary team that
includes an obstetrician, midwifery staff and an obstetric anaesthetist are
essential to improve maternal and fetal outcomes.
Standard adult resuscitation guidelines need to be followed with some
modifications, taking into account the maternal–fetal physiology, which clinicians
should be familiar with.
During cardiac arrest, the emphasis is on advanced airway management, manual
uterine displacement to relieve aortocaval compression and performing a
resuscitative hysterotomy (peri-mortem caesarean delivery) swiftly in patients
who are more than 20 weeks gestation to improve maternal survival.
Annual multidisciplinary simulation training is recommended for all professionals
involved in maternity care; this can improve teamwork, communication and
emergency preparedness during maternal collapse.

Key resuscitation principles –
Key principles for resuscitation of pregnant patients are (algorithm 1)
 Code blue – Call a maternal code blue, which should include a
multidisciplinary team.
 Uterine displacement – If the uterus is above the umbilicus, displace it off
aortocaval vessels. We suggest manually displacing the uterus laterally
to the patient's left rather than tilting the entire patient (Grade 2C).
 Oxygenation – Assume a difficult airway. Bag-mask ventilation with 100
percent oxygen and suctioning of the airway are critical before intubation
in a pregnant patient. Oxygenate well to avoid desaturation and avoid
respiratory alkalosis; ventilation volumes may need to be lower than in
nonpregnant females if the uterus is very large

 Chest compression – Place hands for chest compression at the
same location, and perform compressions in the same way as in
nonpregnant adults.
Defibrillation and medication management –
 Do not delay usual measures such as defibrillation and the administration
of medications.
 Energy requirements for adult defibrillation are the same as in
nonpregnant females.
 All medications at the same doses for treatment of cardiopulmonary arrest
in the nonpregnant patient are used for the pregnant patient.

Resuscitative newborn delivery at four minutes
 Designate a dedicated timer to notify the resuscitation team
when four minutes have elapsed after the onset of a maternal
cardiac arrest.
 Ideally, the cesarean should be started at four minutes following
cardiac arrest and delivery of the newborn completed by five
minutes following the arrest.
 Perform delivery (cesarean or vaginal) at the site of
resuscitation.

Key resuscitation principles
Prognosis – Cardiac arrest in pregnant patients is associated
with high maternal and neonatal fatality rates.
• Survival of the mother and neonate depends on several
factors, including the underlying etiology for the arrest,
maternal location at the time of the arrest (out-of-hospital
versus in-hospital, location in hospital), speed of
resuscitative efforts, and the skills and resources of the
health care providers.

My World of sharing happiness!
Shrikhande Fertility Clinic
Ph- 91 8805577600 / 8805677600
shrikhandedrlaxmi@gmail.com

The more you give, the more you
will get.
Then life will become a sheer
dance of love.
H. H. Sri. Sri. Ravishankar
The Art of Living

Sudden Maternal Collapse - Understanding Causes and Emergency Management

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