postpartum collapse

lecture for medical students

1. Dr.tarig mahmoud MD SUDAN HAIL UNIVERSITY KSA Post partum collapse

2. 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).

3. causes Shock- eg postpartum haemorrhage. Pulmonary embolus Amniotic fluid embolus Cardiac causes Intracranial events Drug overdose/toxicity Biochemical causes –e.g. hypoglycaemia

4. Primary PPH Secondary PPH Loss of MORE than or EQUAL to 500mL blood from the genital tract within 24 hours of delivery Loss of MORE than or EQUAL to 500mL blood from the genital tract between 24 hours and 12 weeks post delivery Postpartum haemorrhage

5. PPH CAUSES: 1.Uterine atony 2.Retained placenta 3.Genital tract laceration 4.Coagulopathy 5.Acute inversion of uterus

6. REMEMBER 4 “T”s Uterine atony Retained placenta and/or membranes Clotting disorder Tone Tissue Trauma Thrombin Injury to vagina, perineum and uterine tears at C/S

7. 1.Uterine atony Predisposing conditions: Multiparity . Over distension of uterus ( Macrosomia,polyhydramnios ). Prolong labour (uterine inertia). Fibroid. Placenta previa . Oxytocin induce labour .

8. 2.Retained placenta Prevent a uterus from contracting . Causes: Placenta separated but undelivered. Placenta partly or wholly attached. Placenta accreta .

9. 3.Genital tract laceration Perineal or vaginal tears. Causes: Instrumental delivery (Cervical & vaginal tears). Extension of episiotomy . Uterine rupture.

10. 4.Coagulopathy Causes: Von Willebrand's Disease, Platelet disorder. Placenta abruption (retro placental clot leads to consumption of clotting factors). Unidentified dead fetus. Amniotic fluid embolus (amniotic fluid entering maternal circulation)

11. 5.Acute inversion of uterus Caused by traction on the umbilical cord before placenta has separated. Associated factors: - Fundal placenta -Short cord -Morbidly adherent placenta Lead to Cardiovascular collapse & shock.

12. Mangment of PPH ABC (fluid resuscitation). Feel abdomen-uterus poorly contracted rub the fundus gently (see wether uterus contract and bleeding arrested). Set up IV line & IV infusion of 40 units of syntocinon. Bimanual compression potent drugs can also be used these include ergometrine , prostaglandin F2α or misoprostol . The bladder should be catheterized as an empty bladder aids uterine contraction.

13. Send blood for group and cross matching. Examine placenta to see if it is complete(If uncompleted, sent to theatre for manual remove). If complete(Examine vagina and cervix in lithotomy position for laceration ) No laceration(allow further measures ( eg . uterine tamponade,radioloical occlusion) Exploratory Laporotomy (iliac artery ligation) or B lynch (sutures which are placed in double loop surround the uterus & aim to squeeze whole uterus) . Hysterectomy correction of clotting factors using fresh frozen plasma , platelets and cryoprecipitate.

14. Bimanual compression

15. B lynch

16. Pulmonary embolism Thrombosis is the most common cause of maternal death in the UK. The most common presentation is of mild breathlessness, or inspiratory chest pain, in a woman who is not cyanosed but may be slightly tachycardic (90 bpm ) with a mild pyrexia (37.5ºC). massive PE may present with sudden cardiorespiratory collapse.

17. Diagnosis and management: PE can be a cause of sudden cardiorespiratory collapse. In this situation, diagnosis and management should occur simultaneously. Urgent resuscitation using the structured ABC approach is needed. If PE is suspected, anticoagulation should be instituted.

18. Amniotic fluid embolism caused by amniotic fluid entering the maternal circulation. This causes acute cardiorespiratory compromise and severe DIC. Difficult to diagnose in life, and is typically diagnosed at postmortem , with the presence of fetal cells ( squames or hair) in the maternal pulmonary capillaries.

19. Diagnosis and management: Symptoms occurring just before the collapse may be helpful in diagnosis. • breathlessness. • chest pain. • feeling cold. • lightheadedness . • restlessness, distress and panic. • pins and needles in the fingers. • nausea and vomiting.

20. The prognosis is poor, with around 30 per cent of patients dying in the first hour and only 10 per cent surviving overall. Management is supportive, requiring intensive care and there are no specific therapies available.

21. Cardiac causes The main cardiac events are myocardial infarction, aortic dissection and cardiomyopathy. signs and symptoms such as central chest or interscapular pain, a wide pulse pressure, and a new cardiac murmur. Management by ABC approach and seek help of cardiologist.

22. Intracranial events Intracranial haemorrhage is complication of uncontrolled hypertension, but can also result from ruptured aneurysms and arteriovenous malformations. severe headache often precedes maternal collapse.

23. Drug overdose/toxicity In obstetric practice, the two main drugs that can give rise to overdose or toxic problems are magnesium sulphate and local anaesthetic agents. The antidote to magnesium toxicity is 10 ml 10% calcium gluconate given I.V . Intralipid 20%should be used in cases of collapse secondary to local anaesthetic toxicity.

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