Maternal Collapse in Pregnancy and the Puerperium (Green-top Guideline No. 56)

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Post category

Corresponding Author

the Royal College of Obstetricians, Gynaecologists

Publish date

12/17/2019
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Comment count

Executive summary

Clinical issues

Can women at risk of impending collapse be identified early?

An obstetric modified early warning score chart should be used for all women undergoing observation, to allow early recognition of the woman who is becoming critically ill.

Grade of recommendation: D

What are the causes of maternal collapse?

Maternal collapse can result from a number of causes. A systematic approach should be taken to identify the cause. [New 2019]

Grade of recommendation: B

In cases of collapse assumed to be due to anaphylaxis mast cell tryptase levels can be useful in confirming the diagnosis.

Grade of recommendation: GPP

What are the physiological and anatomical changes in pregnancy that affect resuscitation?

It is essential that anyone involved in the resuscitation of pregnant women is aware of the physiological differences. This includes pre-hospital care clinicians, paramedics and emergency medicine department staff.

Grade of recommendation: GPP

Aortocaval compression significantly reduces cardiac output from 20 weeks of gestation onwards and the efficacy of chest compressions during resuscitation. [New 2019]

Grade of recommendation: C

Changes in lung function, diaphragmatic splinting and increased oxygen consumption make pregnant women become hypoxic more readily and make ventilation more difficult. [New 2019]

Grade of recommendation: C

Difficult intubation is more likely in pregnancy. [New 2019]

Grade of recommendation: C

Pregnant women are at an increased risk of aspiration. [New 2019]

Grade of recommendation: C

What is the optimal initial management of maternal collapse?

Maternal collapse resuscitation should follow the Resuscitation Council (UK) guidelines using the standard ABCDE approach, with some modifications for maternal physiology, in particular relief of aortocaval compression.

Grade of recommendation: D

If maternal cardiac arrest occurs in the community setting, basic life support should be administered and rapid transfer arranged.

Grade of recommendation: GPP

Manual displacement of the uterus to the left is effective in relieving aortocaval compression in women above 20 weeks’ gestation or where the uterus is palpable at or above the level of the umbilicus. This permits effective chest compressions in the supine position in the event of cardiac arrest.

Grade of recommendation: D

A left lateral tilt of the woman from head to toe at an angle of 15–30o on a firm surface will relieve aortocaval compression in the majority of pregnant women and still allow effective chest compressions to be performed in the event of cardiac arrest.

Grade of recommendation: C

In cases of major trauma, the spine should be protected with a spinal board before any tilt is applied. In the absence of a spinal board, manual displacement of the uterus should be used. [New 2019]

Grade of recommendation: GPP

Intubation in an unconscious woman with a cuffed endotracheal tube should be performed immediately by an experienced anaesthetist.

Grade of recommendation: GPP

Supplemental high flow oxygen should be administered as soon as possible to counteract rapid deoxygenation.

Grade of recommendation: GPP

Bag and mask ventilation or insertion of a simple supraglottic airway should be undertaken until intubation can be achieved.

Grade of recommendation: GPP

If the airway is clear and there is no breathing, chest compressions should be commenced immediately.

Grade of recommendation: B

Two wide-bore cannulae (minimum 16 gauge) should be inserted as soon as possible. If peripheral venous access is not possible, early consideration of central venous access, intraosseous access or venous cutdown should be considered.

Grade of recommendation: GPP

There should be an aggressive approach to volume replacement, although caution should be exercised in the context of pre-eclampsia or eclampsia.

Grade of recommendation: GPP

Abdominal ultrasound by a skilled operator can assist in the diagnosis of concealed haemorrhage.

Grade of recommendation: C

The same defibrillation energy levels should be used as in a nonpregnant woman.

Grade of recommendation: B

There should be no alteration in algorithm drugs or doses used in the Resuscitation Council (UK) protocols.

Grade of recommendation: GPP

Common, reversible causes of maternal cardiopulmonary arrest should be considered throughout the resuscitation process.

Grade of recommendation: D

Resuscitation efforts should be continued until a decision is taken by the consultant obstetrician and consultant anaesthetist to discontinue resuscitation efforts. This decision should be made in consensus with the cardiac arrest team.

Grade of recommendation: GPP

When, where and how should perimortem caesarean section (PMCS) be performed?

In women over 20 weeks of gestation, if there is no response to correctly performed CPR within 4 minutes of maternal collapse or if resuscitation is continued beyond this, then PMCS should be undertaken to assist maternal resuscitation. Ideally, this should be achieved within 5 minutes of the collapse.

Grade of recommendation: D

PMCS should not be delayed by moving the woman. It should be performed where maternal collapse has occurred and resuscitation is taking place.

Grade of recommendation: GPP

The operator should use the incision, which will facilitate the most rapid access. This may be a midline vertical incision or a suprapubic transverse incision.

Grade of recommendation: GPP

A scalpel and umbilical cord clamps (or alternative ligatures) should be available on the resuscitation trolley in all areas where maternal collapse may occur, including the accident and emergency department.

Grade of recommendation: GPP

What does the ongoing management consist of?

Senior staff with appropriate experience should be involved at an early stage.

Grade of recommendation: GPP

Transfer should be supervised by an adequately skilled team with appropriate equipment.

Grade of recommendation: GPP

In the case of maternal collapse secondary to antepartum haemorrhage, the fetus and placenta should be delivered promptly to allow control of the haemorrhage.

Grade of recommendation: GPP

In the case of massive placental abruption, caesarean section may occasionally be indicated even if the fetus is dead to allow rapid control of the haemorrhage.

Grade of recommendation: GPP

Intravenous tranexamic acid significantly reduces mortality due to postpartum haemorrhage. [New 2019]

Grade of recommendation: A

Massive pulmonary embolism should be treated according to RCOG Green-top Guideline No. 37b Acute Management of Thrombosis and Embolism during Pregnancy and the Puerperium[New 2019]

Grade of recommendation: D

The management of amniotic fluid embolism (AFE) is supportive rather than specific, as there is no proven effective therapy.

Grade of recommendation: GPP

Early involvement of senior experienced staff, including midwives, obstetricians, anaesthetists, haematologists and intensivists, is essential to optimise outcome.

Grade of recommendation: GPP

Coagulopathy needs early, aggressive treatment, including the use of fresh frozen plasma.

Grade of recommendation: GPP

Recombinant factor VII should only be used if coagulopathy cannot be corrected by massive blood component replacement as it causes poorer outcome in women with AFE. [New 2019]

Grade of recommendation: C

After successful resuscitation, cardiac cases should be managed by an expert cardiology team.

Grade of recommendation: GPP

Septic shock should be managed in accordance with the Surviving Sepsis Campaign guidelines.

Grade of recommendation: D

The antidote to magnesium toxicity is 10 ml 10% calcium gluconate or 10 ml 10% calcium chloride given by slow intravenous injection.

Grade of recommendation: GPP

If local anaesthetic toxicity is suspected, stop injecting immediately.

Grade of recommendation: GPP

Lipid rescue should be used in cases of collapse secondary to local anaesthetic toxicity.

Grade of recommendation: C

Intralipid® 20% should be available in all hospitals offering maternity services.

Grade of recommendation: GPP

Manage arrhythmias as usual, recognising that they may be very refractory to treatment.

Grade of recommendation: GPP

All cases of lipid rescue should be reported to NHS Improvement and the Lipid Rescue site.

Grade of recommendation: GPP

Eclampsia should be managed in accordance with the NICE Clinical Guideline 107 Hypertension in Pregnancy: Diagnosis and Management [New 2019]

Grade of recommendation: D

Neuroradiologists and neurosurgeons should be involved in the care of pregnant women with intracranial haemorrhage at the earliest opportunity. [New 2019]

Grade of recommendation: GPP

In cases of anaphylaxis, all potential causative agents should be removed, and the ABCDE approach to assessment and resuscitation followed.

Grade of recommendation: GPP

If the anaphylactic reaction occurs in the community, the woman should have basic life support and be transferred to a hospital setting as quickly as possible, unless a suitably trained healthcare professional is present with appropriate equipment and drugs in which case definitive resuscitation and treatment should be commenced.

Grade of recommendation: GPP

The treatment for anaphylaxis is 1:1000 adrenaline 500 micrograms (0.5 ml) intramuscularly. This dose is for intramuscular use only.

Grade of recommendation: GPP

What are the outcomes for mother and baby after maternal collapse?

Outcomes for mothers and babies depend on the cause of collapse, gestational age and access to emergency care, with survival rates being poorer if the collapse occurs out of hospital. In maternal cardiac arrest maternal survival rates of over 50% have been reported. [New 2019]

Grade of recommendation: C

Who should be on the team?

In addition to the general arrest team, there should also be a senior midwife, an obstetrician and an obstetric anaesthetist included in the team in cases of maternal collapse.

Grade of recommendation: GPP

The most senior obstetrician and senior anaesthetist should be called at the time of a cardiopulmonary arrest call.

Grade of recommendation: GPP

The neonatal team should be called early if delivery is likely (antepartum collapse over 22 +0  weeks of gestation).

Grade of recommendation: GPP

Where the woman survives, a consultant intensivist should be involved as soon as possible.

Grade of recommendation: GPP

Clinical governance

Documentation

Accurate documentation is essential in all cases of maternal collapse, whether or not resuscitation is successful.

Grade of recommendation: GPP

Incident reporting

All cases of maternal collapse should generate a clinical incident form and the care should be reviewed through the clinical governance process.

Grade of recommendation: GPP

All cases of maternal death should be reported to MBRRACE-UK. [New 2019]

Grade of recommendation: D

Training

All generic life support training should consider the adaptation of CPR in pregnant women.

Grade of recommendation: GPP

All maternity staff should have annual formal multidisciplinary training in generic life support and the management of maternal collapse.

Grade of recommendation: GPP

Life support training improves resuscitation skills.

Grade of recommendation: A

Small group multidisciplinary interactive practical training is recommended to improve the management of maternal collapse.

Grade of recommendation: C

Debriefing

Debriefing is recommended for the woman, the family and the staff involved in the event.

Grade of recommendation: GPP

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