What is Maternal Collapse and How Can It Be Managed?

Maternal Collapse is an acute event that involves cardiovascular, respiratory and central nervous system damage leading to an unconscious state and the patient’s vitals are unstable. It is a life-threatening event which occurs during the pregnancy and may last up to six weeks after delivery.

MedPiper Technologies and JournoMed had conducted a webinar on 14^th June 2022, with ISA Thrissur and Thrissur Obstetrics and Gynaecological Society where the speaker Dr. Vennila Rajagopal spoke about Maternal Collapse and how to manage it. Dr. Rajagopal has specialised in obstetric, emergency and surgical anaesthesia. Her experience in paediatrics and life support motivated her to work on Maternal Collapse. She currently works as a consultant anaesthesiologist at Apollo Women’s Hospital, Chennai.

Thrissur Obstetrics and Gynaecological Society is a professional body that works with gynaecologists. It helps in reducing the maternal mortality rate by recognising high-risk mothers and managing risk factors involved in pregnancy to avoid further grave complications. Maternal collapse is one such event which involves both maternal and foetal risks.

Any adverse event that occurs in a pregnant woman, such as variations in blood pressure and heartbeat, must be monitored and diagnosed carefully to prevent further complications. A survey can help recognize high-risk mothers who are dealing with pregnancy complications such as maternal collapse, foetal growth restrictions, pre-eclampsia etc. Awareness and knowledge regarding maternal collapse and its complications need to be provided to such high-risk mothers.

Common causes of maternal collapse/death

The common causes of maternal collapse or death include

• Vasovagal collapse
• Postictal seizures
• Obstetric haemorrhage
• Eclampsia
• Embolism/AFE (Amniotic fluid embolism)
• Sepsis
• Cardiac causes
• Drugs/Anaphylaxis

Vasovagal Collapse and Postictal Seizures

Vasovagal collapse and postictal seizures are two common causes of maternal collapse or death. Vasovagal collapse occurs when the mother gets up too soon after her delivery. To avoid this, the doctors need to monitor the mother’s pulse rate, blood pressure, fundus and PV loss (Per vaginal loss). It is always suggested to put the mother in a medically induced coma to monitor her recovery.

Surgical Procedures and Anaesthesia

There are a few variables which lead to maternal collapse. These include obstetric complications, surgical or anaesthesia-related variables, procedure-related variables and drug-related factors. The common surgical variables for maternal collapse incorporate tissue harm, uncontrolled drain, AFE (amniotic liquid embolism) at the time of mobilization, uterus exteriorisation, and not taking care of vaginal tissues.

Analgesic components are used to induce anaesthesia. Anaesthesia can be injected in either forms i.e. tall spinal, incidental spinal, epidural, troublesome aviation route etc. all of which are complex procedures. Moreover, common anaesthesia can cause complications for several pregnant ladies due to the physiological changes they experience. Even local anaesthesia can turn poisonous in some cases. Hence, anaesthetists and obstetricians must be aware of such complications related to anaesthesia and accordingly work on them.

Drugs Prescribed

There are a few medications prescribed besides anaesthesia. Administering these medicines may raise the risk of problems such as induced nausea, induced tachycardia and bradycardia. To prevent maternal collapse, mothers with illnesses such as obesity, heart disease, chronic kidney disease, antiphospholipid syndrome and systemic lupus erythematosus must be closely monitored and given the appropriate care or advice during pregnancy.

In-vitro fertilization pregnancies, postpartum haemorrhage in teens who are susceptible, pregnancy-induced hypertension, eclampsia, intracranial bleeding and sometimes, pregnancy itself are some obstetric causes that predispose maternal collapse. To prevent maternal collapse due to the above mentioned reasons, maternal care and monitoring is essential.

Emergency escalation monitoring and management

Emergency escalation management and administration framework are well clarified through the ABCDE approach. In case of suspected anaphylaxis, all potential causative operators are to be evacuated, and the ABCDE approach to revival should be taken. If the anaphylactic response happens within the community, the lady need to have fundamental life support and should be sent immediately to a clinic setting unless a reasonably prepared healthcare proficient shows up with suitable hardware and drugs, in which case authoritative revival and treatment can be done.

Obstetric Haemorrhage

All obstetricians and physicians strive for patients’ better outcomes during surgery. In obstetric haemorrhage, severe blood loss leads to maternal death in many cases. In most cases, amniotic fluid gushes out along with the blood so it’s difficult to quantify the blood loss. The patient appears anaemic due to massive blood loss. Postpartum haemorrhage (PPH), is one such serious and rare obstetric haemorrhagic event. It occurs when a mother bleeds heavily after giving birth and usually happens within a day to 12 weeks after delivery.

Haemostasis is the appropriate physiological response which prevents bleeding, conserves blood loss and repairs damage in case of haemorrhages. If haemostasis is disturbed, there can be problems of severe or less clotting. Performing compression sutures can help maintain haemostasis to some extent.

The concerned doctors must provide a local protocol to high-risk mothers which can help avoid issues related to maternal collapse. Hospitals and specialists should also have a liaison with a blood bank for tackling pregnancy complications and surgeries involved in it.

Cardiac causes

The mother may suffer from progressive cardiac deterioration, anaemia, PIH, arrhythmias, hypertension or hypotension, coronary event or pulmonary oedema. The key is to recognize early cardiac cases and follow regular ALS guidelines. Early delivery is recommended for such mothers. An ECHO cardiogram allows for early detection of cardiac complications.

How to prevent cardiac arrest?

An active lifestyle must be maintained to prevent cardiac arrest. 30 minutes of physical activity keeps maintains metabolism which in turn activates the blood flow in arteries and prevents cardiac arrest.

Managing obstetric cardiac arrest: Oxygen delivery to vital organs is limited by the blood flow during the cardio placental resuscitation process. The current guidelines for managing obstetric cardiac arrest states that chest impressions should not be interrupted as pregnant women have a limited oxygen reserve.

Eclampsia

Eclampsia and intracranial haemorrhage are the most common causes of maternal collapse. It is a life-threatening medical condition which should be detected and treated early to avoid further issues and control elevated blood pressure. Early delivery of the baby is recommended. The specialists must closely monitor the foetus to avoid organ failure.

Amniotic fluid embolism

Amniotic fluid embolism develops rapidly and is a serious complication where the amniotic fluid surrounding the foetus enters the mother’s bloodstream. Symptoms of amniotic fluid embolism include shortness of breath, pulmonary oedema, cardiovascular collapse and low blood pressure. Amniotic fluid embolism has serious repercussions for both mother and foetus. It includes brain injury, lengthy hospital stay, maternal death and infant death.

Sepsis

Sepsis is the body’s heightened inflammatory response to an infection, which is often times life-threatening. If sepsis occurs during pregnancy (maternal sepsis) it can be extremely catastrophic. One-third of pregnant women all over the world suffer from maternal sepsis and it leads to major complications if not diagnosed in time.

In-hospital emergency management for maternal collapse and event

A modified advanced life support algorithm is provided for in-hospital obstetric emergencies. A collapsed or unwell pregnant woman should shout for help in case of an emergency

Depending on the signs of life, emergency management would differ. If the signs of life are YES, seek expert help and follow an ABCDE approach which are of two types (one for if there is a high oxygen flow and the other for if there is a left lateral tilt or manual displacement of the uterus). If the signs of life are NO, start preparing for a post-mortem section early in women who are greater than 20 weeks pregnant. The best survival rates is when the infants are given cardio-pulmonary resuscitation (CPR) within 5 minutes of delivery.

Teamwork and preparedness

Managing a critically ill patient in obstetric care and performing timely delivery is collaborative team effort. Effective communication, efficient team skills and taking proper care all require good teamwork.

The team should involve obstetricians, midwives, anaesthetists, critical care, haematology and ancillary team professionals. Along with the general arrest team, there should be a senior midwife, an obstetrician and an obstetric anaesthetist to manage maternal collapse. The senior obstetrician and senior anaesthetist are required in case of a cardiopulmonary arrest call.

Conclusion

Maternal collapse can cause morbidity and mortality if not addressed right away. Early monitoring, and energetic management are extremely essential in managing maternal collapse. Regular education to expecting mothers and those concerned can help them be aware and thus, prevent maternal morbidity. Accurate documentation is vital in all instances of maternal collapse, whether or not resuscitation is successful. In case of maternal fall apart, a scientific incident form needs to be generated and reviewed through the scientific governance process.