Maternal Collapse in Pregnancy and the Puerperium

This is the second edition of this guideline. The first edition was published in 2011 under the same title. 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 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 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 Accurate documentation is essential in all cases of maternal collapse, whether or not resuscitation is successful. Grade of recommendation: GPP 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 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 is recommended for the woman, the family and the staff involved in the event. Grade of recommendation: GPP Maternal collapse is a rare but life-threatening event, with a wide ranging aetiology. The outcome primarily for the mother, but also the fetus, depends on prompt and effective resuscitation. The purpose of this guideline is to discuss the identification of women at an increased risk of maternal collapse and the different causes of maternal collapse, to delineate the initial and ongoing management of maternal collapse, and review the maternal and neonatal outcomes. It covers both hospital and community settings, and includes all gestations and the postpartum period. The resuscitation team and equipment, and training requirements will also be covered. Maternal collapse is defined as an acute event involving the cardiorespiratory systems and/or central nervous systems, resulting in a reduced or absent conscious level (and potentially cardiac arrest and death), at any stage in pregnancy and up to 6 weeks after birth. Importantly, if maternal collapse which is not as the result of cardiac arrest is not treated effectively, maternal cardiac arrest can then occur. There is a robust and effective system for maternal mortality audit in the UK in the form of the Confidential Enquiry into Maternal Death performed by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK). However, the incidence of maternal collapse or severe maternal morbidity is unknown as morbidity data is not routinely collected. Even when it is, it is not collected in a standardised way to facilitate comparisons.1 The incidence of cardiac arrest in pregnancy is much rarer than maternal collapse at around 1 in 36 000 maternities2, with a case fatality rate of 42%. In a UK study, a total of 25% of cardiac arrests in pregnancy were secondary to anaesthesia and all were associated with a 100% survival rate.2 It is accepted that lessons can be learned from severe morbidity and near misses, and MBRRACE-UK now undertake targeted maternal morbidity confidential enquiries.3 The UK Obstetric Surveillance System (UKOSS), run by the National Perinatal Epidemiology Unit, has made a significant contribution towards the study of rare events and maternal morbidity.4 Severe maternal morbidity data were collected across Scotland for 10 years and published in 2014.5 A woman was defined as having had a severe maternal morbidity event if there was a risk of maternal death without timely intervention. The data showed a severe maternal morbidity rate of 7.3 in 1000 (730 in 100 000) maternities in 2012, but not all cases of severe maternal morbidity involved maternal collapse (although all cases of collapse were included in the figures). A publication from Ireland showed a severe maternal morbidity rate of 6.35 in 1000 (635 in 100 000) births in 2015.6 These reports demonstrate that the rate of maternal morbidity has increased year on year. This is likely to reflect the changing demographics of women and better reporting, rather than a decline in care.7 Between 2012 and 2014, the maternal mortality rate was 8.5 in 100 000 in the UK.3 However, not all maternal collapse results in maternal death. Thus, the true rate of maternal collapse is unknown. Whilst maternal collapse is such an uncommon event, the consequences are potentially devastating, therefore it is essential that the clinical team are skilled in initial effective resuscitation techniques, and are able to investigate and diagnose the cause of the collapse to allow appropriate, directed ongoing management. Unfortunately, in reports regarding morbidity5, 6 and the MBRRACE-UK report 2016,3 areas of substandard care continue to be identified, including poor resuscitation skills. However, it should also be remembered that death and disability may result despite excellent care. It should be noted that vasovagal attacks and epileptic seizures8 are the most common causes of maternal collapse and are not covered by this guideline. This guideline was developed in accordance with standard methodology for producing Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guidelines. The Cochrane Library (including the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects [DARE]), EMBASE, Trip, MEDLINE and PubMed (electronic databases) were searched for relevant randomised controlled trials (RCT), systematic reviews and meta-analyses. The search was restricted to articles published up to June 2018. The databases were searched using the relevant Medical Subject Headings (MeSH) terms, including all subheadings, and this was combined with a keyword search. Search words included, ‘*labor complication’, ‘*maternal morbidity’, ‘*maternal mortality’, ‘*pregnancy complication’ and ‘*heart arrest’. The search was restricted to humans and the English language. The National Library for Health and the National Guideline Clearinghouse were also searched for relevant guidelines and reviews. Where possible, recommendations are based on available evidence. In the absence of published evidence, these have been annotated as ‘good practice points’. Further information about the assessment of evidence and the grading of recommendations may be found in Appendix 1. 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 It is also important to consider the potential risks associated with the use of different scoring systems in the same organisation for the same patient depending on their stage of pregnancy. A scoring system may still miss an unwell patient and a high level of clinical suspicion should be present if a patient looks unwell, even if her MEWS/Modified Early Obstetric Warning Score (MEOWS)/NEWS2 score is normal. Maternal collapse can result from a number of causes. A systematic approach should be taken to identify the cause. Grade of recommendation: D Drug toxicity and overdose should be considered in all cases of collapse. Substance misuse should be remembered as a potential cause of collapse especially outside of hospital. In terms of therapeutic drug toxicity, the commonly used drugs in obstetric practice are magnesium sulphate in the presence of renal impairment and local anaesthetic agents. In terms of local anaesthetics, total spinal block or high spinal/epidural block are rare. A high index of suspicion is needed in cases of maternal collapse following spinal anaesthesia or epidural top up. Appropriate training of medical and midwifery staff to recognise the signs and symptoms of high block is essential. Eclampsia as the cause of maternal collapse is usually obvious in the inpatient setting. Often the diagnosis of pre-eclampsia has already been made and the seizure witnessed. In the community setting, fitting after 20 weeks’ gestation may be attributable to eclampsia, notably where there is no known history of epilepsy. However, epilepsy should always be considered in cases of maternal collapse associated with seizure activity.8 Intracranial haemorrhage is a significant complication of uncontrolled, particularly systolic, hypertension, but can also result from ruptured aneurysms and arteriovenous malformations. The initial presentation may be maternal collapse, but often severe headache precedes this. 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 Anaphylaxis is a severe, life-threatening generalised or systemic hypersensitivity reaction,43 resulting in respiratory, cutaneous and circulatory changes, and possibly gastrointestinal disturbance and collapse. There is significant intravascular volume redistribution, which can lead to decreased cardiac output. Acute ventricular failure and may occur. airway secondary to and of all to significant and with are a of and The incidence of severe obstetric anaphylaxis is 1 and 100 with a mortality rate of Anaphylaxis is likely when all of the following are These and and causes of airway secondary to or cardiac secondary to or and an anaesthetic the causes of collapse be local anaesthetic toxicity or There will be very and rare causes of maternal collapse, but of all causes is beyond the of this guideline. 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. 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. Grade of recommendation: C Difficult intubation is more likely in pregnancy. Grade of recommendation: C Pregnant women are at an increased risk of aspiration. Grade of recommendation: C 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 Maternal collapse can in the community setting, and pre-hospital care of the pregnant patient should follow the same from the Resuscitation Council (UK) above and will be delivered by paramedics and/or pre-hospital care The care delivered in the pre-hospital setting have been in the UK Clinical and in the In the event of maternal collapse, signs of life should be if the is in this for and If the is not or there is any in the of signs of cardiopulmonary resuscitation should be commenced. However, if signs of life are a standard ABCDE approach should be The woman should be in the left lateral obstetric review should be the for oxygen should be and access should be An assessment should be undertaken as an alteration of can be a of The cause of the maternal collapse should be identified and treated to potential to maternal arrest. ABCDE assessment should be performed as the risk of to cardiac arrest until the cause of the collapse is of should be undertaken after ABCDE assessment 20 weeks of gestation, changes in maternal that are made to the resuscitation process. Resuscitation Council (UK) for and neonatal life support are available in standardised for maternal resuscitation are but are not available in and this the Resuscitation Council (UK) algorithm for life support has been modified by the and is included in Appendix 4 of this guideline. 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. Grade of recommendation: GPP There are essential to the management of a pregnant woman of the physiological and anatomical changes of pregnancy. Intubation in an unconscious woman with a cuffed endotracheal tube should be performed immediately by an experienced anaesthetist. Grade of recommendation: GPP be used to and tube and may be used to the of CPR and to an early of of Appendix 5 of this guideline equipment that should be available for cases where airway management may be difficult. 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 using a or a supraglottic airway and or a cuffed endotracheal may be more of the physiological changes of pregnancy as It can also be to the chest 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 Ideally, early access will be with wide-bore intravenous cannulae inserted above the level of the This the of to not be by aortocaval compression. If peripheral venous access is there should be early consideration of central venous access, intraosseous or venous cutdown to volume is the most common cause of maternal collapse, and is a of causes of collapse. There be a high index of suspicion for and of the of maternal clinical be exercised in the clinical context of severe pre-eclampsia and eclampsia, where fluid can to poor outcome. In the case where significant haemorrhage, and pre-eclampsia or fluid management is essential. 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 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 there are no in a PMCS when the equipment should be immediately available on the resuscitation All that is is a scalpel and clamps for the umbilical In the absence of a a scalpel will delivery of the fetus and and of the umbilical which can then be until a is found if the is 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 management depends on the cause of the