Causes of Obstetric Collapse and its Management

Introduction

Maternal collapse is defined as an acute occurrence involving the cardiorespiratory system and brain that causes a diminished or absent conscious state (and possibly death) during any stage of pregnancy and up to six weeks following birth.Maternal collapse is an uncommon yet life-threatening occurrence with numerous underlying causes. The result for both the mother and the fetus is reliant on adequate resuscitation and the identification of the underlying reason. If the collapse occurs during pregnancy, the fetus will be impacted by the maternal compromise.

What Are the Causes of Obstetric Collapse?

Maternal epileptic seizures and vasovagal reactions are the most common causes of maternal collapse. The bulk of these incidents are self-limiting and usually result in a positive outcome. Other causes of maternal failure include pulmonary embolism, amniotic fluid embolism, bleeding of obstetric and non-obstetric origin, ruptured ectopic pregnancy (occurs when a fertilized egg grows outside of the uterus), intracranial hemorrhage, cerebral hemorrhage or infarction (a cerebral hemorrhage is a form of stroke). It occurs when a weakened blood artery in the brain begins to leak or unexpectedly breaks, cerebral venous thrombosis (a blood clot forms in the brain's venous sinuses), and metabolic or anesthetic complications.

• Hemorrhage: Major obstetric hemorrhage is among the most common obstetric emergencies. It can occur prenatally, during labor, or after birth. If left untreated, it causes hypovolemia (a condition where the liquid portion of the blood (plasma) is abnormally low), maternal collapse, cardiac arrest, and maternal death. Severe hemorrhage during early pregnancy can be caused by miscarriage or ruptured ectopic pregnancy. Placenta praevia is one of the reasons for late pregnancy hemorrhage.

• Thromboembolism: Pregnant women are four to five times more likely to develop venous thromboembolism than non-pregnant women, and it remains the major cause of direct maternal mortality. Most of the women died as a result of a blood clot during pregnancy or after birth. In half of these individuals, better care could have saved their lives. Lower limb swelling and shortness of breath are common concerns during normal pregnancy, making it difficult to diagnose venous thromboembolism.

• Cerebral Vein Thrombosis: The risk of cerebral venous thrombosis is highest within the first three weeks after birth. Its death rate reaches 30 percent. The great majority of patients report a diffuse, growing headache accompanied by focal neurological impairments, seizures, and symptoms of intracranial hypertension. It is critical to begin treatment with low molecular weight heparin immediately. The diagnosis can be made with a computed tomography venogram or a venous angiography magnetic resonance imaging.

• Amniotic Fluid Embolism: Amniotic fluid embolism (AFE) is a rare but devastating occurrence. One in every five patients dies despite resuscitation. The typical manifestation of Amniotic fluid embolism is acute hypoxia and hypotension surrounding birth, which leads to maternal collapse and cardiac arrest. Amniotic fluid embolism is typically followed by coagulopathy. If it occurs before childbirth, sudden fetal distress is related to maternal collapse. Patients require rapid fluid resuscitation.

• Subarachnoid Hemorrhage: Subarachnoid hemorrhage is a rare but deadly illness with a death rate of 40% to 50%. One-fifth of patients die before reaching the hospital. The risk of subarachnoid hemorrhage is highest during the postpartum period. Patients experience a sudden, severe 'thunderclap' headache, which is typically described as the worst pain of their life. It is typically followed by vomiting and collapse.

• Septic Shock: The most prevalent causes of severe sepsis that progresses to septic shock are urinary tract infections and chorioamnionitis. Endometritis, wound infection, and pneumonia are further potential causes of infection. Escherichia coli, group A and B Streptococcus, Streptococcus pneumoniae, and Staphylococcus aureus are among the most prevalent pathogens responsible for peripartum sepsis.

• Eclampsia: Eclampsia is a neurologic consequence of preeclampsia. It is described as an altered conscious state followed by seizures that cannot be related to a known neurological disorder. The use of magnesium sulfate and proper treatment of severe preeclampsia have considerably reduced the incidence of eclampsia.

• Cardiovascular Disease: Cardiac disease has been the leading indirect cause of maternal death. Women who died from an indirect cause had pre-existing heart problems. It is necessary to do a thorough investigation whenever chest discomfort, tachypnoea (a breathing rate that is higher than normal), prolonged tachycardia, or shortness of breath worsens while lying down. These are frequently indicators of cardiovascular impairment.

• Toxicity: Maternal suicide is still the greatest cause of late direct mortality after pregnancy. Alcohol and drug overdoses account for half of all mental causes of maternal mortality. Therefore, drug and alcohol abuse should be considered in all cases of maternal breakdown. Furthermore, medicines typically used in pregnancy may be harmful. Oxytocin delivered in large quantities can cause water intoxication and hyponatremia (when the concentration of sodium in the blood is abnormally low).

• Neurological Illness: Women who died during pregnancy or after childbirth had underlying somatic or mental health issues. Thus, rigorous clerking and pre-pregnancy counseling are critical. Neurological diseases such as epilepsy and stroke are the third leading cause of mortality after heart disease.

• Anaphylaxis: Anaphylaxis is a systemic hypersensitivity response to an allergen. Acute vasodilation and intravascular fluid leak into the tissues cause laryngeal and pulmonary edema, which leads to respiratory collapse. Skin erythema, pruritus, angioedema, nausea, vomiting, and wheezing are all important warning signs.

• Maternal Resuscitation: Cardiac arrest during pregnancy is one of the most challenging clinical circumstances. While the majority of the resuscitation steps are comparable to typical adult resuscitation.

What Is the Management Obstetric Collapse?

• Adequate left uterine displacement is required during cardiac massage to mitigate the effects of aorto-caval compression. There are numerous methods for doing this, but the goal is to tilt the mother to the left so that chest compression may still be provided efficiently. Methods to incline the mother to the left include using a Cardiff resuscitation wedge (not generally available), cushions or pillows, or the back of an upturned chair. Alternatively, a 'human' wedge can be used, with the patient tilted on the bent knees of a kneeling rescuer.

• Begin cardiopulmonary resuscitation using current resuscitation guidelines.

• Cricoid pressure should be used to intubate patients early. If intubation is not possible, keep oxygen levels stable using bag-mask ventilation or a laryngeal mask airway.

• Remember that maintaining appropriate chest compression in the slanted posture is tough and energy-intensive. Ensure that the team members are rotated.

• If enough circulation cannot be established within five minutes of cardiac arrest a Cesarean section is required. This is done not to preserve the fetus' life but to increase the mother's chances of successful resuscitation by alleviating aorto-caval compression. Delays in transfer to the theatre should be avoided, and if required, a cesarean section should be performed where the arrest occurred. Equipment to accomplish this rapidly should be available. Continue cardiopulmonary resuscitation throughout the procedure. If the resuscitation is successful, transfer the mother and baby to the appropriate intensive care facilities.

• If resuscitation fails, the team must decide whether or not to continue performing CPR. Given the devastating nature of failed resuscitation in a pregnant woman, the entire resuscitation team must receive proper counseling and debriefing.

Conclusion

Maternal collapse is a rare but catastrophic event and a dire emergency. It can be caused by multiple conditions some of which are unique to pregnancy, for example, eclampsia. The most common causes should always be considered, for example, thromboembolism, hemorrhage, and maternal cardiac disease. Basic as well as advanced life support principles should be