Case of the Month #42 Maternal Collapse

Published 17/08/2023

What are the priorities of management?

Management is entirely supportive. 
It is essential that senior members of the MDT are involved as soon as possible e.g. obstetrician, intensivist, anaesthetist, haematologist, senior midwife, and neonatologist. 
An urgent decision on delivery and critical care transfer is likely to be required. 
Initial management should follow standards ALS principles with the following scenario specific points.  
Severe cases will require early endotracheal intubation particularly in labour with the increased risk of aspiration. 
Aortocaval compression must be remembered in pregnancy and uterine displacement/patient tilt should be considered. 
Initial instability will be managed with fluids and peripheral vasopressors. Early invasive lines and monitoring is desirable. TTE may be helpful in diagnosis and response to treatment. Vasopressin may be a useful addition to avoid increasing the pulmonary vascular resistance further. 
If cardiac arrest occurs perimortem caesarean section should be carried out after 4 minutes (2 cycles) of CPR. 
Haemorrhage control: 
Early activation of the obstetric major haemorrhage protocol. 
Standard uterotonics as required for uterine atony. Mechanical techniques e.g. bimanual massage, uterine packs or balloons may be necessary. Hysterectomy should not be delayed if bleeding persists. 
Early discussion with the haematology team. 
Major obstetric haemorrhage management as per local guidelines. 
Low fibrinogen is common and requires cryoprecipitate or fibrinogen concentrate. 
Serial point of care thromboelastography is useful where available. 
Consider tranexamic acid.