Postpartum haemorrhage
Genital tract/abdominal sepsis
Amniotic fluid embolism
Peripartum cardiomyopathy
General anaesthesia
Regional anaesthesia
Cardiac disease
Respiratory disease
Adverse drug reactions
Metabolic
Primary neurological
Other
Aspiration pneumonitis, atelectasis, respiratory depression, airway obstruction
Hypotension, high block, local anaesthetic toxicity, meningitis, spinal haematoma/abscess
Cardiac failure, myocardial infarction, aortic dissection, arrhythmias
Asthma, pneumonia
Anaphylaxis*, toxicity/side-effects, drug withdrawal
Hypo/hyperglycaemia; hyponatraemia
Epilepsy, stroke
Air embolus, vasovagal syncope, splenic artery rupture, mesenteric infarction
The list is not exhaustive and there is some overlap, i.e. more than one may co-exist.
Leading causes of maternal death as reported by the MDE report for 2009–11 and 2010–12 [2]
| Rate per 100 000 maternities | ||
|---|---|---|
| Condition | 2009–2011 | 2010–2012 |
| Direct causes | ||
| Genital tract sepsis | 0.63 | 0.5 |
| Pre-eclampsia and eclampsia | 0.42 | 0.38 |
| Thromboembolism | 1.26 | 1.08 |
| Amniotic fluid embolism | 0.29 | 0.33 |
| Early pregnancy deaths | 0.17 | 0.33 |
| Haemorrhage | 0.59 | 0.46 |
| Anaesthetic | 0.12 | 0.17 |
| Other direct | – | – |
| Indirect causes | ||
| Cardiac | 2.14 | 2.25 |
| Neurological | 1.26 | 1.29 |
| Psychiatric | 0.55 | 0.67 |
| Malignancies | 0.17 | 0.13 |
| Other indirect | 3.03 | 2.54 |
Presentation
The timing, speed of onset and presentation depend on the underlying pathology and may even suggest the cause. However, conditions that typically develop relatively slowly in the non-obstetric setting may do so much faster in pregnancy or after delivery. For example, it is unusual for non-pregnant patients to suffer rapidly progressing, overwhelming sepsis, whereas the MDE reports describe many cases in which an apparently healthy woman becomes moribund and dies of sepsis within hours of the first symptoms [2,6]. This may be related to an impaired ability to withstand infection associated with pregnancy itself, or it may reflect the ability of young, fit patients to compensate for physiological challenges very effectively until just before their compensatory mechanisms become overwhelmed. A classic example of this in obstetrics is the response to haemorrhage, in which the mother maintains blood pressure and perfusion relatively well until sudden, catastrophic collapse.
Since mothers may be discharged from the delivery suite to other wards or into the community soon after delivery, those who develop an acute illness may do so in a variety of locations. It is important, therefore, that staff who might encounter such cases (e.g. general practitioners, emergency department doctors and nurses) are aware of the immediate problems they may pose, and that the women themselves have ready access to clinical services if they are not in hospital.
Presentation ranges from non-specific mild symptoms to sudden collapse with loss of consciousness. It is important that all symptoms are taken seriously and, if appropriate, investigated and treated as early as possible, the aim being to prevent clinical deterioration leading to severe systemic collapse. Successive MDE reports abound with tales of women whose condition’s severity was not recognized until it was too late, and the 2005 report first emphasized the potential value of early warning systems based on deviations from pre-determined physiological limits (e.g. heart rate, blood pressure, respiratory rate, temperature, urine output and neurological response), to alert staff to clinical deterioration [7]. Such early warning systems have now been widely implemented and a number of studies have suggested a high sensitivity and specificity in the identification of obstetric patients at risk of deterioration, but a low positive predictive value [8,9,10].
Management
The basic principles of management are the same as for any patient presenting acutely, and can be divided into immediate and subsequent.
Immediate Management
The two initial priorities are, first, resuscitation and stabilization of the patient and, second, assessment and immediate investigations to determine the differential diagnosis. In practice, a focused history and examination, in the context of any known specific issues relating to the recent pregnancy, can be undertaken during immediate resuscitation.
Resuscitation and Stabilization
Guidelines for basic and advanced adult life support are now well established and all clinical staff should be familiar with them [11]. However, in the obstetric setting there are three factors that may make it more difficult to keep up both individual and team skills: (1) the physiological changes accompanying pregnancy and the particular aspects of resuscitation, especially in late pregnancy, many of which continue into the early postpartum period (Table 17.3) [3,12]; (2) the rarity of cardiac arrest in this patient population; and (3) a relatively high turnover of large numbers of staff (especially junior) that is typical of most delivery units.
Main points of current resuscitation guidelines [11] with comments related to specific aspects relevant to pregnancy and the immediate postpartum period
| General | Obstetric | |
|---|---|---|
| A – Airway |
|
|
| B – Breathing |
| |
| C – Circulation |
|
|
| D – Disability |
| |
| E – Exposure |
|
|
| Reversible causes in cardiac arrest |
| |
| Monitoring |
|
|
| Investigations |
|
Assessment
Assessment should be directed towards the most likely causes (see Table 17.1 and below). Level of consciousness is most usefully assessed using the Glasgow Coma Score (GCS), which although originally introduced for the assessment of patients with head injury, has been adopted as a convenient and useful tool in most clinical settings (Table 17.4).
| Response | Score | |
|---|---|---|
| Eye opening | Spontaneous Eye opening to speech Eye opening to pain No eye opening | 4 3 2 1 |
| Verbal | Orientated, spontaneous speech Confused conversation Inappropriate words Incomprehensible sounds/grunts No verbal response | 5 4 3 2 1 |
| Motor | Obeys commands Localizes to pain Withdraws limb from painful stimuli Abnormal flexion or decorticate posture to pain Extensor response, decerebrate posture to pain No motor response | 6 5 4 3 2 1 |
After the immediate ‘ABC’ assessment, a systematic assessment is then required.
Obstetric: see other chapters.
Respiratory: breathlessness is a common feature of acute illness, but the degree may indicate the severity. Chest pain may suggest pulmonary embolism or pneumonia if pleuritic, or cardiac causes if central. Wheeze may indicate aspiration of gastric contents, anaphylaxis or pulmonary oedema; crepitations may indicate aspiration, pneumonia or pulmonary oedema. Tachypnoea is a relatively non-specific symptom and can occur in most illnesses; it is an important feature of early warning systems and frequently mentioned in MDE reports as a clinical sign that merits more attention [2,6]. Hypoxaemia (on saturation monitoring or blood gas analysis) is also non-specific but important to detect, so early use of a pulse oximeter is vital. One potential problem with the pulse oximeter is that in hypoventilation, once oxygenation has been treated by administering oxygen, the saturation may be restored to near-normal even though the patient may only be taking a few breaths each minute. In such situations there may be severe hypercapnia despite reassuring oxygen saturation. Therefore, it is important to monitor respiratory rate and, if low, to monitor carbon dioxide tension by taking blood gas samples. A chest X-ray may be useful, although many conditions (e.g. amniotic or thromboembolism, bronchospasm) are typically not associated with early signs.
Cardiovascular: breathlessness is a non-specific symptom, as discussed above. Cardiac pain is typically central and may indicate myocardial ischaemia or aortic dissection (classically severe and radiating through to the back). Hypertension may indicate pre-eclampsia or be related to pain/anxiety. Rarely it may indicate raised intracranial pressure. Hypotension may reflect loss of circulating volume, a pump problem (heart failure, pulmonary embolism) or a dilated vasculature, e.g. in sepsis. Tachycardia is relatively non-specific but, like tachypnoea, important. Bradycardia may suggest vasovagal syncope (which does not exclude other conditions), but it may also indicate severe hypovolaemia or hypoxaemia, in which sudden severe slowing of the heart rate may indicate imminent cardiac arrest. Heart murmurs can either reflect simple flow murmurs that often develop in pregnancy due to an increased cardiac output, or structural disease. If a cardiac condition is suspected, electrocardiography (ECG) is vital, and a cardiological referral and echocardiogram should be considered.
Neurological: the GCS is a useful overall assessment tool, as discussed above. A reduced conscious level may result from a primary neurological disorder, such as stroke, or be secondary to other pathology, such as severe hypotension. Hypoglycaemia should always be sought as a cause of unconsciousness. Limb weakness may indicate stroke, although residual neuraxial blockade may confuse the clinical picture. Visual disturbances may be seen in primary hypertension, secondary to pre-eclampsia or due to raised intracranial pressure. A headache might be innocent in nature, but might also suggest post-dural puncture headache, intracranial haemorrhage or thrombosis, or severe hypertension/pre-eclampsia. Convulsions may be due to previously diagnosed epilepsy, or result from eclampsia or local anaesthetic toxicity.
Other: bleeding may be obvious from operative site or vagina but may be concealed. Bleeding from puncture sites suggests a coagulopathy. Pyrexia may indicate an infective process. Skin rash may indicate allergic reaction or sepsis.
Subsequent Management
Clearly, this will depend on the underlying cause and may involve further investigation and/or treatment that may involve other specialists and units. Labour wards are busy clinical areas, and this presents difficulties in coordinating care of the acutely unwell mother. It may be difficult to devote adequate attention to her while other priorities continue to present, and organizing invasive procedures and investigations may take longer in an area unfamiliar to them. It is important that specialists from other acute areas, especially the critical care/high-dependency unit, be involved early, and that all staff appreciate that the patient does not physically have to be in the intensive care unit in order to receive high-level care.
Specific Conditions
Hypertensive Disorders
Pre-eclampsia can deteriorate after delivery, leading to acute collapse with pulmonary oedema, cerebral haemorrhage, coagulopathy or convulsions. Oedema may also affect the airway leading to respiratory collapse. In the UK almost 40% of eclamptic fits occur after delivery [13].
This topic is covered in more detail in Chapter 25.
Postpartum Haemorrhage
Acute blood loss is a major cause of collapse in the immediate and early postpartum period. It is defined as blood loss >500 ml after delivery of the placenta. The degree of blood loss is frequently underestimated and sometimes unnoticed when attention is focused on the baby. In addition, young patients are often able to compensate until hypovolaemia is severe.
Because of the tendency to underestimate hypovolaemia, it is important that administration of intravenous fluids is prompt and that appropriately sized cannulae are used. Below is an estimate of flow rates through different sizes of cannula:
20 G = 40–80 ml/min
18 G = 75–120 ml/min
16 G = 130–220 ml/min
14 G = 250–360 ml/min
Postpartum haemorrhage is covered in more detail in Chapter 15.
Genital Tract/Abdominal Sepsis
‘Sepsis’ is a non-specific term that refers to the systemic inflammatory response to infection. Systemic inflammatory response syndrome (SIRS) is defined as a clinical state including two or more of the following:
temperature >38 °C or <36 °C;
heart rate >90 bpm;
respiratory rate >20/min or PaCO2 <4.3 kPa;
white cell count >12 × 109/L
The clinical condition defined as ‘SIRS’ is very non-specific and occurs commonly, especially in pregnancy. Furthermore, it may be caused by many other conditions than infection alone.
In severe sepsis, organ dysfunction develops as a result of hypotension and hypoperfusion. ‘Septic shock’ is defined as severe sepsis with hypotension, despite adequate fluid resuscitation, along with perfusion abnormalities such as lactic acidosis, oliguria and mental disturbance.
The clinical presentation of sepsis is very variable and often insidious, with rapid clinical deterioration. Typically the patient presents with pyrexia >38 °C, tachycardia and tachypnoea, progressing to hypotension and hypoxaemia. There may be other symptoms such as abdominal pain, nausea and vomiting, and abdominal features are common in deaths associated with pregnancy [2,6].
A high index of suspicion should be maintained with early implementation of broad-spectrum antibiotics after screening for sources of sepsis, and early referral to critical care services if severe. Management of sepsis involves the use of the Surviving Sepsis care bundles [14]. These bundles are a selected set of evidence-based clinical interventions. The care bundles for the first three and six hours are:
To be completed within three hours:
measure lactate level;
obtain blood cultures before administering broad-spectrum antibiotics;
if patient is hypotensive or blood lactate >4 mmol/l, give IV crystalloid (30 ml/kg).
To be completed within six hours:
aim for a MAP >65 mmHg. If patient does not respond to IV fluids, give vasopressors;
if patient is persistently hypotensive/lactate >4 mmol/l, measure CVP and central venous oxygen saturation (aim for CVP >8 mmHg and ScvO2 >70%).
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