Haemorrhage

In a pregnant woman, the increase in cardiac output by about 30–60% till 32–36 weeks and the hyperdynamic circulation results in excessive blood loss from the uterus after delivery. If the mother is anaemic or there is a coexistent coagulation disorder, the blood loss can be more detrimental for the mother. Concealed haemorrhage often delays action in a woman with collapse and needs to be looked for wherever hypovolaemia is suspected.

One quarter of all maternal deaths result from severe obstetric haemorrhage, and hence it is a significant cause of collapse. Postpartum haemorrhage can be caused by uterine atony and trauma (such as in case of uterine rupture, cervical/vaginal lacerations) and also due to coagulopathy. Visible haemorrhage in a case of collapse is detected earlier and thus with a better salvage rate. However in concealed haemorrhage such as in caesarean section, in large perineal hematomas, a high degree of suspicion is required for early detection and management.

Thromboembolism

It was found to be the commonest cause of maternal death in the last CEMACH report. There were 41 deaths from thromboembolism (33 pulmonary embolisms and 8 cerebral venous thromboses) [3].

Amniotic fluid embolism has been found to have a frequency of about 7.7 per 100,000 deliveries, with a mortality rate of about 60–80% [4].

These symptoms occur during labour or within 30 min of delivery.

In the CEMACH report, cardiac disease was found to be a significant cause of maternal death, responsible for 48 maternal deaths [3]. The high-risk cardiac group for postpartum collapse includes patients with coronary artery disease, pulmonary hypertension, endocarditis, cardiomyopathy and dysrhythmias.

Sepsis

Sepsis is a leading cause of maternal morbidity and mortality in intensive care units. The obstetric patient in labour can develop sepsis because of associated conditions such as pyelonephritis, chorioamnionitis, endometritis, pancreatitis, etc. Sepsis, severe sepsis and finally septic shock lead to collapse. Streptococci groups A, B and D, pneumococcus and Escherichia coli are the common pathogens responsible for sepsis in obstetrics [1].

Drug Toxicity/Overdose

Drugs used in anaesthesia and labour room should be classified and stored in labelled containers to avoid inadvertent faulty administration in a hurry. Magnesium sulphate given in a patient with renal impairment, opioids and local anaesthetic agents given intravenously by mistake are the drugs causing overdose or toxicity.

Eclampsia

The occurrence of seizures in a pregnant woman with a history suggestive of pre-eclampsia can lead to an early diagnosis of eclampsia. In a woman with seizures and collapse, in the absence of hypertension and albuminuria, epilepsy or other neurological causes should be looked for.

Intracranial Haemorrhage

Patients with uncontrolled hypertension, particularly systolic hypertension, may develop intracranial haemorrhage during labour or after delivery. However intracranial haemorrhage may also occur from ruptured aneurysms and arteriovenous malformations.