12) Postnatal - Maternal collapse/death

Question 1

Incidence of maternal collapse

Answer 1

14-600 per 100,000 births

Question 2

Most common cause of collapse

Answer 2

Vasovagal

Post-ictal

Question 3

Causes of maternal cardiac arrest

Answer 3

4Hs:

• Hypovolemia
• Hypoxia
• Hypo/hyperkalaemia
• Hypothermia

4Ts:

• Thromboembolism
• Toxicity
• Tension pneumothorax
• Tamponade

Eclampsia + intracranial haemorrhage

Question 4

Incidence of maternal haemorrhage

Answer 4

3.7/1000

Question 5

Most common cause of cardiac arrest in pregnancy (and other common causes)

Answer 5

Haemorrhage (45%)

2) AFE, Heart failure (13%
(3) Anaesthetic complications (8%)
(4) Trauma (3%)

Question 6

Rate of primary cardiac arrest

Answer 6

1/30,000

Question 7

Incidence of anaphylaxis

Answer 7

3-10/1000

Question 8

Mortality of anaphylaxis

Answer 8

1%

Question 9

Incidence of AFE

Answer 9

2/100,000

Question 10

Mortality of AFE

Answer 10

20%

Question 11

Perinatal mortality of AFE

Answer 11

135/1000

Question 12

How does AFE present?

Answer 12

Collapse during labour/delivery/30 minutes of delivery with hypotension, respiratory distress and hypoxia.
Pulmonary hypertension –> left ventricular dysfunction.
Coagulopathy.

Question 13

Antidote to MgSO4

Answer 13

10% 10mL Calcium gluconate

Question 14

Antidote to LA

Answer 14

Intralipid 20% 1.5ml/kg over 1 minute the 0.25ml/kg/min.

Bolus can be repeated x2 and then infusion increased to 0.5ml/kg/min if adequate circulation not restored.

Question 15

Treatment for anaphylaxis

Answer 15

500 micrograms (0.5mL) of 1:1000 IM Adrenaline

Question 16

Compressions/ventilations during CPR

Answer 16

30:2 unless intubated in which case compressions at 100bpm and ventilations 10/minute

Question 17

Change in plasma volume in pregnancy

Answer 17

Increase 50%

Question 18

Change in heart rate in pregnancy

Answer 18

Increase 15-20bpm

Question 19

Change in cardiac output in pregnancy

Answer 19

Increase 40%

Question 20

What proportion of cardiac output is uterine blood flow?

Answer 20

10%

Question 21

Change in oxygen consumption in pregnancy

Answer 21

Increased 20%

Question 22

Change in residual capacity in pregnancy

Answer 22

Reduced 25%

Question 23

What proportion of circulating volume can be lost by healthy women before becoming symptomatic?

Answer 23

35%

Question 24

How often does maternal cardiac arrest occur?

Answer 24

1 in 12500 pregnancies

Question 25

Maternal survival after cardiac arrest

Answer 25

17-59%

Question 26

Fetal survival after cardiac arrest

Answer 26

61-80%

Question 27

What is the effect of aortocaval compression on cardiac output?

Answer 27

Reduced up to 60%

Question 28

When should perimortem CS be performed?

Answer 28

If no ROSC after 4 minutes of correctly performed CPR in a woman >20 weeks gestation (or uterus at umbilicus or higher) with aim for delivery after 5 minutes of arrest.

Question 29

How to close uterus after PMCS?

Answer 29

Use number 1 vicryl. Upper segment incision in 3 layers - first layer interrupted figure 8 sutures, subsequent can be interrupted or continuous.

Question 30

Blood loss in each of the classes of haemorrhage (as a percentage and as volume in 70kg pregnant woman)

Answer 30

Class I: 15%, <1000ml Class II: 15-30%, 1000-2000ml Class III: 30-40%, 2000-2700mL Class IV: >40%, >2700mL

Question 31

Respiratory rate for each class of haemorrhage

Answer 31

Class I: 14-20 Class II: 20-30 Class III: 30-40 Class IV: >40

Question 32

HR for each class of haemorrhage

Answer 32

Class I: <100 Class II: 100-120 Class III: 120-140 Class IV: >140

Question 33

Blood pressure for each class of haemorrhage

Answer 33

Class I: Systolic and diastolic normal Class II: Systolic normal, diastolic increased Class III: Systolic and diastolic low Class IV: Systolic and diastolic low

Question 34

Mental state for each class of haemorrhage

Answer 34

Class I: Anxious Class II: Anxious, confused Class III: Confused, agitated Class IV: Lethargic

Question 35

Urine output for each class of haemorrhage

Answer 35

Class I: >30 Class II: 15-30 Class III: 5-15 Class IV: Negligible

Question 36

Maternal mortality rate

Answer 36

9 per 100,000

Question 37

What percentage of maternal deaths have autopsy?

Answer 37

84%

Question 38

Most common type of autopsy for maternal deaths

Answer 38

Medico-legal (coronial) autopsy if doctor unable to state cause of death

Question 39

Time period for maternal death

Answer 39

6 weeks (42 days)

Question 40

Direct maternal death

Answer 40

Disease process specific to pregnancy and delivery (includes suicide + VTE)

Question 41

Indirect maternal death

Answer 41

Diseases that also occur in women who are not pregnant but which are exacerbated by pregnancy

Question 42

Coincidental maternal death

Answer 42

Diseases unrelated to pregnancy

Question 43

When should cases be reported to a coroner?

Answer 43

- Deceased died in violent or unnatural death - Cause of death unknown - Deceased died in custody or state detention

Question 44

When should autopsy be done?

Answer 44

Next day ideally

Question 45

What is sudden arrhythmic cardiac death syndrome with a morphologically normal heart? (SADS/MNH)

Answer 45

- Acute cardiac arrhythmia and dies - Diagnosis of exclusion - Suspected secondary to inherited channelopathies

Question 46

Most likely site of embolism

Answer 46

left iliac vein

Question 47

Positive autopsy evidence of PET

Answer 47

Abnormal spiral arteries in decidua Abnormal placental histology Glomerular endotheliosis kidney Liver periportal haemorrhage (HELLP)

Question 48

Lifetime risk of endocarditis with congenital bicuspid aortic valves

Answer 48

10-30%

Question 49

Leading cause of death overall

Answer 49

Cardiac

Question 50

Leading cause of indirect death

Answer 50

Cardiac

Question 51

Leading cause of direct death

Answer 51

VTE

Question 52

Leading cause of direct late deaths

Answer 52

Suicide

Question 53

Risk of maternal death based on ethnicity

Answer 53

White 7 in 100,000 Asian 13 in 100,000 Mixed 23 in 100,000 Black 38 in 100,000

Question 54

Percentage of women who died who were at severe and multiple disadvantage

Answer 54

6%

Question 55

Leading cause of late deaths (overall)

Answer 55

Malignancy - coincidental

Question 56

Percentage of maternal deaths known to have pre-existing medical problems

Answer 56

67%