Presentación del tema: "COLAPSO MATERNO JAVIER ESTEBAN TORO LÓPEZ RESIDENTE DE ANESTESIA"— Transcripción de la presentación:
1COLAPSO MATERNO JAVIER ESTEBAN TORO LÓPEZ RESIDENTE DE ANESTESIA UNIVERSIDAD CESOCTUBRE 2011Asesor: Dr. Martín Gómez
2Africa 1:13 Europa 1:3200 Latinoamerica 1:70 EpidemiologíaCada MINUTO 1 mujer muere, 100 tienen complicaciones,200 adquieren una ITS y 300 se embarazan sin desearlo558 mil mujeres mueren al añoEl 99% de las muertes en paises pobresRiesgo de morirEuropa1:3200Latinoamerica1:70Africa1:13OMS/OPS BULLETIN 1998
3Relación entre atención calificada del parto y mortalidad materna 20001800160014001200Tasa de muertes matwernas por n.v.1000800600400200% de los partos atendidos por personal calificado
4Tendencia global mortalidad materna 1980–2008 Lancet 2010; 375:
5Tendencia global mortalidad materna 1980–2008 Lancet 2010; 375:
6Mortalidad materna según semanas de gestación Colombia 2008 Fuente Sivigila 2008
7Número de casos y razón de mortalidad materna por 100. 000 N. V Número de casos y razón de mortalidad materna por N.V. en Antioquia
8Causas de mortalidad materna en Antioquia Fuente Dirección seccional de salud de Antioquia, Octubre 2011
9Mortalidad materna según sitio de muerte AntioquiaFuente Dirección seccional de salud de Antioquia, Octubre 2011
10Mortalidad materna según causa evitable AntioquiaFuente Dirección seccional de salud de Antioquia, Octubre 2011
12Consecuencias de la mortalidad materna Más de un millón de huérfanos por año en el mundoDos mil seiscientos huérfanos por año en ColombiaCiento setenta y seis huérfanos por año en AntioquiaAbandono del menor.maltratoviolencia intrafamiliar.violencia sexual.prostitución, embarazo en adolescentes, criminalidadesclavitud laboral del menorOMS/OPS BULLETIN 1998
13Pérdida parcial o total de la conciencia DefiniciónColapso es un término no específico que implica:Pérdida parcial o total de la concienciaCerebralCardiovascularCollapse is a non-speci¢c term implying a complete or partial loss of consciousness, either as a primary cerebral event or secondary to a cardiovascular event leading to cerebral hypoperfusion.It is important that all clinicians involved in clinical care are able to recognize and deal with a patient who collapses; this should always be viewed as a medical emergency. To this end, they should keep their basic life support skills up to date and be familiar with current al- gorithms relating to the immediate management of a col- lapsed patient. It cannot be overstated that whatever the cause of the collapse, the ¢rst few minutes of resus- citation are vital to ensure that the patient remains oxy- genated and maintains an e¡ective circulation. Delay can lead to irreversible damage to the woman.A collapse may be transient and self limiting, as in a faint, or may be the harbinger of a more life-threatening event. In a hospital setting, if there is any doubt regarding the cause or management of the collapse, the cardiac arrest team must be summoned immediately. Once initial resuscitation has taken place, the obstetric team must work closely with the resuscitation team to determine the cause of the collapse, instigating investigation and appropriate treatment as soon as possible.EMERGENCIA MÉDICACurrent Obstetrics & Gynaecology (2003) 13, 67-73Current Obstetrics & Gynaecology (2006) 16, 72–78Curr Opin Anaesthesiol 18:257–262
14Alteración cardiovascular Lesión cerebral primaria Embolismo pulmonar FisiopatologíaEl colapso materno usualmente se debe a uno de los siguientes:Arritmia / IAMEpilepsiaAlteración cardiovascularLesión cerebral primariaEmbolismo pulmonarHipoglucemiaHemorragiaHipoxiaCauses of postpartum collapseNon-serious causes commonly cause suspected collapse and these include hyperventilation and vasovagal attacks. These episodes are usually self-limiting and maternal observations will rapidly return to normal with simple measures such as reassurance and changing maternal position. Hypoglycaemia should be excluded in all women with a change in consciousness of uncertain cause.There are many serious causes of collapse but in all cases management involves prompt resuscitation whilst the differential diagnosis is considered. Table 2 lists causes of collapse, incidence and important management points.PATHOPHYSIOLOGYPost-partum collapse is usually due to one of the following.Primary cerebral event leading to loss of consciousnessEpileptic ¢t Hypoglycaemia Profound hypoxia Intracerebral bleed Cerebral infarction Anaesthetic or analgesic drugsCardiovascularPrimary cardiac event, e.g. arrhythmia or myocardial infarction, impairing the ability of the heart to act as an e¡ective pumpA blockage in the circulation, e.g. pulmonary embolismAn absolute reduction in circulating volume, e.g. major haemorrhageA relative decrease in e¡ective circulating volume from profound vasodilatation, e.g. anaphylaxis or sepsisVasodilataciónSangrado / infartoIntoxicaciónIntoxicación A.L.Curr Opin Obstet Gynecol 17:157–160Current Obstetrics & Gynaecology (2006) 16, 72–78
15Progresión Curr Opin Obstet Gynecol 13:563-568. The majority of studies focus on direct causes of obstetric morbidity (this results from obstetric complica- tions arising from interventions, omissions, incorrect treatments, or from a chain of events resulting from any of the above) . Mantel et al.  categorize severe morbidity as `near misses' (Fig. 1). The presence of any one marker of organ dysfunction in a pregnancy or in a woman who has had her pregnancy terminated within the previous 6 weeks is de®ned as a near miss.Figure 1 diagrammatically indicates a sequence of events in a population of pregnant women leading from good health to death. A woman with organ dys- function or failure would usually die if inadequate or no treatment or support were given. Intuitively, a near miss is a very ill woman who would have died had it not been that luck or good care was on her side. A near miss, then, is a woman with severe organ dysfunction or organ failure.Curr Opin Obstet Gynecol 13:
16Mortalidad materna y anestesia Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010)Br J Anaesth 2005 Apr; 94(4): 417e423.
17Caso clínico 44 AÑOS, MULTIGESTANTE PRECESAREADA ( TRANSVERSA ) PLACENTA PREVIA TOTAL ( ANTENATAL )PLACENTA PERCRETA ( INTRAPARTO )CESÁREA ( PLACENTA IN SITU )MANEJO EXPECTANTE : METOTREXATEEXAMEN BAG VS. HISTERECTOMÍACOLAPSO MATERNO: AESP – RCCPHISTERECTOMÍA - EMPAQUETAMIENTOTRASLADO UCI : EMBOLIZACIÓN
20Disminuir morbimortalidad PreparaciónAnticiparPlanear el manejoFR maternosEvaluación activaComunicaciónDisminuir morbimortalidadAdvance preparation for carersFortunately in modern obstetrics maternal collapse is a rare event, however, less fortunately it is often a sudden unexpected event. Thus to ensure the best possible outcome all healthcare professionals involved in the care of postnatal women must be prepared in case they are faced with this situation, and if risk factors are present, the situation should be anticipated and planned for.Multiple factors will have to be considered during an emotionally dramatic event. Higher awareness of maternal risk factors (Table 2) together with active surveillance to identify causes of early maternal compromise leading to early intervention and good level of communication can minimize maternal morbidity and mortality. Clear plans for management during pregnancy, labour and throughout the postpartum course when put in place will help care providers to prepare and hopefully prevent poor outcome.This can be achieved through early antenatal identification of maternal risk factors and multidisciplinary team involve- ment. Clinical consultation with the obstetric anaesthetist during antenatal assessment of patients with co-existing medical conditions can anticipate problems and reduce morbidity.All units in the UK should have guidelines for management of maternal collapse; these should be widely circulated both within the maternity department and the accident and emergency department. They must also be readily acces- sible in an emergency and updated on regular basis.Pregnancy induces physiological changes in all major maternal organs that may mimic early signs of maternal compromise. Early recognition of subtle changes in the level of consciousness, for example, changes in pulse rate and respiratory rate, can prevent a case of cardiopulmonary collapse.Current Obstetrics & Gynaecology (2006) 16, 72–78
21Entrenamiento cada año EclampsiaHemorragiaParo CREntrenamiento cada añoResuscitation of a newly delivered mother can be challen- ging if the rescuer is not prepared. Nowadays, obstetricians and midwives are expected to be able to provide the necessary care if and when required. Our exposure to managing acute emergencies (obstetric and non-obstetric has been largely influenced by the way we are trained. Recent changes to training pattern meant less time spent on duty, which undoubtedly has major consequences on the level of exposure and therefore competence. To overcome this problem, units should practice emergency skills and drills sessions (CNST requirement), including management of eclampsia, massive haemorrhage, and cardiopulmonary arrest. This can be achieved by using manikins and simulators to teach the skills required for effective resuscitation. Drills involve an unexpected simulation of an emergency situation with the organizer of the drill under- taking to observe the action of the multidisciplinary team in responding to this situation and to feedback regarding performance to the individuals involved. Rehearsals have been shown to decrease anxiety for the staff involved in real emergencies and to increase response times. The rehearsal should include clarifying the plan of action for each specific emergency including clinical management, location of supplies and sources of extra equipment and identification of other personnel required to assist in management. New resuscitation guidelines in the UK now suggest that all healthcare workers, including obstetricians and midwives, need training every year. For many Trusts this is now part of mandatory training required as part of the appraisal process.In addition to internal training, there are a number of courses that are organized to be available for doctors and midwives involved in the care of critically ill women. These courses again utilize manikins and scenarios teaching to assist in the practical aspect of resuscitation and manage- ment of obstetric emergencies.Current Obstetrics & Gynaecology (2006) 16, 72–78
22Cardiopatía corregida Factores de riesgoEdad maternaCardiopatía corregidaGemelarSindrome de marfanHTAImplantación placentariaTrabajo de parto prolongadoEmbarazo múltipleTraumaEmbarazoTrombofiliaPost cesáreaPreeclampsiaHipertonia uterinaInducción TPInstrumentación uterinaEmbolismo pulmonarCardiopatiaHemorragiaEclampsiaEmbolismo líquido amnióticoIncidencia1:1000Incidencia1:Incidencia1:Incidencia1:1000Incidencia1:2000Identifying antenatal factorsWith changing patterns of antenatal care many women will not be seen on a routine basis by an obstetrician during their pregnancy. It is important that a comprehensive history is taken during the booking visit and that any risk factors that may be present are identified allowing obstetrician and specialist review with planning for the pregnancy including intra-partum and postpartum management. The Confiden- tial Enquiry into Maternal Death continues to highlight cases where care was sub-standard as risk factors were either not identified or not acted on appropriately. Some high-risk groups of women may book late in their pregnancies sometimes not seeking care until labour starts. Asylum seekers, women experiencing domestic violence, and women with drug addiction are examples, all departments must ensure that special arrangements are in place to reduce the risk to these vulnerable groups of women.Current Obstetrics & Gynaecology (2006) 16, 72–78
23Acción inmediata Asegurar un ambiente seguro Administrar oxigeno Obtener información relevanteTrauma?Evaluar respuesta verbalIniciar monitorizaciónImmediate actionThe first step is to ensure a safe environment for the woman and the resuscitation team. If she has been brought from home it is essential to obtain as much history as possible from the woman herself, the paramedic crew and her family/companion regarding events during pregnancy, im- mediately leading up to her collapse and her medical history including any medications. If communication is possible with the woman this provides important information regarding her respiration and cerebral perfusion.The Resuscitation Council UK recommends starting cardiopul- monary resuscitation (CPR) using adjunct airways and defibril- lation within 3 minutes of collapse due to cardiac arrest.Many physiological factors in pregnancy may impede expec- ted response to CPR and thus need to be considered in advance. Table 2 shows physiological alterations in pregnancy and puerperium and their implications for resuscitation.It is important that personal safety and the safety of the support staff are ensured prior to commencing resuscitation. Taking a brief history from the paramedics or the midwife is helpful in beginning to address the possible cause of the collapse and should include a rapid review of antenatal and intrapartum problems and a description of the events around the time of the collapse. This history can be taken simultaneous to the initial assessment of A, B, C. The initial approach should attempt to get a verbal response of some kind from the woman as the presence or the absence of response will indicate both the extent of cerebral perfusion and respiratory status. A cervical spine injury is rare in postnatal collapse and only needs to be considered if there is a possible history of trauma or a serious fall (e.g. down stairs) during the collapse. If an injury to the neck is a possibility, manual inline stabilisation with avoidance of any head tilt must be employed until a collar can be fitted and the head immobilised by blocks. A left lateral tilt should become an automatic response during the initial resuscitation of any pregnant or recently pregnant woman. In the context of a pregnant woman, high flow oxygen can be administered from the outset whilst assessment is occurring.Abordaje estructurado ABCDDecubito lateral izquierdoCurrent Obstetrics & Gynaecology (2006) 16, 72–78OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:8
24Transmite sólo el 80% de la fuerza aplicada PosiciónTransmite sólo el 80% de la fuerza aplicadaatient PositioningPatient position has emerged as an important strategy to improve the quality of CPR and resultant compression force and output. The pregnant uterus can compress the inferior vena cava, impeding venous return and thereby reducing stroke volume and cardiac output. Reports of noncardiac arrest parturients indicate that left-lateral tilt results in improved maternal hemodynamics of blood pressure, cardiac output, and stroke volume96,98,104; and improved fetal parameters of oxygenation, nonstress test, and fetal heart rate.100 –102Although chest compressions in the left-lateral tilt position are feasible in a manikin study,105 they result in less forceful chest compressions than are possible in the supine position.106 Two studies found no improvement in maternal hemodynamic or fetal parameters with 10° to 20° left-lateral tilt in patients not in arrest.107,108 One study reported more aortic compression at 15° left-lateral tilt compared with a full left-lateral tilt.97 In addition, aortic compression has been found at 30° of tilt,109 however the majority of these patients were in labor.If left-lateral tilt is used to improve maternal hemodynamics during cardiac arrest, the degree of tilt should be maximized. However, at a tilt 30° the patient may slide or roll off the inclined plane,106 so this degree of tilt may not be practical during resuscitation. Although important, the degree of tilt is difficult to estimate reliably; 1 study reported that the degree of table tilt is often overestimated.110 Using a fixed, hard wedge of a predetermined angle may help.Two studies in pregnant women not in arrest found that manual left uterine displacement, which is done with the patient supine, is as good as or better than left-lateral tilt in relieving aortocaval compression (as assessed by the incidence of hypo- tension and use of ephedrine).111,112Therefore, to relieve aortocaval compression during chest compressions and optimize the quality of CPR, it is reasonable to perform manual left uterine displacement in the supine position first (Class IIa, LOE C). Left uterine displacement can be performed from either the patient’s left side with the 2-handed technique (Figure 2) or the patient’s right side with the 1-handed technique (Figure 3), depending on the positioning of the resuscitation team. If this technique is unsuccessful, and an appropriate wedge is readily available, then providers may consider placing the patient in a left-lateral tilt of 27° to 30°,106 using a firm wedge to support the pelvis and thorax (Figure 4) (Class IIb, LOE C).Lateral displacement of the uterusThe 2000 International Guidelines for CPR and 2005 Emergency Cardiac Care (ECC) Guidelines64 state that it is not advisable to resuscitate a pregnant patient in the supine position, because the weight of the gravid uterus obstructs the venous return via the inferior vena cava.64 For chest compressions to be more effective during the second half of pregnancy, studies have confirmed that applying a partial left lateral tilt to the patient will relieve the aortocaval compression.65 Rees and Willis concluded that the best compromise for cardiopulmonary resuscitation is achieved by wedging the patient This led to the development of the Cardiff Resuscitation wedge e a wooden frame inclined at a 27 angle and specifically designed for performing CPR on pregnant patients.64 However, at this angle, there is a disadvantage in that the rescuer can provide only 80% of the transmitted external force. Because the transmission forces during external CPR in this position are not perpen- dicular to the thorax and a part of the transmitted force is lost, left lateral positioning for CPR is not ideal. Overturned chairs, human wedge with the knee, full lateral position and the Cardiff wedge make external compressions and CPR ineffective.66 The best compromise for CPR and optimal venous return is in ‘the supine position with manual displacement of the uterus to the left’.What Defines a Gravid Uterus With the Potential to Cause Aortocaval Compression? A study found that maternal aortocaval compression can occur for singleton pregnancies at 20 weeks of gestational age.156 However, the exact gestational age at which aortocaval com- pression occurs is not consistent, especially with multiple- gestation pregnancies or intrauterine growth retardation, and gestational age and number of fetuses may not always be known in the emergency situation. Fundal height is often used to estimate gestational age. In a singleton gestation, by 20 weeks fundal height is approximately at the level of the umbilicus157; however the fundus may reach the umbilicus between 15 and 19 weeks of gestation.158 Fundal height may also be skewed by other factors such as abdominal distention157 and increased body mass index; therefore fundal height may be a poor predictor of gestational age.One review of emergency cesarean sections in maternal cardiac arrest before the third trimester concluded that if the fundus extends above the level of the umbilicus, aortocaval compression can occur, and emergency cesarean section should be performed regardless of gestational age.158Two cases of maternal cardiac arrest in early pregnancy of 13 to 15 weeks were reported in which the mother was resuscitated without an emergency cesarean section being performed and the pregnancy continued to successful delivery of a live infant at term.159,160 Not every pregnant woman in cardiac arrest is a candidate for an emergency cesarean section; the decision depends on whether or not the gravid uterus is thought to interfere with maternal hemodynamics.Current Obstetrics & Gynaecology (2006) 16, 72–78Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010)Circulation. 2010;122[suppl 3]:S829–S861.
25Reanimación Los cambios fisiológicos del embarazo inciden en la reanimaciónMayor requerimiento de oxígenoCompliance torácica disminuidaMayor riesgo de aspiraciónRiesgo de aspiraciónRiesgo de no ventilación / no intubaciónDecúbito lateral izquierdoCompresiones torácicasMonitorizaciónVía aéreaVentilaciónMany factors peculiar to pregnancy can adversely affect the chances of survival of a collapsed woman especially if those involved in resuscitation have not thought through the challenges that these may present in advance. Normal breast enlargement can make cardiac massage and monitor placement more difficult. Likewise physiological factors such as increased oxygen consumption and increased like- lihood of pulmonary aspiration present challenges for the resuscitation. Pathological laryngeal oedema may result in intubation difficulties in some women. Many pregnant women gain weight and obesity is another factor known to make resuscitation more difficult.The structured approach refers to the A, B, C, D and E approach to resuscitation and is recommended as universal practice in all specialities by the Advances Life Support Group (ASLG). Assessment is carried out by primary survey during initial resuscitation and secondary survey performed if required when the woman has been stabilized. A, B, C, D and E are attended to during the primary survey. This aims to uncover immediately life-threatening problems according to priority ‘i.e. the order in which they can kill’. There is a process of continuous re-evaluation and resuscitation.Whenever possible, senior staff should be involved (senior obstetrician, senior anaesthetist and experienced midwife). Monitoring should be commenced immediately and should include pulse oximetry, electrocardiogram (ECG) and auto- mated blood pressure recording. A urinary catheter should be inserted as soon as it is possible to do so without hindering basic life support.Implications on resuscitationA: AirwayIn the early postpartum period this usually involves main- tenance and protection of the airway. Primary airway problem is unusual and the only exception is severe laryngeal oedema. An unconscious woman who had just delivered is at risk of aspiration of gastric contents leading to serious chemical pneumonitis (due to lower pH of gastric contents in the pregnant woman).Clearing the airway of secretion or vomit (in hospital suction will usually be available for this) and insertion of an oropharyngeal or nasopharyngeal airways are the first steps. However, the gold standard in airway protection is intuba- tion. An experienced anaesthetist should carry this out, as pregnant women are more difficult to intubate. This is mainly due to the risk of failure secondary to laryngeal oedema and the increased risk of regurgitation of gastric contents and aspiration.B: BreathingBreathing should be assessed for 10s by looking, listening and feeling. If the woman is not breathing spontaneously then the next step is to initiate assisted ventilation. Resuscitation guidelines recommend giving two initial rescue breaths by mouth to pocket facemask or by facemask and ambubag. If spontaneous respiration does not resume, respiration must be maintained by these techniques. As previously stated tracheal intubation should take place as soon as possible to allow airway protection and effective ventilation. If spontaneous breathing is confirmed then she should be placed in the left lateral position. High-flow supplementary oxygen should be administered in all cases of collapse at a flow rate of 12–15 l/min.C: CirculationThe circulation should be assessed if spontaneous breathing fails to establish by checking the carotid pulse for 10 s. In the absence of carotid pulsation, resuscitation should continue by starting external chest compressions. A monitor to assess cardiac rhythm should be attached and the defibrillator prepared. A ratio of 15 compressions to two breaths should be maintained until signs of circulation are established or defibrillation is advised by the Advanced Life Support Team (Cardiac Arrest Team). Many hospitals are now installing automated debrillation equipment and if available these should be used and the instructions followed potentially allowing defibrillation prior to the arrival of the cardiac arrest team.CirculaciónCurrent Obstetrics & Gynaecology (2006) 16, 72–78Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010)Circulation. 2010;122[suppl 3]:S829–S861.
26Desfibrilación Seguro en embarazo Puede haber muerte fetal DefibrillationDefibrillation should be performed at the recommended ACLS defibrillation doses (Class I, LOE C).122Although there are no studies documenting maternal or fetal complications with defibrillation, there are case reports123–130 and case series131–133 that describe potential harm to the fetus when an accidental electric shock (lightning, electric circuit) is delivered directly to the mother. After a pregnant woman receives an electric shock, the range of clinical presentations varies from the mother feeling only a strange sensation with no fetal effects to fetal death either immediately or a few days after the shock. Risk factors for adverse fetal outcomes include the magnitude of current and duration of contact. The greatest predictor of risk for adverse fetal outcome is if the current travels through the uterus, because amniotic fluid most likely transmits current in a manner similar to that transmitted via other body fluids, which could increase the risk of fetal death or burns.Although there is a small risk of inducing fetal arrhythmias, cardioversion and defibrillation on the external chest are consid- ered safe at all stages of pregnancy.134 –136Some experts have raised concern that electric arcing may occur if fetal monitors are attached during defibrillation of a pregnant woman, but there is no evidence to support this. Overall it is reasonable to assume that if the shock is delivered to the mother’s thorax, there is very low to no risk of electric arcing to fetal monitors. If internal or external fetal monitors are attached during cardiac arrest in a pregnant woman, it is reasonable to remove them (Class IIb, LOE C).Quitar monitoria fetal antes de la descargaCurrent Obstetrics & Gynaecology (2006) 16, 72–78Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010)Circulation. 2010;122[suppl 3]:S829–S861.
27Causas reversibles 5 H´s y 5 T´s DefibrillationDefibrillation should be performed at the recommended ACLS defibrillation doses (Class I, LOE C).122Although there are no studies documenting maternal or fetal complications with defibrillation, there are case reports123–130 and case series131–133 that describe potential harm to the fetus when an accidental electric shock (lightning, electric circuit) is delivered directly to the mother. After a pregnant woman receives an electric shock, the range of clinical presentations varies from the mother feeling only a strange sensation with no fetal effects to fetal death either immediately or a few days after the shock. Risk factors for adverse fetal outcomes include the magnitude of current and duration of contact. The greatest predictor of risk for adverse fetal outcome is if the current travels through the uterus, because amniotic fluid most likely transmits current in a manner similar to that transmitted via other body fluids, which could increase the risk of fetal death or burns.Although there is a small risk of inducing fetal arrhythmias, cardioversion and defibrillation on the external chest are consid- ered safe at all stages of pregnancy.134 –136Some experts have raised concern that electric arcing may occur if fetal monitors are attached during defibrillation of a pregnant woman, but there is no evidence to support this. Overall it is reasonable to assume that if the shock is delivered to the mother’s thorax, there is very low to no risk of electric arcing to fetal monitors. If internal or external fetal monitors are attached during cardiac arrest in a pregnant woman, it is reasonable to remove them (Class IIb, LOE C).Current Obstetrics & Gynaecology (2006) 16, 72–78Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010)Circulation. 2010;122[suppl 3]:S829–S861.
28Cesárea de emergencia Por qué hacerla? Cuando solicitar? Why Perform an Emergency Cesarean Section in Cardiac Arrest? Several case reports of emergency cesarean section in maternal cardiac arrest indicate a return of spontaneous circulation or improvement in maternal hemodynamic status only after the uterus has been emptied.94 –96,143,149,161–166 In a case series of 38 cases of perimortem cesarean section, 12 of 20 women for whom maternal outcome was recorded had return of spontane- ous circulation immediately after delivery. No cases of worsened maternal status after cesarean section were reported.166 The critical point to remember is that both mother and infant may die if the provider cannot restore blood flow to the mother’s heart.The rescue team is not required to wait 5 minutes before initiating emergency hysterotomy, and there are cir- cumstances that support an earlier start.157 For instance, in an obvious nonsurvivable injury,166,167–169 when the maternal prognosis is grave and resuscitative efforts appear futile, moving straight to an emergency cesarean section may be appropriate, especially if the fetus is viable.Many reports document long intervals between an urgent decision for hysterotomy and actual delivery of the infant, far exceeding the obstetric guideline of 30 minutes for patients not in arrest.170,171 Very few cases of perimortem cesarean section fall within the recommended 5-minute period.94,166 Survival of the mother has been reported with perimortem cesarean section performed up to 15 minutes after the onset of maternal cardiac arrest.94,172–174 If emergency cesarean section cannot be per- formed by the 5-minute mark, it may be advisable to prepare to evacuate the uterus while the resuscitation continues. (Class IIb, LOE C).At 24 to 25 weeks of gestation, the best survival rate for the infant occurs when the infant is delivered no more than 5 minutes after the mother’s heart stops beating.175–178 Typically this requires that the provider begin the hysterotomy about 4 minutes after cardiac arrest. At gestational ages 30 weeks, infant survival has been seen even when delivery occurred after 5 minutes from onset of maternal cardiac arrest.166 In a recent retrospective cohort series, neonatal survival was documented when delivery occurred within 30 minutes after onset of mater- nal cardiac arrest.94When there is an obvious gravid uterus, the emergency cesarean section team should be activated at the onset of maternal cardiac arrest (Class I, LOE B). Emergency cesarean section may be considered at 4 minutes after onset of maternal cardiac arrest if there is no return of spontaneous circulation (Class IIb, LOE C).5 minutos postparo?Current Obstetrics & Gynaecology (2006) 16, 72–78Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010)Circulation. 2010;122[suppl 3]:S829–S861.
29Manifestaciones clínicas Convulsión tónico clónicaHipertensión gravePérdida de la concienciaReflejos aumentadosDisnea súbitaDesaturaciónTrombosis venosaDolor torácicoSangrado vaginalUtero no contraidoPlacenta incompletaDisminución gasto urinarioTaquicardiaHipotensiónDisnea súbitaDolor torácicoFotofobiaNaúsea / vómitoPánicoSensación de dolor en manos y piesCoagulopatíaEclampsiaEmbolismo líquido amnióticoHemorragiaEmbolismo pulmonarTratamientoOxigeno 100%LEVHemoderivadosOxitóxicosCirugíaTratamientoOxígeno 100%LEVHeparina 1 mg/kg bidTratamientoPosición lateral de seguridadAspiradorSulfato de magnesioOxigeno 100%LabetalolTratamientoMortalidad 50% 1 horaOxígeno 100%LEVVentilación mecánicaInotrópicosHemoderivadosAmniotic fluid embolism (AFI)Incidence: In the most recent CEMACH, AFI was the 4th most common direct cause of death. (0.80/100,000 maternities). The UK Obstetric Surveillance System reports an incidence of 1.8 per 100,000 maternities, with over 50% mortality within 1 hour of onset of symptoms.Aetiology: Anaphylactic type reaction to foetal skin squames and amniotic fluid entering the maternal circulation during labour and delivery. Foetal skin squames are commonly found in the maternal circulation and the reasons why some women respond with profound right and left heart failure is unknown.Risk factors: Include multiparity, advanced maternal age, male foetus, trauma, Caesarean section or operative vaginal delivery, abruption, placenta praevia and cervical laceration or uterine rupture.Key clinical and investigation findings: Sudden onset of shortness of breath, chest pain, light headedness, distress, panic, sensation of pins and needles in hands and feet, nausea and vomiting. Rapid onset of coagulopathy results in bleeding causing massive PPH.Key treatment points in definitive management: High flow oxygen and aggressive fluid resuscitation are required. If cardiac arrest has not yet occurred it should be anticipated as should the onset of coagulopathy. Ventilation, inotropic support and administration of fresh frozen plasma, cryoprecipitate and platelets will be required. Hysterectomy may be required to control PPH.Venous thromboembolism (VTE)Incidence: About 100 per 100,000 maternities. The incidence of all VTE is the same antenatally as postnatally but the risk of pulmonary embolism is much greater postnatally (a recent study from Norway showed an incidence of 6 per 100,000 antenatal pregnancies vs 22 per 100,000 postnatal women). In the most recent CEMACH, this was the most common direct cause of death with a mortality of 1.56 per 100,000 maternities.Aetiology: Deep leg and pelvic vein thrombosis result in pulmonary embolism.Risk factors: Include BMI >30, immobility including prolonged hospitalisation, delivery by Caesarean section or other surgery unrelated to pregnancy, severe pre-eclampsia, higher maternal age, previous personal or family history of VTE, history of thrombophilia, air travel and assisted conception.Key clinical and investigation findings: Sudden onset of shortness of breath with falling in oxygen saturations at rest or on any exertion. A deep vein thrombosis may exist (with unilateral leg swelling or tenderness) but there may be no evidence as the clot may be in the femoral or iliac veins. Chest pain may also occur but haemoptysis is rarely seen.Key treatment points in definitive management: High flow oxygen and aggressive fluid resuscitation if the clinical suspi- cion of VTE exists. Therapeutic dose heparin (1 mg/kg bid enoxaparin) must be commenced until investigations to exclude the diagnosis have taken place. Except in rare cases, bleeding in a postoperative woman can be managed and thus, the risk related to VTE significantly outweighs the risk of bleeding.Pre-eclampsia and eclampsiaIncidence: 27 per 100,000 maternities. In the most recent CEM- ACH, this was the joint 2nd most common direct cause of death. The risk of fitting decreases with time since delivery but reports of fits more than a week after delivery do occur.Aetiology: Pre-eclampsia.Risk factors: Essential hypertension, renal disease, foetal growth restriction, multiple pregnancy, a past history of pre-eclampsia in a previous pregnancy, black-African ethnicity, older mothers (especially primigravida) or a high BMI all increase the risk even in a woman who was normotensive during pregnancy and labour.Key clinical and investigation findings: A tonic-clonic convul- sion in the absence of a history of epilepsy should be assumed to be eclampsia until proven otherwise. The reflexes will be brisk, clonus may be elicited and there is often severe hypertension. Loss of consciousness in a woman with hypertension may be due to respiratory failure (pulmonary oedema usually preceded by shortness of breath and falling oxygen saturation) or due to a cerebral event (presenting with focal neurological signs, brisk reflexes and severe hypertension).Key treatment points in definitive management: The airway should be protected by the use of the left lateral position and suction if necessary. A bolus dose of magnesium sulphate should be given to all women when an eclamptic fit is suspected for and should be considered in any woman with a severe complication of pre-eclampsia such as prophylaxis. Oxygen should be administered. The blood pressure should be lowered as soon as possible using an intravenous agent. In postnatal women there is no requirement for preloading with fluid as this is to protect the placental circulation. Further investigations should be considered urgently to establish if other systems are involved in the process (e.g. thrombocytopenia or liver function abnormality). Brain imaging is required urgently in the case of repeated fits or focal neurology suggesting possible intracranial pathology.PPHIncidence: Quoted incidences vary but a rate of about 5% occurs in the UK; however, the majority of cases are not severe enough to cause maternal collapse. About 0.5% of all deliveries are compli- cated by a blood loss of more than 1500 ml. In the most recent CEMACH, PPH was the 5th most common direct cause of death.Aetiology: Revealed PPH may be due to uterine atony, genital tract trauma and retained placental tissue. Concealed haemor- rhage may occur due to haematoma formation in the broad- ligament or the vaginal wall. Coagulopathy is rarely a primary cause of PPH but as part of a serious process such as AFI or as a secondary effect of the initial haemorrhage.Risk factors: Include grand multiparity, Caesarean and instru- mental vaginal delivery, long first stage of labour with prolonged syntocinon use, antepartum haemorrhage, previous PPH, uterine over distension (e.g. multiple pregnancies, polyhydramnios, severe macrosomia) and a low-lying placenta.Key clinical and investigation findings: Heavy vaginal bleeding with the passage of clots will usually be seen. A broad ligament haematoma causes abdominal pain and uterine deviation to one side. The uterus may be poorly contracted, enlarged due to distension with clots and/or the placenta be known to be incomplete. A tachycardia develops initially and without fluid resuscitation, hypotension will follow. The urine output falls andthis may be an early sign, especially in a postoperative woman with some intravenous fluid replacement ongoing. If untreated or rapid, haemorrhage can result in confusion and reduced consciousness due to cerebral hypoperfusion.Key treatment points in definitive management: High flow oxygen and aggressive fluid resuscitation (with blood as soon as possible), simultaneous with interventions to stop bleeding. A head down tilt or leg elevation will reduce cerebral hypoperfusion. The major obstetric haemorrhage protocol should be activated. Bimanual uterine compression should be considered to allow ‘catch-up’ resuscitation. Systematic step-wise use of interventions to stop bleeding with: oxytocics (Syntocinon, Ergometrine, Carbo- prostÒ, Misoprostol); simple surgical interventions (uterine evacu- ation, suturing of vaginal or cervical tears, uterine tamponade with pack or balloon, insertion of brace suture); advanced surgical interventions (uterine devascularisation by ligation of uterine or internal iliac arteries); interventional radiology; and definitive surgery (hysterectomy).Current Obstetrics & Gynaecology (2006) 16, 72–78Anesthesiology Clin 26 (2008) 197–230
30PREVENIR LO MÁS IMPORTANTE… Colapso materno Current Obstetrics & Gynaecology (2006) 16, 72–78Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010)Circulation. 2010;122[suppl 3]:S829–S861.
31Decúbito lateral izquierdo PrevenciónCausas reversiblesDecúbito lateral izquierdoOxígeno 100%2 accesos IVEvitar hipotensiónKey Interventions to Prevent ArrestThe following interventions are the standard of care for treating the critically ill pregnant patient (Class I, LOE C):● Place the patient in the full left-lateral position to relieve possible compression of the inferior vena cava. Uterine obstruction of venous return can produce hypotension and may precipitate arrest in the critically ill patient.95,96● Give 100% oxygen. ● Establish intravenous (IV) access above the diaphragm. ● Assess for hypotension; maternal hypotension that warrants therapy has been defined as a systolic blood pressure 100 mm Hg or 80% of baseline.97,98 Maternal hypo- tension can result in reduced placental perfusion.99–102 In the patient who is not in arrest, both crystalloid and colloid solutions have been shown to increase preload.103● Consider reversible causes of critical illness and treat conditions that may contribute to clinical deterioration as early as possible.Current Obstetrics & Gynaecology (2006) 16, 72–78Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010)Circulation. 2010;122[suppl 3]:S829–S861.