MATERNAL COLLAPSE. University Hospital of Wales Steve Morris (Huw Davis)
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1 MATERNAL COLLAPSE University Hospital of Wales Steve Morris (Huw Davis)
2 Thought for the day The real troubles in your life are apt to be things that never crossed your worried mind; the kind that blindside you at 4pm on some idle Tuesday Baz Luhrmann: Everybody s free (to wear sunscreen) 99
3 The Elective Section 36 year old term breech pregnancy 1 previous elective LSCS (breech) Uneventful spinal anaesthetic Good block in 5 minutes Difficult breech extraction Significant fundal pressure by assistant Patient began coughing Reassured Baby boy delivered, cried Shown to parents
4 After delivery No response from mother Eyes rolled back, focal seizure of left arm Face drained of colour Loss of pulse oximetry trace ECG unchanged
5 T=0 Facemask 100% O2 Tracheal intubation Minimal CO2 on Capnograph Barely palpable carotid pulse x3 boluses 100mcg Adrenaline ECM commenced Return of circulation following approximately 20 compressions Arterial line inserted
6 T=15 Peripheral and central cyanosis Chest and face purple and mottled Manual IPPV No improvement in colour Systolic BP >100mmHg CVP line under U/S guidance Level 1 Noradrenaline started
7 ABG ph 7.28 pco2 6.7kPa po2 8.8kPa HCO BE -4.0 SaO2 89.9%
8 Differential diagnoses Massive embolus Air Thrombus Amniotic fluid Total spinal Anaphylaxis (no antibiotics yet) Haemorrhagic shock Myocardial infarction Drug toxicity/error
9 Differential diagnoses 2 Eclampsia Uterine rupture Peripartum cardiomyopathy Aortic dissection Sepsis Arrhythmia Transfusion reaction
10 T=30 Blood oozing from surgical site Surgeons described it as like Ribena 4 FFP and 4 Blood ordered and given Tranexamic acid Atonic uterus Syntocinon infusion Ergometrine 250mcg B Lynch sutures and Bakri baloon Carboprost 250mcg intramyometrially
11 T=40 EBL 3000mls 2 Consultant Haematologists arrive in theatre
12 Results Time 13 min PT s APTT s Fib g/l Hb 12.2 Plts 19
13 Differential diagnoses Massive embolus Air Thrombus Amniotic fluid Total spinal Anaphylaxis (no antibiotics yet) Haemorrhagic shock Myocardial infarction Drug toxicity/error
14 Results Time 13 min 1 hr PT APTT Fib g/l 0.5 <0.4 Hb Plts
15 T= 1hr 15mins Haematologist returns with 4g Fibrinogen concentrate Pulmonary oedema in ET tube PEEP increased to 10cmH20 60mg Furosemide 30 mins relative stability
16 Results Time 13 min 1 hr 2hr 15 PT APTT Fib g/l 0.5 < g 4g Hb Plts
17 T= 3hr 30mins CVP 15 4 mmhg Noradrenaline 2 10 mls/hr SBP mmhg HR bpm Blood coming from upper abdomen General surgeon called
18 Ruptured subcapsular hepatic haematoma
19 Results Time 13 min 1 hr 2hr 15 4hr 4hr 30 ICU PT APTT Fib g/l 0.5 < g 4g Hb Plts
20 Management 12 litre EBL 16 units Blood 20 units FFP 2 bags platelets 2g Tranexamic acid 2 litres colloid 2 litres crystalloid 8g Fibrinogen concentrate
21 Amniotic Fluid Embolism BJACEACCP 2007 Dedhia & Mushambi Misnomer: Anaphylactoid reaction of pregnancy? Clark 1995
22 Fibrinogen First isolated from horse plasma 1876: Hammarsten Existence proposed 1859: Deni de Commercy Transformation: soluble monomer to insoluble polymer gel Cleaved by Thrombin Polymerised by FXllla
23 Declaration I am not a Haematologist Extrinsic and Intrinsic pathways redefined Tissue factor pathway (FVlla/TF and Fxa/Va complexes) Propagation phase (FXla, FlXa/Fvllla & Fxa/Va) Operates on platelet surface Generates a thrombin burst
24 Initiation
25 Amplification
26 Propagation
27 Clot formation
28 Fibrinogen Essentially a substrate Linear dose-response g/l normal in non-pregnant Pregnancy First trimester g/l Second trimester g/l Third trimester g/l FFP from non-pregnant donors 2.5 g/l = 2.5 mg/ml Cryoprecipitate mg/15ml = mg/ml Fibrinogen concentrate 1g made up in 50ml = 20 mg/ml
29 Fibrinogen Concentrated protein Pooled donors Virus inactivation pasteurised 30 month shelf life Licensed for congenital hypofibrinogenaemia Licensed for acquired hypofib in Europe, not UK Rapid correction of hypofib Sparing of volume Reduction in RBC transfusion
30 The fat lady hadn t started Cardiovascular instability Echo confirmed R ventricular dysfunction Hypotension Hypoxia Increased inotropic support CTPA
31
32 CTPA there are filling defects in the central and segmental pulmonary arteries in keeping with known amniotic emboli
33
34 Results Time 13 min 1 hr 2hr 15 4hr 4hr 30 ICU mane PT APTT Fib g/l 0.5 < g 4g Hb Plts
35 Final result Anticoagulated on unfractionated heparin infusion Returned to theatre for removal of packs Discharged home on day 15
36 Discussion Would she have survived a night-time arrest? 3 consultant anaesthetists 2 consultant haematologists 3 consultant obstetricians 1 consultant general surgeon Would she have survived without Fibrinogen concentrate?
37
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