(Based on RCOG, ACOG, WHO and Bangladesh National Guidelines)
Definition
Maternal collapse is the acute loss of consciousness with absence of effective circulation in pregnancy or within 6 weeks postpartum, requiring immediate resuscitation.
Common Causes
Remember the 4Hs & 4Ts
- Cardiac: Myocardial infarction, arrhythmia, cardiomyopathy, congenital heart disease, cardiac arrest.
- Respiratory: Massive pulmonary embolism (PE), amniotic fluid embolism (AFE), severe asthma, anaphylaxis, aspiration.
- Hemorrhage: Antepartum or postpartum hemorrhage (PPH), uterine rupture, trauma.
- Hypertensive: Severe pre-eclampsia/eclampsia, intracranial bleed, stroke.
- Sepsis: Chorioamnionitis, puerperal sepsis.
- Metabolic: Hypoglycemia, electrolyte disturbance.
- Others: Trauma, anesthesia-related events.
Initial Response (First Responder)
A–E approach with maternal–fetal considerations
- Call for Help → Activate Maternal Emergency Team.
- Alert senior obstetrician, anesthetist, neonatologist, ICU.
- Inform blood bank.
- Airway → Maintain airway patency; insert airway if needed.
- Give 100% oxygen via face mask.
- Consider early intubation by skilled anesthetist.
- Breathing → Assess chest rise, SpO₂, respiratory rate.
- Bag–mask ventilation if inadequate.
- Rule out aspiration, bronchospasm, PE, AFE.
- Circulation
- Check pulse, BP, ECG, establish IV access (2 large-bore).
- Start IV fluids (crystalloids).
- Send blood: FBC, group & cross-match, coagulation, ABG, electrolytes.
- Control hemorrhage: bimanual compression, uterotonics, balloon tamponade.
- If shock → follow WHO maternal near-miss emergency protocol.
- Disability → Check GCS, pupils, seizure activity.
- If eclampsia → IV Magnesium sulfate.
- Exposure → Look for bleeding, trauma, rash, uterine rupture.
- Keep patient warm (blankets/warmer).
Cardiac Arrest in Pregnancy
- Start CPR immediately: high-quality chest compressions (100–120/min, depth 5 cm).
- Hand position slightly higher on sternum.
- 30:2 compression–ventilation ratio if no advanced airway.
- Manual left uterine displacement (LUD) if uterus >20 weeks.
- Avoid supine hypotension.
- Defibrillation: Use standard energy (no change for pregnancy).
- Drugs: Standard adult doses (adrenaline, amiodarone).
Perimortem Cesarean Section (PMCS)
Indication: Maternal cardiac arrest, uterus >20 weeks, no ROSC within 4 minutes.
Action:
- Perform resuscitative hysterotomy by 5 minutes.
- Aim: Improve maternal venous return & fetal survival.
- Location: Do not transfer; perform at site of arrest.
Definitive Management Based on Cause
- PPH: Uterotonics (oxytocin, misoprostol, ergometrine, tranexamic acid), balloon tamponade, B-Lynch, hysterectomy.
- Eclampsia/HTN: IV MgSO₄, antihypertensives, stabilize BP.
- Sepsis: IV broad-spectrum antibiotics, fluids, source control.
- Anaphylaxis: IM Adrenaline, airway support, fluids, antihistamine, steroids.
- PE/AFE: Supportive care, anticoagulation (PE), ECMO (where available).
- MI/Arrhythmia: ACLS protocols, cardiology input.
Team Roles in Bangladesh Context
- Team Leader: Senior obstetrician/anesthetist.
- Airway & Breathing: Anaesthetist.
- Circulation & IV Access: Obstetric SHO/nurse.
- Monitoring & Documentation: Midwife/nurse.
- Neonatal Resuscitation: Pediatrician.
- Blood & OT Arrangement: Junior doctor/nurse.
Post-Resuscitation Care
- Transfer to ICU/HDU.
- Monitor vitals, urine output, ABG, electrolytes.
- Provide psychological support and family counseling.
- Debrief team for clinical learning.
References
- RCOG Green-top Guideline No. 56: Maternal Collapse (2022).
- ACOG Committee Opinion: Cardiopulmonary Resuscitation in Pregnancy.
- WHO Maternal Near-Miss Approach (2019).
- Bangladesh National Guidelines on Maternal Health (DGHS, updated 2022).
Compiled By:
Dr. Polly Ahmed
Dr. Sumaiya Binte Asif
Contributors
- Prof Fawzia Hossain
- Prof KH Shahnewaz
- Prof Firoza Begum
- Dr Arifa Sharmin Maya
- Dr Runa Akter Dola
- Dr Taslima Akter
- Dr Maniza
- Dr Tamanna
- Dr Mahamoda Sultana
- Dr Maskura Jahan
- Dr Nipa Ghosh
- Dr Syeda Farhana Islam
- Dr Jinat Fatema
- Dr Syeda Ummay Kulsum
- Dr Nigar Sultana Lia