Medical Minute: Resuscitation in Pregnancy

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July 10, 2014 by dailybolusoflr

By Erik Verzemnieks, MD
Cardiac arrest in pregnancy is rare, occurring in estimated 1/30,000 deliveries.
Maternal physiology and body habitus have changed that make standard resuscitation difficult:
– Increased circulating blood volume
– Higher minute ventilation
– Increased oxygen consumption
– Anatomical compression iliac vessels in supine position
Common Causes Associated with Maternal Cardiac Arrest
– Cardiac disease
– Pulmonary embolism
– Psychiatric disorders
– Hypertensive disorders of pregnancy
– Sepsis
– Hemorrhage;
– Amniotic-fluid embolism
– Ectopic pregnancy

Special considerations:

Airway:
Upper airway frequently narrowed compared to non-pregnant women from edema:
            – Downsize ETT 0.5-1.0 mm

Breathing:
Higher metabolic demands means increased oxygen requirements. However, titrate oxygen down from high flow based on pulse oximetry, if obtainable.

Circulation:
Gravid uterus begins to compromise aortocaval blood flow at 20 weeks gestation.   Prior to this, efforts to displace it are unlikely to be necessary.
            – Displace uterus if > 20 weeks: gentle manual deflection to left should be undertaken by assigned participant. This will allow patient to remain in supine position and more effective cardiac compressions to be delivered. (Evidence suggests this is as if not more effective than alternative measures)
– Alternative can be left-lateral decubitus positioning.  Need at least 30° tilt for effective decompression.
– STRONGLY consider perimortem cesarean deliveryfor absolute decompression of uterus in any gestation > 20 weeks. Even if the fetus is not viable, this is a procedure to save the mother as much as a the child. Viability begins at 24 weeks.
Other points of consideration:
– Alert obstetrical and neonatal colleagues early

– Have equipment available for both resuscitation of mother and delivered fetus

References:
  1. Resuscitation Council, U. K. “Resuscitation guidelines.” London: Resuscitation Council UK 65 (2010).
  2. Hoek, Terry L. Vanden, et al. “Part 12: Cardiac Arrest in Special Situations 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Circulation 122.18 suppl 3 (2010): S829-S861.
  3. Farida M. Jeejeebhoy and Laurie J. Morrison, “Maternal Cardiac Arrest: A Practical and Comprehensive Review,” Emergency Medicine International, 2013.

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