Resuscitation of the Pregnant Patient

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Resuscitation of the Pregnant Patient

• Ida Bruni
• February 6, 2008

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Key Points

• During resuscitation there are two patients,
  mother fetus
• The best hope of fetal survival is maternal
  survival
• Consider the physiologic changes due to pregnancy

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Interventions to Prevent Arrest

• To treat the critically ill pregnant patient
• Place the patient in the left lateral position
• Give 100 oxygen
• Establish IV access and give a fluid bolus
• Consider reversible causes of cardiac arrest and
  identify any preexisting medical conditions that
  may be complicating the resuscitation

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Resuscitation of the Pregnant Woman inCardiac
Arrest

• Modifications of Basic Life Support
• At gestational age of greater than 20 weeks, the
  pregnant uterus can press against the IVC
  aorta, impeding venous return and cardiac output
• Uterine obstruction of venous return can produce
  prearrest hypotension or shock and in the
  critically ill patient may precipitate arrest
• It also limits the effectiveness of chest
  compressions

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Modifications of Basic Life Support

• The gravid uterus may be shifted away from the
  IVC aorta by placing in LUD or by pulling the
  gravid uterus to the side
• This may be accomplished manually or by placement
  of a rolled blanket or other object under the
  right hip and lumbar area

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Modifications of Basic Life Support Airway

• Hormonal changes promote insufficiency of the
  gastroesophageal sphincter, increasing the risk
  of regurgitation.
• Apply continuous cricoid pressure during positive
  pressure ventilation for any unconscious pregnant
  woman

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Modifications of Basic Life Support Airway

• Secure the airway early in resuscitation
• Use an ETT 0.5 to 1 mm smaller in internal
  diameter than that used for a nonpregnant woman
  of similar size because the airway may be
  narrowed from edema

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Modifications of Basic Life Support Breathing

• Hypoxemia can develop rapidly because of
  decreased FRC increased O2 demand, so be
  prepared to support oxygenation ventilation
• Ventilation volumes may need to be reduced
  because the mothers diaphragm is elevated

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Modifications of Basic Life Support Circulation

• Perform chest compressions higher, slightly above
  the center of the sternum to adjust for the
  elevation of the diaphragm abdominal contents
• Vasopressor agents, including epinephrine
  vasopressin, will decrease blood flow to the
  uterus, but since there are no alternatives,
  indicated drugs should be used in recommended
  doses

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Modifications of Basic Life Support
Defibrillation

• Defibrillate using standard ACLS defibrillation
  doses
• There is no evidence that shocks from a direct
  current defibrillator have adverse effects on the
  heart of the fetus
• If fetal or uterine monitors are in place, remove
  them before delivering shocks

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Modifications of Basic Life Support Differential
Diagnoses

• Same reversible causes of cardiac arrest that
  occur in nonpregnant women can occur during
  pregnancy
• Providers should be familiar with pregnancy
  specific diseases procedural complications
• Use of abdominal US should be considered in
  detecting possible causes of the cardiac arrest,
  but this should not delay other treatments

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Modifications of Basic Life Support Differential
Diagnoses

• Excess magnesium sulfate
• Iatrogenic overdose is possible in women with
  eclampsia, particularly if the woman becomes
  oliguric
• Administration of calcium gluconate (1 amp/1 g)
  is the treatment of choice
• Empiric calcium administration may be lifesaving

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Modifications of Basic Life Support Differential
Diagnoses

• Acute coronary syndromes
• Pregnant women may experience ACS, typically in
  association with other medical conditions
• Because fibrinolytics are relatively
  contraindicated in pregnancy, PCI is the
  reperfusion strategy of choice for STEMI

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Modifications of Basic Life Support Differential
Diagnoses

• Pre-eclampsia/eclampsia
• Pre-eclampsia/eclampsia develops after the 20th
  week of gestation can produce severe HTN
  ultimate diffuse organ system failure
• If untreated it may result in maternal and fetal
  morbidity mortality

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Modifications of Basic Life Support Differential
Diagnoses

• Life-threatening PE stroke
• Successful use of fibrinolytics for a massive,
  life-threatening PE ischemic stroke have been
  reported in pregnant women

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Modifications of Basic Life Support Differential
Diagnoses

• Trauma and drug overdose
• Pregnant women are not exempt from the accidents
  mental illnesses
• Domestic violence also increases during
  pregnancy homicide suicide are leading causes
  of mortality during pregnancy

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Modifications of Basic Life Support Differential
Diagnoses

• Aortic dissection
• Pregnant women are at increased risk for
  spontaneous aortic dissection

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Alberta woman fine after giving birth during
emergency heart surgeryEdmonton, Alberta

• Surgery was done Jan. 24, hours after the 35 week
  primip complained of SOB Echo showed a thoracic
  aneurysm
• Cardiac Sx opened chest and monitored mothers
  heart while the Obstetrical team delivered the
  baby
• After the obstetrics team delivered the child,
  Cardiac Sx completed the aorta graft
• It was the first such procedure carried out in
  the region and only one of a handful done around
  the world

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Emergency Cesarean Delivery forthe Pregnant
Woman in Cardiac Arrest

• CPR leader should consider the need for an ER
  cesarean delivery as soon as a pregnant woman
  develops cardiac arrest
• The best survival rate for infants 24-25 weeks in
  gestation occurs when the delivery of the infant
  occurs no more than 5 minutes after the mothers
  heart stops beating
• This typically requires that the provider begin
  the delivery about 4 minutes after cardiac arrest

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Emergency Cesarean Delivery forthe Pregnant
Woman in Cardiac Arrest

• Delivery of the baby empties the uterus,
  relieving both the venous obstruction and the
  aortic compression
• Delivery also allows access to the infant so that
  newborn resuscitation can begin
• It is important to remember that you will lose
  both mother infant if you cannot restore blood
  flow to the mothers heart

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Decision Making for Emergency Cesarean Delivery

• Consider gestational age
• Although the gravid uterus reaches a size that
  will begin to compromise aortocaval blood flow at
  approximately 20 weeks of gestation, fetal
  viability begins at approximately 24 to 25 weeks
• Portable US, may aid in determination of
  gestational age positioning, but the use of US
  should not delay the decision to perform delivery

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Decision Making for Emergency Cesarean Delivery

• Gestational age less than 20 weeks
• Need not be considered because this size gravid
  uterus is unlikely to significantly compromise
  maternal cardiac output
• Gestational age approximately 20 to 23 weeks
• Perform to enable successful resuscitation of the
  mother, not the survival of the delivered infant,
  which is unlikely at this gestational age
• Gestational age greater than 24 weeks
• Perform to save the life of both the mother
  infant

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Decision Making for Emergency Cesarean Delivery

• The following can increase the infants
  survival
• Short interval between the mothers arrest the
  infants delivery
• No sustained prearrest hypoxia in the mother
• Minimal or no signs of fetal distress before the
  mothers cardiac arrest
• Aggressive effective resuscitative efforts for
  the mother
• Delivery to be performed in a medical center with
  a NICU

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Decision Making for Emergency Cesarean Delivery

• Consider the professional setting
• Are appropriate equipment and supplies available?
• Is emergency hysterotomy within the rescuers
  procedural range of experience skills?
• Are skilled neonatal support personnel available
  to care for the infant, especially if the infant
  is not full term?
• Are obstetric personnel immediately available to
  support the mother after delivery?

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Summary

• Successful resuscitation of a pregnant woman
  survival of the fetus require prompt excellent
  CPR with some modifications in techniques
• By the 20th week of gestation, the gravid uterus
  can compress the IVC aorta, obstructing venous
  return arterial blood flow
• Rescuers can relieve this compression by
  positioning the woman on her side or by pulling
  the gravid uterus to the side

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Summary

• Defibrillation medication doses used for
  resuscitation of the pregnant woman are the same
  as those used for other adults
• Rescuers should consider the need for ER
  Caesarian Delivery as soon as the pregnant woman
  develops cardiac arrest
• Rescuers should be prepared to proceed if the
  resuscitation is not successful within 4 minutes

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Reference

• Cardiac Arrest Associated With Pregnancy.
  Circulation 2005112IV-150-IV-153 2005.
  American Heart Association