Cardiac arrest in pregnancy
Background
- Occurs in ~1 in 30,000 pregnancies[1]
- Key differences from non-pregnant cardiac arrest[2]:
- Need to remove uterus from IVC (by rolling patient to side or manual lifting of uterus)
- Do not obtain venous access below the diaphragm
- Secure airway immediately
- Non-cardiac cause of arrest is more likely
- Resuscitative hysterotomy should be performed rapidly (within 4 minutes), and may save both fetus and mother
- Need to remove uterus from IVC (by rolling patient to side or manual lifting of uterus)
Clinical Features
- Cardiopulmonary arrest in gravid female.
Differential Diagnosis
Cardiac Arrest in Pregnancy
BEAT CHOPS
- Bleeding / DIC
- Embolism - coronary, pulmonary, amniotic fluid
- Anesthetic complications
- Tone (uTerine aTony)
- Cardiac disease - MI, aortic dissection, cardiomyopathy
- Hypertension, preeclampsia, eclampsia
- Other - all typical H's and T's
- Placental abruption, placenta previa
- Sepsis
Evaluation
- Clinical
Estimated Gestational Age by Fundal Height[3]
| Weeks | Fundal Height / Finding |
| 12 | Pubic symphysis |
| 20 | Umbilicus |
| 20-32 | Height (cm) above symphysis = gestational age (weeks) |
| 36 | Xiphoid process |
| >37 | Regression |
| Post delivery | Umbilicus |
Management
- Standard ACLS management
- Early defibrillation - use standard energy levels (safe for fetus in maternal arrest)
- Anterior/Posterior pad placement is preferred
- May use AP pads to pace as well
- Give typical adult ACLS drugs/dosages
- Airway management / Ventilate with 100% FiO2
- Monitor EtCO2
- Ensure post cardiac arrest care
- Early defibrillation - use standard energy levels (safe for fetus in maternal arrest)
Maternal Modifications
- Resuscitative hysterotomy (aka perimortem c-section) if estimated gestational age >24wks (fundus >~4cm above umbilicus)
- Must make decision early, <4min without ROSC
- Manual left uterine displacement
- Displaces uterus to patient's left, relieving aortocaval compression
- May be of concern even if < 20 wks
- Put hands on right side of gravid abdomen, and pull upwards towards ceiling and leftwards
- OR tilt patient 15–30° to left[4]
- Downward force will worse IVC compression
- IVs above diaphragm - avoids IVC which may be compressed
- Administer fluids and blood products
- Anticipate difficult airway with high risk of aspiration
- If patient receiving IV magnesium prearrest, stop mag and give arrest dose calcium
- Continue CPR, positioning, de-fib, drugs, and fluids during and after C-section
- Therapeutic hypothermia contraindicated if patient still intrapartum, but may be safe for postpartum cardiac arrest[5]
Disposition
- Admit (if ROSC obtained)
See Also
External Links
References
- ↑ McDonnell, NJ. Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem Caesarean delivery. Br J Anaesth. (2009)103(3):406-409.
- ↑ Engels PT, Caddy SC, Jiwa G, Douglas Matheson J. Cardiac arrest in pregnancy and perimortem cesarean delivery: case report and discussion. CJEM. 2011 Nov;13(6):399-403.
- ↑ Vasquez V, Desai S. Labor and delivery and their complications. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:2296–2312.
- ↑ Campbell TA and Sanson TG. Cardiac arrest and pregnancy. J Emerg Trauma Shock. 2009 Jan-Apr; 2(1): 34–42.
- ↑ Song et al. Safely completed therapeutic hypothermia in postpartum cardiac arrest survivors. Am Jour Emer Med. June 2015. Volume 33, Issue 6, Pages 861.e5–861.e6.