Cardiac arrest in pregnancy: Difference between revisions

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==Background==
==Background==
*Key differences from AHA ACLS for non-maternal cardiac arrest
*Occurs in ~1 in 30,000 pregnancies<ref>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.</ref>
**If no ROSC by 4 min of resuscitation, perform immediate [[perimortem cesarean delivery]]
*Key differences from non-pregnant cardiac arrest<ref>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.</ref>:
**Goal of delivery within 5 min of starting resuscitation (1 minute to deliver)
**Need to remove uterus from IVC (by rolling patient to side or manual lifting of uterus)
*DDx - '''BEAT CHOPS'''
***Do not obtain venous access below the diaphragm
**Bleeding / DIC
**Secure airway immediately
**Embolism - coronary, pulmonary, amniotic fluid
**Non-cardiac cause of arrest is more likely
**Anesthetic complications
**[[Resuscitative hysterotomy]] should be performed rapidly (within 4 minutes), and may save both fetus and mother
**Tone (uTerine aTony)
**Cardiac disease - MI, aortic dissection, cardiomyopathy
**HTN, preeclampsia, eclampsia
**Other - all typical H's and T's
**Placental abruption, placental previa
**Sepsis


==Interventions==
==Clinical Features==
*In keeping with regular ACLS algorithms
*[[Cardiac arrest|Cardiopulmonary arrest]] in gravid female.
**Early defibrillation, same energy dosages; safe for fetus in maternal arrest
 
**Give typical adult ACLS drugs/dosages
==Differential Diagnosis==
**Ventilate with 100% FiO2
===Cardiac Arrest in Pregnancy===
''BEAT CHOPS''
*[[hemorrhage|'''B'''leeding]] / [[DIC]]
*'''E'''mbolism - coronary, [[PE|pulmonary]], [[amniotic fluid embolus|amniotic fluid]]
*'''A'''nesthetic complications
*'''T'''one (uTerine aTony)
*'''C'''ardiac disease - [[MI]], [[aortic dissection]], [[peripartum cardiomyopathy|cardiomyopathy]]
*[[hypertensive emergency|'''H'''ypertension]], [[preeclampsia]], [[eclampsia]]
*'''O'''ther - all typical H's and T's
**[[Hypovolemia]]
**[[Hypoxemia]]
**Hydrogen ion (i.e. [[acidosis|acidemia]])
**[[Hypokalemia|Hypo]]/[[hyperkalemia]]
**[[Hypothermia]]
**[[Tension Pneumothorax]]
**[[Pericardial effusion and tamponade|Cardiac tamponade]]
**[[Toxicology (main)|Toxins]]
**[[Pulmonary embolism|Thrombosis, pulmonary]]
**[[Acute coronary syndrome (main)|Thrombosis, coronary]]
*[[Placental abruption|'''P'''lacental abruption]], [[placenta previa]]
*[[Sepsis|'''S'''epsis]]
 
==Evaluation==
[[File:Bumm 123 lg - Copy.jpg|thumb|Estimated gestational age based on physical exam.]]
*Clinical
 
{{Fundal height in pregnancy}}
 
==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
**Monitor EtCO2
**Ensure post-cardiac arrest care  
**Ensure [[post cardiac arrest]] care  


==Maternal Modifications==
===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
*Manual left uterine displacement
**Displaces uterus to pt's left, relieving aortocaval compression
**Displaces uterus to patient's left, relieving aortocaval compression
**May be of concern even if < 20 wks
**May be of concern even if < 20 wks
**Put hands on left side of gravid abdomen, and '''pull upwards towards ceiling''' and '''leftwards'''
**Put hands on right side of gravid abdomen, and '''pull upwards towards ceiling''' and '''leftwards'''
**'''OR''' tilt patient 15–30° to left<ref>Campbell TA and Sanson TG. Cardiac arrest and pregnancy. J Emerg Trauma Shock. 2009 Jan-Apr; 2(1): 34–42.</ref>
**Downward force will worse IVC compression
**Downward force will worse IVC compression
*IVs above diaphragm - avoids IVC which may be compressed
*IVs above diaphragm - avoids IVC which may be compressed
*Administer fluids and blood products
*Administer [[IVF|fluids]] and [[pRBCs|blood]] products
*Anticipate difficult airway with high risk of aspiration
*Anticipate [[difficult airway]] with high risk of aspiration
*If pt receiving IV magnesium prearrest, stop mag and give arrest dose calcium
*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
*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<ref>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.</ref>
 
==Disposition==
*Admit (if [[ROSC]] obtained)
 
==See Also==
*[[Pregnancy (main)]]
*[[Perimortem cesarean delivery]]
 
==External Links==
*https://first10em.com/cardiac-arrest-in-pregnancy-the-perimortem-cesarean-section/


==References==
==References==
*Lipman et Al. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Management of Cardiac Arrest in Pregnancy. Anesth Analg 2014;118:1003–16.
<References/>
 
[[Category:Critical Care]]
[[Category:OBGYN]]

Latest revision as of 20:30, 3 August 2022

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

Clinical Features

Differential Diagnosis

Cardiac Arrest in Pregnancy

BEAT CHOPS

Evaluation

Estimated gestational age based on physical exam.
  • 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

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

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ Campbell TA and Sanson TG. Cardiac arrest and pregnancy. J Emerg Trauma Shock. 2009 Jan-Apr; 2(1): 34–42.
  5. ↑ 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.
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