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

Clinical Features

Differential Diagnosis

BEAT CHOPS

Evaluation

  • Clinical

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[3]
    • 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[4]

Disposition

  • Admit (if ROSC obtained)

See Also

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