PREGNANCY AND CARDIOPULMONARY ARREST

12 Jun

A bit of literature:

J.Soar et al, Resuscitation 81(2010)1400-1433

Resuscitation guidelines for pregnancy largely based on case series, extrapolation, manikin studies and expert opinion.

Maternal death associated with:

–       cardiac disease

–       pulmonary embolism

–       psychiatric disorders

–       hypertensive disorders of pregnancy

–       sepsis

–       haemorrhage

–       amniotic-fluid embolism

–       ectopic pregnancy

–       or same causes as women of the same age group

Left lateral tilt (LLT):

–       After 20 wks of gestation the pregnant uterus can press down against the inferor vena cava and the aorta

–       Non arrest studies show  LLT improves maternal BP, CO en stroke volume and improves getal oxygenation and heart rate

–       Two studies found no improvement with 10-20 degrees LLT

–       One study found more aortic compression and 15 degrees compared wth full LLT

–       Aortic compression is found to persist >30 degrees

–       Two non arrest studies showed than manual displacement is as good as / better than LLT in relieving aortocaval compression

–       Non cardiac arrest data show that a shift away from the cava occurs in 15 degrees left lateral ecubitus position

–       The value of relieving aortic or caval compression during CPR is however unknown

BLS modifications:

–       Help includes an obstetrician and neonatologist

–       Standard guidelines CPR

–       Manually displace the uterus to the left

–       Add LLT 15-30 degrees if this is feasible. Optimal angle unknown. The angle needs to allow good quality chest compressions and if needed an Caesarean

–       Prepare for emergency Caesarean section

ALS modifications:

–       Early tracheal intubation because of the greater potential for aspiration and to make the ventilation easier.

–       Tube 0.5-1 mm smaller because of airway narrowing

–       Standard shock energies

Reversibe causes:

Haemorrhage

–       Postpartum single most common cause of maternal death wordlwide.

–       Ectopic pregnancy

–       Placental abruption

–       Placenta praevia

–       Placenta accreta

–       Uterine rupture

A massive haemorrhage protocol must be available.

Consider:

Fluid resuscitation, rapid transfusion system and cell salvage.

Oxytocin and prostaglandin analogues to correct uterine atony.

Massaging the uterus.

Correction of coagulopathy, including the use of tranexamic acid or recombinant activated factor VII.

Uterine balloon tamponade.

Uterine compression sutures.

Angiography and endovascular embolization.

Hysterectomy.

Aortic cross-clamping in catastrophic heamorrhage.

Cardiovascular disease

– Myocardial infarction. PCI in STEMI or even thrombolysis.

A review of 200 cases of thrombolysis for massive PE in pregnancy reported a maternal death rate of 1% and concluded that trombolytic therapy is reasonably safe in pregnancy. Ahearn, massive pe during pregnancy succesfully treated with RTPA, a case report and review of treatment options. Arch Intern Med 2002; 162:1221-7.

– Aneurysm of the aorta

– Dissection of the aorta or its branches

Pre-eclampsia and eclampsia

Eclampsia, the development of convulsions +/- coma.

Magnesium sulphate is effective in preventing approximately half of the cases of eclampsia developing in labour or immediately postpartum in women with pre-eclampsia.

Pulmonary embolism

Estimated incidence: 1-1.5/10.000 pregnancies, case fatality 3.5%. Succesful use of fibrinolytics for massive, life threatening PE has been reported.

Amniotic-fluid embolism

Presents around time of delivery with sudden cardiovascular collapse. Pts may have warning sign. Reported incidence 2/100.000 deliveries, case fatality 13-30%, perinatal mortality 9-44%. Supportive treatmentm AVBDE approach, no specific therapy, correction of coagulopathy. Succesfull use of extracorporeal life support techniques is reported.

If immediate resusciation attempts fail:

Consider the need fora n emergency hysterotomy or Caesarean section (SC) as soon as a pregnant woman goes into cardiac arrest.

The best survival rate for infants over 24-25 weeks gestation occurs when delivery of the infant is achieved within 5 min of the mother’s cardiac arrest.

At 30-38 weeks, infant survival is possible even when delivery was after 5 min from the onset of maternal cardiac arrest.

A case series suggests increased use of SC during CPR with team training. In this series no deliveries were achieved within 5 minutes, 8/12 women had ROSC after delivery. Maternal case fatality rate 83%, neonatal case fatality rate 58%. Dijkman, cardiac arrest in pregnancy: increasing use of perimortem sc duet o emergency skills raining? BJOG 2010:117:282-7.

Delivery will relieve caval compression and may improve chances of maternal resuscitation. It allso enables access to the infant, so that newborn resuscitation can begin.

Decicion making for emergency hysterotomy:

A gravid uterus begins at  20 weeks to compromise aortocaval blood flow.

Fetal viability begins at 24-25 weeks.

At gestational age < 20 weeks CS need not be considered.

20-23 weeks: SC to enable succesfull resuscitation of the mother, not survival of the delivered infant.

> 24-25 weeks: SC to save both lives.

Colleagues!

Want to share your massive haemorrhage protocol?

Please share what precautions (plans / equipment) your department has undertaken for the resuscitation of pregnant patients and the newborn.

Who has as EP regular training en obstetric emergencies?

I am going to search for evidence regarding thrombolytic therapy in pregnancy, especially during CPR, because in my mind I’m still not certain it’s a safe treatment. Who wants to join?

More articles will follow. This is it for today… Laura

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2 Responses to “PREGNANCY AND CARDIOPULMONARY ARREST”

  1. Eric June 12, 2013 at 22:36 #

    Thrombolysis in pregnancy remains a massive grey area, no good studies out there, I suppose in PEA arrest in >20weeks pregnancy with suspected DVT/PE that’s what you’ve got to offer, before the C-section or after, that’s a different issue. One way or another it will be messy

  2. dereksifford June 16, 2013 at 13:49 #

    Great post! Succinct and clear!

    What I’d like to see is evidence either supporting or negating the use of post arrest hypothermia in pregnancy. I did a small lit search some time ago and was only able to find case reports of positive outcomes- I’d like to explore more why the American Heart Association seems to classify this as a relative contraindication?

    Maybe I’m missing something- I’d love to hear your take on this!

    Derek

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