Maternal Cardiac Arrest

Cardiac Arrest Associated With Pregnancy

·         Maternal mortality rate 13.95 deaths per 100 000 maternities

·         There were 8 cardiac arrests with a frequency 1:20 000.

·         Most common causes of maternal death from cardiac disease are myocardial infarction, followed by aortic dissection

·         Providers have 2 potential patients: the mother and the fetus

·         Best hope of fetal survival is maternal survival

Key Interventions to Prevent Arrest

·         Place patient in the full left-lateral position

·         Give 100% oxygen.

·         Intravenous (IV) access above the diaphragm

·         Assess for hypotension

·         Maternal hypotension:  SBP <100 mm Hg or a decrease in 20% from baseline

Notes:

The pregnant uterus can compress the inferior vena cava, impeding venous return and thereby reducing stroke volume and cardiac output.

Left-lateral tilt results in improved maternal hemodynamics of blood pressure, cardiac output, and stroke volume, and improved fetal parameters of oxygenation, nonstress test, and fetal heart rate

Maternal hypotension can result in reduced placental perfusion

In the patient who is not in arrest, both crystalloid and colloid solutions have been shown to increase preload

Consider reversible causes of critical illness

 Circulation. 2010;122(suppl 3):S829–S861.

Patient Positioning

·         MD to attempt manual left uterine displacement

·         Chest compressions in the left-lateral tilt position left-lateral of 27° to 30°

·         Use a firm wedge to maintain lateral tilt and support the pelvis and thorax

Compressions

·         Chest compressions should be performed slightly higher on the sternum

·         Monitor compressions with waveform capnography

·         If chest compressions inadequate after lateral uterine displacement or left-lateral tilt, immediate emergency cesarean section should be considered

Defibrillation/cardioversion

·         Defibrillation should be performed at the recommended ACLS defibrillation doses

·         Cardioversion and defibrillation on the external chest are considered safe at all stages of pregnancy

·         No reported fetal effects to fetal death either immediately or a few days after the shock

·         Small risk of inducing fetal arrhythmias

·         If internal or external fetal monitors are attached during cardiac arrest in a pregnant woman, it is reasonable to remove them

·         The most common causes of maternal death from cardiac disease are myocardial infarction, followed by aortic dissection

·         Because fibrinolytics are relatively contraindicated in pregnancy, PCI is the reperfusion strategy of choice for ST-elevation myocardial infarction

Airway

·         Airway management more difficult during pregnancy

·         Changes in airway mucosa, including edema, friability, hypersecretion, and hyperemia

·         The upper airway in the third trimester of pregnancy is smaller

·         Decreased functional residual capacity

·         Increased oxygen demand

·         Increased intrapulmonary shunting

Medications

·         Give standard dose during maternal cardiac arrest

·         Intravenous (IV) access above the diaphragm

·         If patient receiving pre-arrest IV Magnesium infusion then stop the infusion and consider either calcium gluconate or calcium chloride

Emergency Cesarean Section in Cardiac Arrest

·         Several case reports of emergency cesarean section in maternal cardiac arrest indicate a return of spontaneous circulation or improvement

·         Critical point to remember is that both mother and infant may die if the provider cannot restore blood flow to the mother's heart

·         Consider emergency cesarean section if no response with 5 minutes of resuscitative efforts

Consider Contributing Factors (BEAU-CHOPS)

Bleeding

Embolism (pulmonary, coronary, amniotic fluid)

Anesthesia complications

Uterine atony

Cardiac disease

Hypertension (preeclampsia, eclampsia)

Other: Hs & Ts

Placentia abruption or previa

Sepsis

Reference

Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A. Part 12: cardiac arrest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(suppl 3):S829–S861