MANAGEMENT OF CARDIAC ARREST IN PREGNANCY MODERATOR – DR. CHANDRIKA ASSOCIATE PROFESSOR DEPT. OF EMERGENCY MEDICINE RESOURCE : DEPT. OF EMEERGENCY MEDICINE

Reason for this workshop

overview Introduction Adult cardiac arrest algorithm Cardiac arrest algorithm specific to pregnancy Modifications in ACLS and BLS Perimortem caesarean section Complications of CPR Post cardiac arrest care Key interventions to prevent arrest overview

INTRODUCTION Cardiac arrest in preganacy is 1 IN 12000 as per 2015 AHA statement. Maternal near miss --- a woman who nearly died but survived a complication ---incidence 1 in 143. rate of survival to hospital discharge after maternal cardiac arrest may be as high as 58.9%,1 far higher than most arrest populations 2 potential patients: the mother and the fetus. The best hope of fetal survival is maternal survival.

Etiology Hemorrhage Cardiovascular diseases (including myocardial infarction, aortic dissection, and myocarditis) Amniotic fluid embolism Sepsis Aspiration pneumonitis PE and Eclampsia

Iatrogenic causes Hypermagnesemia from magnesium sulfate administration and Anesthetic complications

SUGGESTED COMPOSITION OF THE MATERNAL CARDIAC ARREST TEAM Adult resuscitation team Obstetrics: one obstetrician, one midwife or a nurse Anaesthesia : obstetrical anaesthesiologist if available, or staff anaesthesiologist, anaesthesia assistant if available Emergency physician Neonatology team: one nurse, one physician, one neonatal respiratory therapist

EQUIPMENT NEEDED FOR THE RESUSCITATION

THE CPR TEAM

7 Step method to save a life…! What can we do…. 7 Step method to save a life…! 1. SCENE SAFETY 2. CHECK RESPONSE 3. SHOUT FOR HELP 4. OPEN AIRWAY 5. CHECK PULSE & BREATHING 6. 30 CHEST COMPRESSIONS 7. 2 RESCUE BREATHS

Left uterine displacement using 1-handed technique Left uterine displacement with 2-handed technique Left uterine displacement using 1-handed technique

Patient in a 30° left-lateral tilt using a firm wedge to support pelvis and thorax

Airway optimal use of bag-mask ventilation and suctioning, while preparing for advanced airway placement is critical Breathing Ventilation volumes may need to be reduced because the mother’s diaphragm is elevated Providers should be prepared to support oxygenation and ventilation and monitor oxygen saturation closely

Circulation- Before approximately 22 to 24 weeks' gestation, all efforts should focus on the mother, with no modifications to CPR Beyond 22 weeks or if the gravid uterus can be palpated above the umbilicus, several modifications of CPR should be instituted: (1) the patient should be positioned to minimize aortocaval compression, and (2) appropriate preparations for a potential cesarean section and care of a viable fetus should be made Defibrillation-Use of an AED on a pregnant victim has not been studied but is reasonable

SEQUENCE FOR CPR IN PREGNANT PATIENTS Intubate early, protect vulnerable airway, supply oxygen Tilt the patient, limit aortocavalcompression Obtain rapid IV access, avoid the femoral and saphenous veins Follow current ACLS recommendations Perimortem cesarean section within 5 min of maternal arrest if fetus >20 wk explore differential diagnosis, include iatrogenic causes (e.g., spinal analgesia) Consider cardiopulmonary bypass(amniotic fluid embolism)

ROLE OF PERIMORTEM CESEAREAN SECTION WHY? WHERE? WHEN? HOW? WHO ? BENEFITS RISKS THROUGH OUT THE PROCEDURE MAINTAIN LUD AND CONTINUE CPR.

Perimortem caesarean

IMPENDING VAGINAL DELIVERY COMPLETED USING INSTRUMENTAL DELIVERY.

Complications from CPR Maternal problems secondary to CPR and ACLS include liver lacerations, uterine rupture, hemothorax, and hemopericardium Fetal complications include cardiac dysrhythmias from maternal defibrillation and ACLS drugs, central nervous system toxicity from ACLS drugs, and altered uteroplacental blood flow from maternal hypoxia, acidosis, and vasoconstriction

Post–Cardiac Arrest Care One case report showed that post–cardiac arrest hypothermia can be used safely and effectively in early pregnancy without emergency cesarean section No cases in the literature have reported the use of therapeutic hypothermia with perimortem cesarean section Therapeutic hypothermia may be considered on an individual basis after cardiac arrest in a comatose pregnant patient based on current recommendations for the non-pregnant patient During therapeutic hypothermia of the pregnant patient, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication

INSTITUTIONAL PREPAREDNESS FOR MATERNAL CARDIAC ARREST Providers at medical centers must review whether performance of an emergency hysterotomy is feasible, and if so, they must identify the best means of accomplishing this procedure rapidly. Team planning should be done in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services.

AHA Recommendations Code team members with responsibility for pregnant women should be familiar with the physiological changes of pregnancy that affect resuscitation technique and potential complications . Pregnant women who become ill should be risk stratified by the use of a validated obstetric early warning score . Hospital units with a pregnant woman in their care should ensure that proper pre-event planning has been instituted, including preparation for maternal cardiac arrest and neonatal resuscitation

Recent updates

KEY INTERVENTIONS TO PREVENT ARREST Full left-lateral position to relieve possible compression of the inferior vena cava Give 100% oxygen Establish intravenous (IV) access above the diaphragm Assess for hypotension Consider reversible causes of critical illness and Treat conditions that may contribute to clinical deterioration as early as possible. Perimortem ceaserean should be intiated by 4th min and delivery of fetus by 5th min of resuscitation.

TAKE HOME MESSAGE ANTICIPATE CARDIAC ARREST IN PREGNANCY WITH COMPLICATIONS PREPAREDNESS IN LABOUR ROOM/ ICU/ ER/ WARD. TEAM EFFORT ---RIGHT COMMUNICATION AND COORDINATION ALL OBSTETRICIANS SHOULD BE TRAINED IN RESUSCITATION AND PERIMORTEM CS.

MATERNAL RESUSCITATION IS THE BEST FETAL RESUSCITATION

Thank you