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

2. Reason for this workshop

3. 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

4. INTRODUCTION
Cardiac arrest in preganacy is 1 IN 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.

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

6. Iatrogenic causes
Hypermagnesemia from magnesium sulfate administration and
Anesthetic complications

8. 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

9. EQUIPMENT NEEDED FOR THE RESUSCITATION

10. THE CPR TEAM

11. 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
CHEST COMPRESSIONS
RESCUE BREATHS

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

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

21. 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

22. 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

23. 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)

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

25. Perimortem caesarean

26. IMPENDING VAGINAL DELIVERY COMPLETED USING INSTRUMENTAL DELIVERY.

27. 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

28. 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

30. 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.

31. 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

33. Recent updates

34. 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.

35. 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.

36. MATERNAL RESUSCITATION IS THE BEST FETAL RESUSCITATION

37. Thank you