1. Ojaghi Haghighi MD

2. It’s 3:00 AM now and you are very tired after an exhausting shift Suddenly a pregnant patient is transferred in to ED by EMTs You evaluate the patient quickly you are shocked, the patient is unresponsive without any respiratory effort

3. So What are you going to do?

5. Perspective overall maternal mortality rate: 13.95 deaths per 100 000 maternities 1 Cardiac arrest in pregnancy: 1:20 000 in 2007 1:30 000 in 2002 2 Survival Rate: 6.9% (poorer than others) 3 1 Lewis G, ed. The Confidential Enquiry into Maternal and Child Health(CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer—2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH. 2007. 2 Department of Health, Welsh Office, Scottish Office Department of Health, Department of Health and Social Services, Northern Ireland. Why mothers die. Report on confidential enquiries into maternal deathsin the United Kingdom 2000–2002. London (UK): The Stationery Office; 2004. 3 Dijkman A, Huisman CM, Smit M, Schutte JM, Zwart JJ, vanRoosmalen JJ, Oepkes D. Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training? BJOG. 2010;117:282–287.

6. Ethiology Cardiac disease * : Acute MI Aortic dissection Congenital Heart Disease & Pulmonary HTN Mg toxicity Preeclampsia/ Eclampsia PTE Amniotic fluid embolism Anesthetic complications * Lewis G, ed. The Confidential Enquiry into Maternal and Child Health(CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer—2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH. 2007.

7. Critical elements when you face with critically ill pregnant patients You faced with two patient Best hope of fetal survival is maternal survival Pregnancy caused physiologic changes Identify critical patients and try to prevent cardiac arrest

8. How can we prevent the doom event? Place the patient in the full left-lateral position Give 100% oxygen IV access above the diaphragm Assess for hypotension Consider reversible cause of critical illness

9. But we can’t prevent cardiac arrest every time So You must start CPR immediately

11. Call for Help Activate maternal cardiac arrest team immediately Do not forget documentation event onset time

13. CAB Sequence

14. Patient positioning??? Place patient in supine position!! With manual Lt uterine displacement for obviously gravid uterus

16. Start chest compression immediately with high quality 30:2 Place hands slightly higher on the sternum Assess quality with waveform capnography If your try is unsuccessful Place patient in Lt lateral tilt position 27-30 degree

19. But if chest compression remain inadequate? Consider immediate emergency C/S

20. Airway You face with: Potentially difficult airway Increased risk of aspiration Rapid desaturation This is critical to use: BMV and suctioning optimally Prepare for advanced airway management

22. Breathing The facts: Rapid hypoxemia ↓FRC and ↑O 2 Demand ↑ Intrapulmonary shunt ↓ Ventilation volumes Elevated diaphragm Support Oxygenation/ Ventilation Monitor SPO 2 Closely But How?

23. Do not forget: You should look for visible chest rise

25. Defibrillation The Facts: It is safe Concern about arcing around external & internal fetal monitors?? There is no evidence But reasonable to remove them Defibrillation dose?? An AED * should be apply as soon as possible * Automated external defibrillator

28. Do Not Forget!! BLS is cornerstone of ACLS All activities(CAB) should keep on What’s your Idea about ABCD of ACLS??

29. Airway You faced with an difficult airway, Why?? You should insert an advanced airway Experienced provider

30. Breathing Ventilation with O 2 100% What is Compression/Ventilation ratio? 100 Compressions/ min / 8-10 breathes/min without synchronization Do avoid hyperventilation plz!!! Continuous pulseoximetry Continuous wave capnography

31. Circulation Large bore IV lines Drugs?? According to ACLS recommendations Defibrillation? According to ACLS protocol

32. So what’s D?? Differential Dx Recall: Hs & Ts BEAU-CHOPS

33. Hypovolemia Hypoxia Hydrogen ion Hypo/Hyperkalemia Hypothermia Toxin Tamponade T.P Thrombosis (coronary or pulmonary)

34. BEAU-CHOPS Bleeding Embolism: Pulmonary Amniotic fluid Anesthetic Complication Uterine Atony Cardiac disease HTN: Preeclampsia Eclampsia Other: Mg toxicity Placenta abruptio/previa Sepsis

35. 4 min after cardiac arrest ROSC * has not been achieved So what’s are you going to do? * Return of spontaneous circulation

36. Perimortem C/S

37. Decision to C/S Performance?? Facts: The primary importance is mother life Aortocaval compression by gravid uterus?? Fetal viability No ROSC after 4 min of cardiac arrest Despite good BLS & ACLS an correction of reversible causes Unsuccessful chest compression Obvious nonsurvivable mother injury with viable fetus

38. So this is called Emergency C/S Do not forget continuing BLS & ACLS before and after Emergency C/S

39. How? Activation of emergency C/S team at the onset of arrest If there is an obvious gravid uterus Emergency C/S may be considered at 4 min: If there is no ROSC Goal: The actual delivery takes no longer 5 min This needs institutional preparation with multidisciplinary approach

41. Intensive care Correction of causes Therapeutic hypothermia??

44. THANKS