resuscitation of the pregnant patient

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    Resuscitation of the PregnantResuscitation of the Pregnant

    PatientPatient

    Ida BruniIda Bruni

    February 6, 2008February 6, 2008

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    Key PointsKey Points

    During resuscitation there are twoDuring resuscitation there are two

    patients, mother & fetuspatients, mother & fetus

    The best hope of fetal survival is maternalThe best hope of fetal survival is maternalsurvivalsurvival

    Consider the physiologic changes due toConsider the physiologic changes due to

    pregnancypregnancy

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    Interventions to Prevent ArrestInterventions to Prevent Arrest

    To treat the critically ill pregnant patient:To treat the critically ill pregnant patient:

    Place the patient in the left lateral positionPlace the patient in the left lateral position

    Give 100% oxygenGive 100% oxygenEstablish IV access and give a fluid bolusEstablish IV access and give a fluid bolus

    Consider reversible causes of cardiacConsider reversible causes of cardiac

    arrest and identify any preexisting medicalarrest and identify any preexisting medicalconditions that may be complicating theconditions that may be complicating the

    resuscitationresuscitation

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    Resuscitation of the Pregnant Woman inResuscitation of the Pregnant Woman in

    Cardiac ArrestCardiac Arrest

    Modifications of Basic Life SupportModifications of Basic Life Support

    At gestational age of greater than 20 weeks, theAt gestational age of greater than 20 weeks, thepregnant uterus can press against the IVC &pregnant uterus can press against the IVC &

    aorta, impeding venous return and cardiacaorta, impeding venous return and cardiacoutputoutput

    Uterine obstruction of venous return canUterine obstruction of venous return canproduce prearrest hypotension or shock and inproduce prearrest hypotension or shock and in

    the critically ill patient may precipitate arrestthe critically ill patient may precipitate arrestIt also limits the effectiveness of chestIt also limits the effectiveness of chestcompressionscompressions

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    Modifications of Basic Life SupportModifications of Basic Life Support

    The gravid uterus may be shifted awayThe gravid uterus may be shifted away

    from the IVC & aorta by placing in LUD orfrom the IVC & aorta by placing in LUD or

    by pulling the gravid uterus to the sideby pulling the gravid uterus to the sideThis may be accomplished manually or byThis may be accomplished manually or by

    placement of a rolled blanket or otherplacement of a rolled blanket or other

    object under the right hip and lumbar areaobject under the right hip and lumbar area

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    Modifications of Basic Life SupportModifications of Basic Life Support

    AirwayAirway

    Hormonal changes promote insufficiencyHormonal changes promote insufficiency

    of the gastroesophageal sphincter,of the gastroesophageal sphincter,

    increasing the risk of regurgitation.increasing the risk of regurgitation.Apply continuous cricoid pressure duringApply continuous cricoid pressure during

    positive pressure ventilation for anypositive pressure ventilation for any

    unconscious pregnant womanunconscious pregnant woman

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    Modifications of Basic Life SupportModifications of Basic Life Support

    AirwayAirway

    Secure the airway early in resuscitationSecure the airway early in resuscitation

    Use an ETT 0.5 to 1 mm smaller inUse an ETT 0.5 to 1 mm smaller in

    internal diameter than that used for ainternal diameter than that used for anonpregnant woman of similar sizenonpregnant woman of similar size

    because the airway may be narrowed frombecause the airway may be narrowed from

    edemaedema

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    Modifications of Basic Life SupportModifications of Basic Life Support

    BreathingBreathing

    Hypoxemia can develop rapidly becauseHypoxemia can develop rapidly because

    of decreased FRC & increased O2of decreased FRC & increased O2

    demand, so be prepared to supportdemand, so be prepared to support

    oxygenation & ventilationoxygenation & ventilation

    Ventilation volumes may need to beVentilation volumes may need to be

    reduced because the mothers diaphragmreduced because the mothers diaphragm

    is elevatedis elevated

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    Modifications of Basic Life SupportModifications of Basic Life Support

    CirculationCirculation

    Perform chest compressions higher,Perform chest compressions higher,slightly above the center of the sternum toslightly above the center of the sternum toadjust for the elevation of the diaphragm &adjust for the elevation of the diaphragm &

    abdominal contentsabdominal contentsVasopressor agents, including epinephrineVasopressor agents, including epinephrine& vasopressin, will decrease blood flow to& vasopressin, will decrease blood flow to

    the uterus, but since there are nothe uterus, but since there are noalternatives, indicated drugs should bealternatives, indicated drugs should beused in recommended dosesused in recommended doses

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    Modifications of Basic Life SupportModifications of Basic Life Support

    DefibrillationDefibrillation

    Defibrillate using standard ACLSDefibrillate using standard ACLS

    defibrillation dosesdefibrillation doses

    There is no evidence that shocks from aThere is no evidence that shocks from adirect current defibrillator have adversedirect current defibrillator have adverse

    effects on the heart of the fetuseffects on the heart of the fetus

    If fetal or uterine monitors are in place,If fetal or uterine monitors are in place,

    remove them before delivering shocksremove them before delivering shocks

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    Modifications of Basic Life SupportModifications of Basic Life Support

    Differential DiagnosesDifferential Diagnoses

    Same reversible causes of cardiac arrest thatSame reversible causes of cardiac arrest that

    occur in nonpregnant women can occur duringoccur in nonpregnant women can occur during

    pregnancypregnancy

    Providers should be familiar with pregnancyProviders should be familiar with pregnancyspecific diseases & procedural complicationsspecific diseases & procedural complications

    Use of abdominal US should be considered inUse of abdominal US should be considered in

    detecting possible causes of the cardiac arrest,detecting possible causes of the cardiac arrest,but this should not delay other treatmentsbut this should not delay other treatments

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    Modifications of Basic Life SupportModifications of Basic Life Support

    Differential DiagnosesDifferential Diagnoses

    Excess magnesium sulfateExcess magnesium sulfate

    Iatrogenic overdose is possible in womenIatrogenic overdose is possible in women

    with eclampsia, particularly if the womanwith eclampsia, particularly if the womanbecomes oliguricbecomes oliguric

    Administration of calcium gluconate (1Administration of calcium gluconate (1

    amp/1 g) is the treatment of choiceamp/1 g) is the treatment of choice

    Empiric calcium administration may beEmpiric calcium administration may be

    lifesavinglifesaving

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    Modifications of Basic Life SupportModifications of Basic Life Support

    Differential DiagnosesDifferential Diagnoses

    Acute coronary syndromesAcute coronary syndromes

    Pregnant women may experience ACS,Pregnant women may experience ACS,

    typically in association with other medicaltypically in association with other medicalconditionsconditions

    Because fibrinolytics are relativelyBecause fibrinolytics are relatively

    contraindicated in pregnancy, PCI is thecontraindicated in pregnancy, PCI is the

    reperfusion strategy of choice for STEMIreperfusion strategy of choice for STEMI

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    Modifications of Basic Life SupportModifications of Basic Life Support

    Differential DiagnosesDifferential Diagnoses

    PrePre--eclampsia/eclampsiaeclampsia/eclampsia

    PrePre--eclampsia/eclampsia develops aftereclampsia/eclampsia develops after

    the 20th week of gestation & can producethe 20th week of gestation & can producesevere HTN & ultimate diffuse organsevere HTN & ultimate diffuse organ

    system failuresystem failure

    If untreated it may result in maternal andIf untreated it may result in maternal and

    fetal morbidity & mortalityfetal morbidity & mortality

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    Modifications of Basic Life SupportModifications of Basic Life Support

    Differential DiagnosesDifferential Diagnoses

    LifeLife--threateningPE & strokethreateningPE & stroke

    Successful use of fibrinolytics for aSuccessful use of fibrinolytics for a

    massive, lifemassive, life--threatening PE & ischemicthreatening PE & ischemicstroke have been reported in pregnantstroke have been reported in pregnant

    womenwomen

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    Modifications of Basic Life SupportModifications of Basic Life Support

    Differential DiagnosesDifferential Diagnoses

    Trauma and drug overdoseTrauma and drug overdose

    Pregnant women are not exempt from thePregnant women are not exempt from the

    accidents & mental illnessesaccidents & mental illnessesDomestic violence also increases duringDomestic violence also increases during

    pregnancy; homicide & suicide are leadingpregnancy; homicide & suicide are leading

    causes of mortality during pregnancycauses of mortality during pregnancy

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    Modifications of Basic Life SupportModifications of Basic Life Support

    Differential DiagnosesDifferential Diagnoses

    Aortic dissectionAortic dissection

    Pregnant women are at increased risk forPregnant women are at increased risk for

    spontaneous aortic dissectionspontaneous aortic dissection

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    Alberta woman fine after giving birth duringAlberta woman fine after giving birth during

    emergency heart surgeryemergency heart surgery

    Edmonton, AlbertaEdmonton, Alberta

    Surgery was done Jan. 24, hours after the 35Surgery was done Jan. 24, hours after the 35week primip complained of SOB & Echo showedweek primip complained of SOB & Echo showeda thoracic aneurysma thoracic aneurysm

    Cardiac Sx opened chest and monitoredCardiac Sx opened chest and monitoredmothers heart while the Obstetrical teammothers heart while the Obstetrical teamdelivered the babydelivered the baby

    After the obstetrics team delivered the child,After the obstetrics team delivered the child,

    Cardiac Sx completed the aorta graftCardiac Sx completed the aorta graftIt was the first such procedure carried out in theIt was the first such procedure carried out in theregion and only one of a handful done aroundregion and only one of a handful done aroundthe worldthe world

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    Emergency Cesarean Delivery forEmergency Cesarean Delivery for

    the Pregnant Woman in Cardiac Arrestthe Pregnant Woman in Cardiac Arrest

    CPR leader should consider the need for an ERCPR leader should consider the need for an ER

    cesarean delivery as soon as a pregnant womancesarean delivery as soon as a pregnant woman

    develops cardiac arrestdevelops cardiac arrest

    The best survival rate for infants 24The best survival rate for infants 24--25 weeks in25 weeks ingestation occurs when the delivery of the infantgestation occurs when the delivery of the infant

    occurs no more than 5 minutes after theoccurs no more than 5 minutes after the

    mothers heart stops beatingmothers heart stops beating

    This typically requires that the provider begin theThis typically requires that the provider begin the

    delivery about 4 minutes after cardiac arrestdelivery about 4 minutes after cardiac arrest

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    Emergency Cesarean Delivery forEmergency Cesarean Delivery for

    the Pregnant Woman in Cardiac Arrestthe Pregnant Woman in Cardiac Arrest

    Delivery of the baby empties the uterus,Delivery of the baby empties the uterus,

    relieving both the venous obstruction andrelieving both the venous obstruction and

    the aortic compressionthe aortic compression

    Delivery also allows access to the infantDelivery also allows access to the infant

    so that newborn resuscitation can beginso that newborn resuscitation can begin

    It is important to remember that you willIt is important to remember that you will

    lose both mother & infant if you cannotlose both mother & infant if you cannot

    restore blood flow to the mothers heartrestore blood flow to the mothers heart

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    Decision Making for EmergencyDecision Making for Emergency

    Cesarean DeliveryCesarean DeliveryConsider gestational ageConsider gestational age

    Although the gravid uterus reaches a size thatAlthough the gravid uterus reaches a size that

    will begin to compromise aortocaval blood flowwill begin to compromise aortocaval blood flow

    at approximately 20 weeks of gestation, fetalat approximately 20 weeks of gestation, fetalviability begins at approximately 24 to 25 weeksviability begins at approximately 24 to 25 weeks

    Portable US, may aid in determination ofPortable US, may aid in determination of

    gestational age & positioning, but the use of USgestational age & positioning, but the use of US

    should not delay the decision to perform deliveryshould not delay the decision to perform delivery

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    Decision Making for EmergencyDecision Making for Emergency

    Cesarean DeliveryCesarean DeliveryGestational age less than 20 weeksGestational age less than 20 weeksNeed not be considered because this size gravidNeed not be considered because this size graviduterus is unlikely to significantly compromiseuterus is unlikely to significantly compromisematernal cardiac outputmaternal cardiac output

    Gestational age approximately 20 to 23 weeksGestational age approximately 20 to 23 weeks

    Perform to enable successful resuscitation of thePerform to enable successful resuscitation of themother, not the survival of the delivered infant,mother, not the survival of the delivered infant,which is unlikely at this gestational agewhich is unlikely at this gestational age

    Gestational age greater than 24 weeksGestational age greater than 24 weeksPerform to save the life of both the mother &Perform to save the life of both the mother &infantinfant

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    Decision Making for EmergencyDecision Making for Emergency

    Cesarean DeliveryCesarean DeliveryThe following can increase the infants survival:The following can increase the infants survival:

    Short interval between the mothers arrest & theShort interval between the mothers arrest & the

    infants deliveryinfants deliveryNo sustained prearrest hypoxia in the motherNo sustained prearrest hypoxia in the mother

    Minimal or no signs of fetal distress before theMinimal or no signs of fetal distress before themothers cardiac arrestmothers cardiac arrest

    Aggressive & effective resuscitative efforts forAggressive & effective resuscitative efforts forthe motherthe motherDelivery to be performed in a medical centerDelivery to be performed in a medical centerwith a NICUwith a NICU

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    Decision Making for EmergencyDecision Making for Emergency

    Cesarean DeliveryCesarean Delivery

    Consider the professional settingConsider the professional setting

    Are appropriate equipment and suppliesAre appropriate equipment and suppliesavailable?available?

    Is emergency hysterotomy within the rescuersIs emergency hysterotomy within the rescuersprocedural range of experience & skills?procedural range of experience & skills?

    Are skilled neonatal support personnel availableAre skilled neonatal support personnel availableto care for the infant, especially if the infant isto care for the infant, especially if the infant is

    not full term?not full term?Are obstetric personnel immediately available toAre obstetric personnel immediately available tosupport the mother after delivery?support the mother after delivery?

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    SummarySummary

    Successful resuscitation of a pregnant woman &Successful resuscitation of a pregnant woman &

    survival of the fetus require prompt & excellentsurvival of the fetus require prompt & excellent

    CPR with some modifications in techniquesCPR with some modifications in techniques

    By the 20th week of gestation, the gravid uterusBy the 20th week of gestation, the gravid uteruscan compress the IVC & aorta, obstructingcan compress the IVC & aorta, obstructing

    venous return & arterial blood flowvenous return & arterial blood flow

    Rescuers can relieve this compression byRescuers can relieve this compression by

    positioning the woman on her side or by pullingpositioning the woman on her side or by pulling

    the gravid uterus to the sidethe gravid uterus to the side

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    SummarySummary

    Defibrillation & medication doses used forDefibrillation & medication doses used forresuscitation of the pregnant woman areresuscitation of the pregnant woman arethe same as those used for other adultsthe same as those used for other adults

    Rescuers should consider the need for ERRescuers should consider the need for ERCaesarian Delivery as soon as theCaesarian Delivery as soon as thepregnant woman develops cardiac arrestpregnant woman develops cardiac arrest

    Rescuers should be prepared to proceed ifRescuers should be prepared to proceed ifthe resuscitation is not successful within 4the resuscitation is not successful within 4minutesminutes

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    ReferenceReference

    Cardiac Arrest Associated WithCardiac Arrest Associated With

    Pregnancy.Pregnancy.C

    irculationC

    irculation 2005;112;IV2005;112;IV--150150--IVIV--153; 2005. American Heart Association153; 2005. American Heart Association