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Cardiac arrest in pregnancy is a particularly distressing emergency where we are caring for a patient with altered physiology and her unborn fetus. The U.S. Nationwide Inpatient Sample reports the cardiac arrest rate to be 1 in 12,000 pregnant women admitted for delivery. While survival to discharge of in-hospital arrest in nonpregnant women is shy of 30%, pregnant women fair much better; surviving at ∼58%. Given the rate of survival, familiarity with the management of cardiac arrest in pregnancy should have our full attention.1-3
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Although we are faced with two patients, a mother and infant, the management of cardiac arrest in the parturient focuses on maternal resuscitation regardless of the fetus’ gestational age. This is because these measures are often aligned. Since the uterus lacks autoregulation, improving maternal perfusion improves fetal perfusion. Additionally, delivery of the fetus allows for Neonatal Intensive Care Unit (NICU) care for the infant and removal of aortocaval compression in the mom. The improved maternal mortality is why this is now being called a resuscitative hysterotomy instead of the older term of perimortem cesarean delivery. We should be prepared to perform a resuscitative hysterotomy within 5 minutes of the arrest to improve the chances of return of spontaneous circulation (ROSC) in the mother.4,5
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Cardiac arrest in pregnancy follows the same algorithms and principles in the American Heart Association guidelines but has a few critical differences.
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Chest compressions, code medications and their doses, as well as defibrillation voltage are identical to the nonpregnant patient.
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The differences in the management of a parturient in cardiac arrest are as follows:
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Immediately call an OB code or OB STAT, which would alert anesthesia, obstetricians, and NICU staff alike, as a STAT resuscitative hysterotomy is a likely outcome.
Continuous manual left uterine displacement (LUD) is essential to minimize aortocaval compression, rendering cardiopulmonary resuscitation ineffective in pregnancy 20 weeks and above. Continuous manual LUD is the best form of LUD in cardiac arrest.
Favor intravenous access above the diaphragm since venous return is hindered.
Place lateral defibrillation pad or paddle below breast tissue.
Before administering a shock, consider removing fetal monitors if it can be done quickly, do not delay shock for that concern. Monitoring fetal heart rate at that time is NOT recommended and can divert attention from other resuscitative efforts.
If the patient is on magnesium, stop the magnesium and intravenous calcium (10 mL of 10% calcium gluconate) should be administered early.
Pregnant patients are more prone to hypoxia (decreased functional residual capacity and increased oxygen demand). Therefore, oxygenation and airway management should be prioritized higher than in the nonparturient.
Prepare to face a difficult airway in pregnancy. The first attempt should be by a senior provider with a smaller endotracheal tube (6.5 mm).
If no return ROSC after 4 minutes, a STAT resuscitative hysterotomy ...