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Resuscitation of the Pregnant Patient

Key Points. During resuscitation there are two patients, mother

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Resuscitation of the Pregnant Patient

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    1. Resuscitation of the Pregnant Patient Ida Bruni February 6, 2008

    2. Key Points During resuscitation there are two patients, mother & fetus The best hope of fetal survival is maternal survival Consider the physiologic changes due to pregnancy

    3. Interventions to Prevent Arrest To treat the critically ill pregnant patient: Place the patient in the left lateral position Give 100% oxygen Establish IV access and give a fluid bolus Consider reversible causes of cardiac arrest and identify any preexisting medical conditions that may be complicating the resuscitation

    4. Resuscitation of the Pregnant Woman in Cardiac Arrest Modifications of Basic Life Support At gestational age of greater than 20 weeks, the pregnant uterus can press against the IVC & aorta, impeding venous return and cardiac output Uterine obstruction of venous return can produce prearrest hypotension or shock and in the critically ill patient may precipitate arrest It also limits the effectiveness of chest compressions

    5. Modifications of Basic Life Support The gravid uterus may be shifted away from the IVC & aorta by placing in LUD or by pulling the gravid uterus to the side This may be accomplished manually or by placement of a rolled blanket or other object under the right hip and lumbar area

    6. Modifications of Basic Life Support Airway Hormonal changes promote insufficiency of the gastroesophageal sphincter, increasing the risk of regurgitation. Apply continuous cricoid pressure during positive pressure ventilation for any unconscious pregnant woman

    7. Modifications of Basic Life Support Airway Secure the airway early in resuscitation Use an ETT 0.5 to 1 mm smaller in internal diameter than that used for a nonpregnant woman of similar size because the airway may be narrowed from edema

    8. Modifications of Basic Life Support Breathing Hypoxemia can develop rapidly because of decreased FRC & increased O2 demand, so be prepared to support oxygenation & ventilation Ventilation volumes may need to be reduced because the mothers diaphragm is elevated

    9. Modifications of Basic Life Support Circulation Perform chest compressions higher, slightly above the center of the sternum to adjust for the elevation of the diaphragm & abdominal contents Vasopressor agents, including epinephrine & vasopressin, will decrease blood flow to the uterus, but since there are no alternatives, indicated drugs should be used in recommended doses

    10. Modifications of Basic Life Support Defibrillation Defibrillate using standard ACLS defibrillation doses There is no evidence that shocks from a direct current defibrillator have adverse effects on the heart of the fetus If fetal or uterine monitors are in place, remove them before delivering shocks

    11. Modifications of Basic Life Support Differential Diagnoses Same reversible causes of cardiac arrest that occur in nonpregnant women can occur during pregnancy Providers should be familiar with pregnancy specific diseases & procedural complications Use of abdominal US should be considered in detecting possible causes of the cardiac arrest, but this should not delay other treatments

    12. Modifications of Basic Life Support Differential Diagnoses Excess magnesium sulfate Iatrogenic overdose is possible in women with eclampsia, particularly if the woman becomes oliguric Administration of calcium gluconate (1 amp/1 g) is the treatment of choice Empiric calcium administration may be lifesaving

    13. Modifications of Basic Life Support Differential Diagnoses Acute coronary syndromes Pregnant women may experience ACS, typically in association with other medical conditions Because fibrinolytics are relatively contraindicated in pregnancy, PCI is the reperfusion strategy of choice for STEMI

    14. Modifications of Basic Life Support Differential Diagnoses Pre-eclampsia/eclampsia Pre-eclampsia/eclampsia develops after the 20th week of gestation & can produce severe HTN & ultimate diffuse organ system failure If untreated it may result in maternal and fetal morbidity & mortality

    15. Modifications of Basic Life Support Differential Diagnoses Life-threatening PE & stroke Successful use of fibrinolytics for a massive, life-threatening PE & ischemic stroke have been reported in pregnant women

    16. Modifications of Basic Life Support Differential Diagnoses Trauma and drug overdose Pregnant women are not exempt from the accidents & mental illnesses Domestic violence also increases during pregnancy; homicide & suicide are leading causes of mortality during pregnancy

    17. Modifications of Basic Life Support Differential Diagnoses Aortic dissection Pregnant women are at increased risk for spontaneous aortic dissection

    18. Alberta woman fine after giving birth during emergency heart surgery Edmonton, Alberta Surgery was done Jan. 24, hours after the 35 week primip complained of SOB & Echo showed a thoracic aneurysm Cardiac Sx opened chest and monitored mothers heart while the Obstetrical team delivered the baby After the obstetrics team delivered the child, Cardiac Sx completed the aorta graft It was the first such procedure carried out in the region and only one of a handful done around the world

    19. Emergency Cesarean Delivery for the Pregnant Woman in Cardiac Arrest CPR leader should consider the need for an ER cesarean delivery as soon as a pregnant woman develops cardiac arrest The best survival rate for infants 24-25 weeks in gestation occurs when the delivery of the infant occurs no more than 5 minutes after the mothers heart stops beating This typically requires that the provider begin the delivery about 4 minutes after cardiac arrest

    20. Emergency Cesarean Delivery for the Pregnant Woman in Cardiac Arrest Delivery of the baby empties the uterus, relieving both the venous obstruction and the aortic compression Delivery also allows access to the infant so that newborn resuscitation can begin It is important to remember that you will lose both mother & infant if you cannot restore blood flow to the mothers heart

    21. Decision Making for Emergency Cesarean Delivery Consider gestational age Although the gravid uterus reaches a size that will begin to compromise aortocaval blood flow at approximately 20 weeks of gestation, fetal viability begins at approximately 24 to 25 weeks Portable US, may aid in determination of gestational age & positioning, but the use of US should not delay the decision to perform delivery

    22. Decision Making for Emergency Cesarean Delivery Gestational age less than 20 weeks Need not be considered because this size gravid uterus is unlikely to significantly compromise maternal cardiac output Gestational age approximately 20 to 23 weeks Perform to enable successful resuscitation of the mother, not the survival of the delivered infant, which is unlikely at this gestational age Gestational age greater than 24 weeks Perform to save the life of both the mother & infant

    23. Decision Making for Emergency Cesarean Delivery The following can increase the infants survival: Short interval between the mothers arrest & the infants delivery No sustained prearrest hypoxia in the mother Minimal or no signs of fetal distress before the mothers cardiac arrest Aggressive & effective resuscitative efforts for the mother Delivery to be performed in a medical center with a NICU

    24. Decision Making for Emergency Cesarean Delivery Consider the professional setting Are appropriate equipment and supplies available? Is emergency hysterotomy within the rescuers procedural range of experience & skills? Are skilled neonatal support personnel available to care for the infant, especially if the infant is not full term? Are obstetric personnel immediately available to support the mother after delivery?

    25. Summary Successful resuscitation of a pregnant woman & survival of the fetus require prompt & excellent CPR with some modifications in techniques By the 20th week of gestation, the gravid uterus can compress the IVC & aorta, obstructing venous return & arterial blood flow Rescuers can relieve this compression by positioning the woman on her side or by pulling the gravid uterus to the side

    26. Summary Defibrillation & medication doses used for resuscitation of the pregnant woman are the same as those used for other adults Rescuers should consider the need for ER Caesarian Delivery as soon as the pregnant woman develops cardiac arrest Rescuers should be prepared to proceed if the resuscitation is not successful within 4 minutes

    27. Reference Cardiac Arrest Associated With Pregnancy. Circulation 2005;112;IV-150-IV-153; 2005. American Heart Association

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