Cardiac arrest in pregnancy

Paleerat Jariyakanjana, MD
Emergency physician
19 Oct 2015

The Critically Ill
Pregnant Patient

Severity of Illness and Early Warning Scores
 obstetric early warning score (Class I; Level of
Evidence C)

Management of the Unstable Pregnant
Patient
 full left lateral decubitus position (Class I;
Level of Evidence C)
 100% oxygen by face mask (≥15 L/min)
(Class I; Level of Evidence C)
 Intravenous access: above the diaphragm

Chest Compressions in Pregnancy
 placed supine for chest compressions(Class I;
 mechanical chest compressions: not advised

Factors Affecting Chest Compressions
in the Pregnant Patient
 Continuous manual LUD: uterus ≥ umbilicus

Factors Affecting Chest Compressions
in the Pregnant Patient

Advanced Cardiovascular Life Support

Special Equipment Required for a Maternal Cardiac
Arrest

Special Equipment Required for a Maternal
Cardiac Arrest

Breathing and Airway Management in
Pregnancy
 Management of Hypoxia
 Airway Management

Management of Hypoxia
 early ventilatory support (Class I; Level of
Evidence C)

Airway Management
 Endotracheal intubation should be performed
by an experienced laryngoscopist (Class I;
Level of Evidence C).
A. ETT with a 6.0-7.0 mm ID (Class I; Level of
Evidence C)
B. ≤2 laryngoscopy attempts (Class IIa; Level of
Evidence C)
C. Supraglottic airway placement: failed intubation
D. airway control fail and mask ventilation is not
possible → emergency invasive airway access

Airway Management
 Cricoid pressure: not routinely recommended
(Class III; Level of Evidence C)

 PMCD: after ≈4 minutes of resuscitative
efforts (Class IIa; Level of Evidence C)

 When PMCD is performed
A. not be transported to OR (Class IIa; Level of
Evidence B)
B. not wait for surgical equipment; only a scalpel is
required (Class IIa; Level of Evidence C)
C. not spend time on lengthy antiseptic procedures
(Class IIa; Level of Evidence C)
D. Continuous manual LUD until the fetus is
delivered (Class IIa; Level of Evidence C)

 If available, transport should be directed
toward a center that is prepared to perform
PMCD, but transport should not be prolonged
by >10 minutes to reach a center with more
capabilities (Class IIb; Level of Evidence C).

Table 5. Most Common Etiologies of Maternal
Arrest and Mortality
Letter Cause Etiology
A Anesthetic complications High neuraxial block
Hypotension
Loss of airway
Aspiration
Respiratory depression
Local anesthetic systemic toxicity
Accidents/trauma Trauma
Suicide
B Bleeding Coagulopathy
Uterine atony
Placenta accreta
Placental abruption
Placenta previa
Retained products of conception
Uterine rupture
Surgical
Transfusion reaction
C Cardiovascular causes Myocardial infarction
Aortic dissection
Cardiomyopathy
Arrhythmias
Valve disease
Congenital heart disease

Table 5. Most Common Etiologies of Maternal
Arrest and Mortality
Letter Cause Etiology
D Drugs Oxytocin
Magnesium
Drug error
Illicit drugs
Opioids
Insulin
Anaphylaxis
E Embolic causes Amniotic fluid embolus
Pulmonary embolus
Cerebrovascular event
Venous air embolism
F Fever Sepsis
Infection
G General H’s and T’s
H Hypertension Preeclampsia
Eclampsia
HELLP syndrome, intracranial
bleed

 point-of-care checklists (Class I; Level of
Evidence B)

 still pregnant: full left lateral decubitus position
 not in full left lateral tilt: manual LUD (Class I;

Cardiac arrest in pregnancy

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