A slideshow that describes the BLS & ACLS modifications of CPR in pregnancy.

1. RESUSCITATION IN PREGNANCY
Dr. Krushna Patel
Postgraduate, MEM
KDAH, Mumbai
17-07-2012

2. GOALS
1. To understand and perform basic and advance
life support in pregnant patients
2. Understand the adaptations of CPR
3. Understand the importance of early
defibrillation when appropriate
4. Understand the need to perform perimortem
cesarean section

3. SCOPE OF THE PROBLEM
According to the Confidential Enquiries into Maternal And
Child Health (CEMACH) overall maternal mortality
rate is 13.95deaths/100,000 maternities (AHA
CIRCULATION :2010)
Out of which 8 are due to cardiac arrest with frequency of
0.05 per 1000 maternities or 1:20,000
Rescuers must provide appropriate resuscitation based on
consideration of physiological changes caused by
pregnancy.

4. ANATOMICAL AND PHYSIOLOGICAL
CHANGES IN PREGNANCY
CARDIOVASCULAR SYSTEM
Uteroplacental Maternal blood volume
Arterial
blood flow pressure
Increases 30 – 20th week of
Cardiac output 45% gestation
Maternal heart increases 10- 15 beats/min
rate
First two trimesters – Returns to
SBP and DBP decreases by 10 – 15 mm hg baseline by term

5. Supine pregnant patient
Gravid uterine pressure
Compression of IVC
Decreased venous return
Decreased cardiac output – 10 – 30%

6. Poor venous flow
Compromises
infradiaphragmatic
i.v sites
Femoral / saphenous routes
Not recommended for
i.v access
During resuscitation

7. RESPIRATORY SYSTEM
Progesterone
Increased Tidal stimulated
Increased minute
Volume hyperventilation ventilation
Decreased Rapid decrease
Chronic
Functional in arterial
respiratory
Residual oxygen content
alkalosis
Capacity – 20% during arrest
Right side shift of
Maintain maternal
oxyhemoglobin
PO2 of >60 mm hg
curve during
in arrest state
arrest state

8. GASTO-INTESTINAL SYSTEM
Delayed Gastric emptying
in pregnancy Increased acidity of
(progesterone like effects stomach contents
of placental hormones)
cardiac sphincter Increased chance of
relaxation causes aspiration and vomiting
regurgitation of stomach
contents

9. AIRWAY AND VENTILATION
CONSIDERATION IN PREGNANCY
Decreased tolerance for hypoxia and apnoea
Tongue, mucosa, supraglottic edema & friability
Difficult mask ventilation
• Low FRC
• Elevated diaphragm
• Raised intra-abdominal pressure
Mallampatti class 3 airway
Weight gain & obesity
• Increased neck folds
• Foreshortened neck
Increased risk of aspiration
• Increased gastric emptying time
• Decreased lower esophageal sphincter tone

10. KEY INTERVENTIONS TO PREVENT
ARREST
 Place the patient in the full left-lateral position to relieve
possible compression of the inferior vena cava. Uterine
obstruction of venous return can produce hypotension
and may precipitate arrest in the critically ill patient.
 Give 100% oxygen.
 Establish intravenous (IV) access above the diaphragm.

11.  Assess for hypotension : maternal hypotension that
warrants therapy has been defined as a systolic blood
pressure 100 mm Hg or 80% of baseline.
 Maternal hypotension can result in reduced placental
perfusion.
 In the patient who is not in arrest, both crystalloid and
colloid solutions have been shown to increase preload.
 Consider reversible causes of critical illness and treat
conditions that may contribute to clinical deterioration as
early as possible.

12. RESUSCITATION OF THE PREGNANT
PATIENT IN CARDIAC ARREST
MODIFICATIONS OF CARDIOPULMONARY
RESUSCITATION
Patient Positioning
 Important strategy to improve the quality of CPR and
resultant compression force and output.
 The pregnant uterus especially of >20 weeks gestation or
gravid uterus palpated above the umbilicus, compresses the
inferior vena cava, impeding venous return and thereby
reducing stroke volume and cardiac output.
 In non cardiac arrest parturients left-lateral tilt results in
improved maternal hemodynamics of blood pressure,
cardiac output, and stroke volume and improved fetal
parameters of oxygenation, nonstress test, and fetal heart
rate.

13.  Left lateral tilt - 30 degrees
using wedge (hard) of
predetermined angle. Eg.
Cardiff wedge
 Manual left uterine
displacement, with the patient
in supine, also relieves
aortocaval compression .

14.  Left uterine displacement -
patient’s left side with the 2-
handed technique
 The patient’s right side with
the 1-handed technique ,
depending on the
positioning of the
resuscitation team.
 If chest compressions
remain inadequate after
lateral uterine displacement
or left-lateral tilt, immediate
emergency cesarean section
should be considered.

15. BLS AND ACLS MODIFICATIONS

16. AIRWAY AND BREATHING
 Active airway management is the initial consideration.
 Airway management is more difficult during pregnancy
 Secure airway early in resuscitation
 OPTIMAL use of bag-mask ventilation and suctioning, while
preparing for advanced airway placement should be done
 Use small endotracheal tubes, short laryngoscope handles
 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
 Give 100 % oxygen and mainatain good saturation

17. CIRCULATION
 Chest compressions should
be performed slightly higher
on the sternum than normally
recommended to adjust for
the elevation of the
diaphragm and abdominal
contents caused by the
gravid uterus.
 Position is slightly above the
centre of the sternum
 Current recommended drug
dosages for use in
resuscitation of adults can
also be used in resuscitation
of the pregnant patient in
cardiac arrest.

18. DEFIBRILLATION
 Management of ventricular arrhythmias require
defibrillation during maternal resuscitation.
 Thereshould be no delay if use of defibrillation is
indicated
 Energy levels are same as ACLS protocol
 Before delivering the shock, REMOVE FETAL
MONITORING EQUIPMENTS to prevent
electrocution injury to patient or rescuer

19. PREGNANCY-RELATED CAUSES OF MATERNAL
CARDIOPULMONARY ARREST
B- Bleeding(haemorrhage)/ DIC
E- Embolism/coronary/pulmonary/amniotic fluid embolism
A- anesthetic complications
U- Uterine atony
C- Cardiac diseases/MI/Ischemia/aortic dissection/cardiomyopathy
H- Hypertension / Preclampsia/ Eclampsia
O- Others / Diff. Diag of standard ACLS guidelines i.e 5H’s and 5T’s
P- Placenta previa/ Abruptio placenta
S- Sepsis

20. REVERSIBLE CAUSES
Electrolyte
Tamponade Hypothermia
abnormalities
Hypovolemia Hypoxia Hypomagnesemia
Myocardial Pulmonary Tension
infarction embolism pneumothorax

21. HAEMORRAGE
 Case of placenta previa/ abruptio placenta, where
bleeding is significant
 Fluid resuscitation with RL/ NS
 Vasopressor agent - Inj. Ephedrine (5mg every 5 mins till
response is seen) , if fluids fail to restore adequate blood
pressure.

22. EMBOLISM
Pulmonary embolism Amniotic fluid embolism
• Thromboembolic disease risk • Dyspnoea, hypotension associated
increased with pt. is labour/ abortion
• Hypoxic/ hemodynamic unstable • Sudden onset breathlessness, air
• Anticoagulation with heparin – hunger, decreased oxygen saturtion
currently the treatment of choice • Develop cardiac arrest within
• Also , adequate oxygenation and minutes
treating hypotension • DIC
• Elevated D-dimer not a helpful • Multi- organ failure
screen in pregnancy
• Treatment tried : cardiopulmonary
• CT scan or VP scan to confirm bypass, open pulmonary artery
diagnosis on treatment is stated. thromboembolectomy.
• Use of thrombolytics reserved when
potential benefits outweighs the risks,
emergencies beyond 20 wks
gestation, postpartum period

23. ANESTHETIC COMPLICATION
 Bupivacaine induced arrythmia – amiodarone is the
primary drugin the ACLS arrythmia algorithm.
 Early administration of lipid emulsification (20%
intralipid) – used in resuscitation of bupivacaine-
induced cardiotoxicity. ( lipid rescue therapy : picard J .
Anesthesia 2009)

24. CARDIAC DISEASE
 The most common causes of maternal death from cardiac disease are
myocardial infarction, followed by aortic dissection.
 Women deferring pregnancy to older ages, increases the chance of
having atherosclerotic heart disease.
 Fibrinolytics is relative contraindication in pregnancy
 PCI is the reperfusion strategy of choice for ST-elevation
myocardial infarction.
 illnesses related to congenital heart disease and pulmonary
hypertension are the third most common cause of maternal cardiac
deaths.

25. PREECLAMPSIA/ECLAMPSIA
 Preeclampsia/eclampsia develops after the 20th week of
gestation and can produce severe hypertension and
ultimately diffuse organ-system failure.
 Magnesium sulphate
 If untreated, maternal and fetal morbidity and mortality
results.

26. MAGNESIUM SULFATE TOXICITY
 Magnesium toxicity present with ECG interval changes: (prolonged PR,
QRS and QT intervals) at magnesium levels of 2.5–5 mmol/L
 AV nodal conduction block, bradycardia, hypotension and cardiac arrest at
levels of 6–10 mmol/L.
 Neurological effects : loss of tendon reflexes, sedation, severe muscular
weakness, and respiratory depression are seen at levels of 4–5 mmol/L.

27.  Others include: gastrointestinal symptoms (nausea and vomiting), skin
changes (flushing), and electrolyte/ fluid abnormalities
(hypophosphatemia, hyperosmolar dehydration).
 Patients with renal failure and metabolic derangements can develop
toxicity after relatively lower magnesium doses.
 Iatrogenic overdose is possible in the pregnant woman who receives
magnesium sulfate, particularly if the woman becomes oliguric.
 Administration of calcium gluconate (10 ml of a 10% solution) is the
treatment of choice
 Empiric calcium administration may be lifesaving

28. Trauma and drug overdose
 Pregnant women are not exempt from the accidents &
mental illnesses
 Domestic violence also increases during pregnancy;
homicide & suicide are one of the causes of mortality
during pregnancy

29. EMERGENCY CESAREAN SECTION IN
CARDIAC ARREST
 Delivery of the foetus is a part of resuscitation process when
applicable.
 Despite appropriate modifications – mechanical effect of
gravid uterus – decreases venous return from IVC – obstructs
blood flow through abd. aorta – decreases thoracic compliance
– unsuccessful CPR – increased risk of hypoxia going in for
anoxia to mother and foetus BEYOND 4 MINUTES OF
ARREST.

30. WHY PERFORM AN EMERGENCY CESAREAN
SECTION IN CARDIAC ARREST?
 Emergency cesarean section in maternal cardiac arrest
indicate a return of spontaneous circulation or
improvement in maternal hemodynamic status only
after the uterus has been emptied.
 Recent studies indicates ROSC and maternal
hemodynamic stability of the mother and normal
neurological outcome of the neonate post perimortem
casarean.
 The critical point to remember is that both mother and
infant may die if the provider cannot restore blood flow
to the mother’s heart.

31. THE IMPORTANCE OF TIMING WITH EMERGENCY
CESAREAN SECTION
 When the maternal prognosis is grave and resuscitative
efforts appear futile, moving straight to an emergency
cesarean section may be appropriate, especially if the fetus
is viable.
 If emergency cesarean section cannot be performed by the
5-minute mark, it may be advisable to prepare to evacuate
the uterus while the resuscitation continues.

32. 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

33. The following can increase the infant’s survival:
 Short interval between the mother’s arrest & the infant’s
delivery
 Perimortem caesarean section to be performed within 4 mins
of cardiac arrest and delivery of the foetus within 5 mins.
 No sustained pre arrest hypoxia in the mother
 Minimal or no signs of fetal distress before the mother’s
cardiac arrest
 Aggressive & effective resuscitative efforts for the mother
 Delivery to be performed in a medical center with easy access
to NICU.

34. PERIMORTEM CESAREAN SECTION
 Prognosis for intact survival of infant
is best if delivered within 5 mins of
maternal arrest.
 Goal : to remove foetus and continue
resuscitation of both mother and foetus
 During the procedure maternal CPR
has to be continued.
 Vertical midline abdominal incision
from 4 -5 cm below xiphoid process to
pubic symphysis
 Incise through the fascia and muscles
into the peritoneum

35.  Vertical uterine incision .
 Delivery of the fetus
 Manual removal of placenta and
its membranes.
 Closure of abdomen may be
delayed until maternal blood
pressure and pulse is restored.
 Dilute oxytocin 10 units in 9 ml
NS to prevent uterine atony.
 INFORMED CONSENT FOR
PERIMORTEM CS IS NOT
NECESSARY

36. POST–CARDIAC ARREST CARE
 Post–cardiac arrest hypothermia can be used safely and
effectively in early pregnancy without emergency cesarean
section (with fetal heart monitoring), with favorable maternal
and fetal outcome after a term delivery.
 No cases in the literature have reported the use of therapeutic
hypothermia with perimortem cesarean section.
 Therapeutic hypothermia may be considered on an individual
basis after cardiac arrest in a comatose pregnant patient based
on current recommendations for the nonpregnant patient
 During therapeutic hypothermia of the pregnant patient, it is
recommended that the fetus be continuously monitored for
bradycardia as a potential complication, and obstetric and
neonatal consultation should be sought

37. 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 left side or by pulling the gravid uterus
to the side

38.  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

39. SEQUENCE FOR CPR IN PREGNANT PATIENTS
Intubate early
Protect vulnerable airway
Supply oxygen
Tilt the patient
Limit aortocaval compression
Obtain rapid IV access, avoid the femoral and saphenous veins
Follow current ACLS recommendations
Perimortem cesarean section within 5 min of maternal arrest if fetus >20 wk
Consider open chest CPR within 15 min of maternal arrest
Explore differential diagnosis, include iatrogenic causes (e.g., spinal analgesia).
Consider cardiopulmonary bypass, if indicated.

41. REFRENCES
 COURTESY : UPDATE JUNE 2012 LITERATURE
REVIEW
 AHA : CIRCULATION 2010 – CARDIAC ARREST IN
PREGNANCY
 TINTINALLI 7TH EDITION

42. THANK YOU