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- Several special considerations need to be made for a pregnant patient in cardiac arrest. First, the goal is to focus on high-quality CPR, oxygenation, defibrillation, and ACLS medications for the mother. By saving the mother's life, the baby has a greater chance of survival. In addition to a priority on the mother's care, there needs to be one person available whose only responsibility is the care of the newborn. Now, because pregnant patients are more likely to have hypoxia, it's vital to place a high priority on oxygenation and good airway management during resuscitation. Also, because of potential interference with maternal resuscitation, fetal monitoring should not be attempted during cardiac arrest. Compression on the mother's arteries and veins from the baby in the abdomen can impede venous return and decrease cardiac output. To help relieve compression on the mother's abdominal aorta and inferior vena cava, left lateral uterine displacement should be done with one or two hands by pushing or pulling the abdomen to the mother's left side. We also need to consider that initial efforts for maternal resuscitation may not be successful and preparation for perimortem cesarean delivery should begin immediately. Ideally, perimortem cesarean and delivery should be done during resuscitation efforts within five minutes after maternal cardiac arrest. When the baby is born, inflation and ventilation of the lungs are the priority. If an infant is born with meconium-stained amniotic fluid, routine endotracheal suctioning for both vigorous and non-vigorous infants is not recommended. Endotracheal suctioning should only be done if airway obstruction is suspected after providing positive pressure ventilation. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. If a newborn infant needs vascular access right after birth, the umbilical vein is the recommended route. If IV access is not feasible, it may be reasonable to use the IO route. With pregnant patients, it's especially important to consider and treat reversible causes of arrest to give the best chance of survival. In addition to the H's and T's, common causes of maternal cardiac arrest are hemorrhage, heart failure, amniotic fluid embolism, sepsis, aspiration pneumonia, venous thromboembolism, preeclampsia and eclampsia, and complications of anesthesia. To achieve the best outcomes, healthcare systems need to conduct team planning with obstetrics, neonatal anesthesiology, intensive care, emergency, and cardiac arrest services.
In this lesson, we're going to cover treatment options for both the mother and the baby when the mother experiences a cardiac arrest event. At the end of this lesson, we'll explain why the new recommendations were made.
There are several special considerations that you will need to make for a pregnant patient in cardiac arrest. First, the treatment priorities for the mother should focus on the following options:
Pro Tip #1: By saving the mother, the baby will have a far greater chance of survival.
In addition to the above priorities to the mother's care, there also needs to be one healthcare provider whose only responsibility is to care for the newborn.
Because a pregnant patient is more likely to have hypoxia, it's vitally important to place a high priority on oxygenation and proper airway management during resuscitation. Also because of potential interference with maternal resuscitation, fetal monitoring should NOT be attempted during cardiac arrest.
Warning: Compression of the mother's arteries and veins from the baby in the abdomen can impede venous return and decrease cardiac output.
To help relieve compression of the mother's abdominal aorta and inferior vena cava, left lateral uterine displacement should be done with one or two hands by pushing or pulling the abdomen to the mother's left side.
You should also consider that the initial efforts from maternal resuscitation may not be successful, and you should begin to prepare for perimortem cesarean delivery. These efforts should begin immediately.
Pro Tip #2: Ideally, perimortem cesarean delivery should be done within five minutes during resuscitation efforts and following the mother's cardiac arrest.
After the baby is born, inflation and ventilation of the lungs will be your top priority. If the infant is born with meconium-stained amniotic fluid, routine endotracheal suctioning for both vigorous and non-vigorous infants is NOT recommended.
ET suctioning should only be done if the airway obstruction is suspected after providing positive pressure ventilation. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions.
If the newborn requires vascular access immediately following birth, the umbilical vein is the recommended route. If IV access is not feasible, it may be reasonable to use the IO route instead.
With any pregnant patient, it is especially important to consider and treat the reversible causes of cardiac arrest in order to provide the best possible chances of survival.
In addition to the Hs and Ts, other common causes of maternal cardiac arrest are:
To achieve the best possible outcomes for the mother and newborn, healthcare providers need to conduct team planning with the following:
The recommendations for managing cardiac arrest in pregnancy were reviewed in the 2015 Guidelines Update and a 2015 AHA scientific statement. Airway, ventilation, and oxygenation are particularly important in the setting of pregnancy because of an increase in maternal metabolism, a decrease in functional reserve capacity due to the gravid uterus, and the risk of fetal brain injury from hypoxemia.
Evaluation of the fetal heart is not helpful during maternal cardiac arrest, and it may distract from necessary resuscitation elements. In the absence of data to the contrary, pregnant women who survive cardiac arrest should receive targeted temperature management just as any other cardiac arrest survivors would, with consideration for the status of the fetus that may remain in utero.