CPR and Pregnancy

Although there is concern for the viability of the unborn child, effective resuscitation of the mother is the best way to optimise fetal outcome

ANZCOR Guideline 11.10: Resuscitation in Special Circumstances (2011)

OVERVIEW

• Cardiac arrest in pregnancy is rare (1:20,000 pregnancies with out-of-hospital cardiac arrest)

COMMON CAUSES

• Pulmonary Embolism (29%)
• Haemorrhage (17%)
• Sepsis (13%)
• Cardiomyopathy (8%)
• Stroke (5%)
• Hypertensive disorders of pregnancy (Including HELLP Syndrome / Eclampsia / Pre-eclampsia) (2.8%)
• Complications related to anaesthesia (e.g. difficult or failed intubation, local anaesthetic toxicity, aspiration, high neuraxial block) (2%)
• Other Major:
  • Amniotic Fluid Embolism
  • Poisoning and self-harm
  • As well the same causes of cardiac arrest as females of the same age group;
    • Anaphylaxis
    • Trauma
    • Pre-existing cardiac disease
    • Myocardial Infarction

OF NOTE

• Physiological changes of pregnancy mean increased: cardiac output, blood volume, minute ventilation, oxygen consumption and reduced lung volumes which complicate the ABCs of resuscitation
• The gravid uterus compresses the abdominal organs and abdominal vessels (IVC and aorta) when supine
• Don’t forget that there are two people you are resuscitating, call early for obstetric and neonatal assistance, and consider an early call for extracorporeal CPR (ECPR) — especially as it may take time to activate

ALS MODIFICATIONS

• Call for obstetrician and neonatologist early
• Start standard BLS
• Prepare early for emergency hysterotomy (perimortem caesarean section)
• If over 20 weeks pregnant or the uterus is palpable above the level of the umbilicus, add a wedge to give left lateral tilt (pillow or knees of chest compression person), aim for 15-30 degrees
  • You may need to manually displace the uterus to the left to remove caval compression
  • A small amount of tilt is better than no tilt
• Hands in standard position on lower half of the sternum if feasible for chest compressions
• Consider early intubation (watch for reflux / engorged upper airway)
• Defibrillation pads in the standard position with standard shock energies
  • Remove CTG prior to defibrillation
• If over 20 weeks pregnant or the uterus is palpable above the level of the umbilicus and immediate (within 4 mins) resuscitation is not successful, deliver the fetus by emergency hysterotomy aiming for delivery within 5 mins of collapse.
• Consider ECPR as a rescue therapy if ALS measures are failing

References and links

FOAM

• CCC – Advanced Life Support
• CCC – Amniotic Fluid Embolism
• CCC – Anaphylaxis
• CCC – Cardiogenic shock and late pregnancy
• CCC – Eclampsia and Pre-Eclampsia and HELLP
• CCC – Haemorrhage in Pregnancy
• CCC – Perimortem Caeserean Section
• CCC – Peripartum Cardiomyopathy
• CCC – Sepsis and Pregnancy
• CCC – Trauma in Pregnancy
• CCC – VTE and pregnancy
• LITFL Clinical Case – Obstetric Bleeder
• SMACC19 – Emergency Management of Pre-Eclampsia

References

• Deakin, C; et al. (2021). Special circumstances Guidelines. Retrieved 10 October 2022, from https://www.resus.org.uk/library/2021-resuscitation-guidelines/special-circumstances-guidelines
• Guideline 11.10: Resuscitation in Special Circumstances. (2011). Retrieved 10 October 2022, from https://resus.org.au/download/section_11/guideline-11-10-nov-2011.pdf
• Paratz E, Rowe S, van Heusden A, et al. Clinical and Pathologic Features of Out-of-Hospital Cardiac Arrest in Pregnancy. JACC Adv. 2022
• Suresh MS, LaToya Mason C, Munnur U. Cardiopulmonary resuscitation and the parturient. Best Pract Res Clin Obstet Gynaecol. 2010 Jun;24(3):383-400