Cardiac arrest during pregnancy

Cardiac arrest during pregnancy occurs in 1 per 12,000 admissions for delivery. CPR is more difficult than in individuals who are not pregnant, but survival to hospital discharge is as high as 58.9%. The American Heart Association recommends the following changes in the ACLS algorithm for cardiac arrest in pregnancy:

1. Standard basic life support and activation of the maternal cardiac arrest team (if present in the institution) should be initiated immediately upon discovery of a pregnant patient in cardiac arrest.
2. The patient should be placed supine for chest compressions. If the uterus is palpated at or above the umbilicus, or if the uterus cannot be assessed, manual left uterine displacement should be employed to relieve aortocaval compression. (Left lateral tilt is no longer recommended due to hindrance of effective chest compressions.)
3. No change in the hand position for chest compressions is recommended. (Prior guidelines to perform compressions higher on the sternum were not supported by evidence.)
4. When indicated, defibrillation should not be delayed to allow for removal of invasive fetal monitors. Defibrillation energy does not change in pregnancy. Anterolateral pad placement is the recommended default, with attention to the placement of the lateral pad underneath breast tissue.
5. Rapid development of hypoxemia should be anticipated in the pregnant patient due to lower oxygen reserve and higher metabolic demand. Difficult airway management should also be expected.
6. Intravenous or intraosseous access should be obtained above the diaphragm due to possibly impeded lower extremity venous return.
7. Resuscitation drugs should be administered as per ACLS guidelines without modification.
8. Evaluation of fetal well-being during maternal cardiac arrest should not be carried out due to the risk of interference with maternal resuscitation or monitoring.
9. Perimortem cesarean delivery (PMCD) should be completed within 5 minutes of maternal arrest with unsuccessful resuscitation in a woman with fundal height at or above the umbilicus. PMCD may facilitate maternal resuscitation while also limiting fetal anoxia. Delivery should be performed at the site of arrest; the patient should not be transported.
10. Causes of maternal cardiac arrest may be remembered with the mnemonics BEAUCHOPS (bleeding/DIC, embolism, anesthetic complications, uterine atony, cardiac disease, hypertension, other [common etiologies as in standard ACLS guidelines], placenta previa or placental abruption, sepsis) or ABCDEFGH (anesthetic complications or accidents/trauma, bleeding, cardiovascular causes, drugs, embolic phenomena, fever, general [Hs and Ts], hypertension [preeclampsia/eclampsia/HELLP syndrome]).