Anesthesia for Obstetrics and Gynecology - Cardiopulmonary Resuscitation During Pregnancy

Cardiac arrest during pregnancy

Cardiac arrest during pregnancy occurs in 1 per 20,000 pregnancies with a survival rate of only 6.9% despite the relative health of this population. CPR is more difficult and less successful than in individuals who are not pregnant. The following modifications to ACLS guidelines for adults are recommended for pregnant women by the American Heart Association and the Society for Obstetric Anesthesia and Perinatology:

  1. Standard basic life support (Chapter 38) 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. Compressions should occur 2 to 3 cm higher on the sternum in third trimester patients.
  3. Left uterine displacement should be used for all patients with a palpable or visible uterus at or above the umbilicus. Manual uterine displacement is likely preferable to left table tilt to prevent spinal hypotension and maximize mechanics for effective chest compressions.
  4. CPR should continue while an automated external defibrillator is prepared. All fetal monitors may be removed prior to defibrillation but should not delay the delivery of a shock. Pads are preferred to paddles when available.
  5. Airway management. In the nonintubated patient, two breaths of tidal volumes between 500 to 750 mL should be delivered alternating with 30 compressions. Nasal airways and repeated nasal manipulations should be avoided due to the risk for airway trauma and bleeding. Oxygenation and ventilation should be prioritized over risk for aspiration; cricoid pressure may not be effective and is not recommended.
  6. IV or intraosseous access is essential and must be obtained above the diaphragm in a timely fashion.
  7. Resuscitation drugs should be administered as per ACLS guidelines.
  8. Neonatal survival may be optimized when the fetus is delivered within the first 5 minutes of cardiac arrest.
  9. The mnemonic BEAUCHOPS may aid in considering causes of maternal cardiac arrest (Bleeding/DIC, Embolism, Anesthetic complications, Uterine atony, Cardiac disease, Hypertension, Other (common etiologies as in standard ACLS guidelines), Placenta previa or placental abruption, Sepsis).

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