Chapter 40 Management and Resuscitation of the Critical Patient.
Resuscitation of the Pregnant Patient
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Transcript of Resuscitation of the Pregnant Patient
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Resuscitation of the PregnantResuscitation of the Pregnant
PatientPatient
Ida BruniIda Bruni
February 6, 2008February 6, 2008
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Key PointsKey Points
During resuscitation there are twoDuring resuscitation there are two
patients, mother & fetuspatients, mother & fetus
The best hope of fetal survival is maternalThe best hope of fetal survival is maternalsurvivalsurvival
Consider the physiologic changes due toConsider the physiologic changes due to
pregnancypregnancy
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Interventions to Prevent ArrestInterventions to Prevent Arrest
To treat the critically ill pregnant patient:To treat the critically ill pregnant patient:
Place the patient in the left lateral positionPlace the patient in the left lateral position
Give 100% oxygenGive 100% oxygenEstablish IV access and give a fluid bolusEstablish IV access and give a fluid bolus
Consider reversible causes of cardiacConsider reversible causes of cardiac
arrest and identify any preexisting medicalarrest and identify any preexisting medicalconditions that may be complicating theconditions that may be complicating the
resuscitationresuscitation
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Resuscitation of the Pregnant Woman inResuscitation of the Pregnant Woman in
Cardiac ArrestCardiac Arrest
Modifications of Basic Life SupportModifications of Basic Life Support
At gestational age of greater than 20 weeks, theAt gestational age of greater than 20 weeks, thepregnant uterus can press against the IVC &pregnant uterus can press against the IVC &
aorta, impeding venous return and cardiacaorta, impeding venous return and cardiacoutputoutput
Uterine obstruction of venous return canUterine obstruction of venous return canproduce prearrest hypotension or shock and inproduce prearrest hypotension or shock and in
the critically ill patient may precipitate arrestthe critically ill patient may precipitate arrestIt also limits the effectiveness of chestIt also limits the effectiveness of chestcompressionscompressions
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Modifications of Basic Life SupportModifications of Basic Life Support
The gravid uterus may be shifted awayThe gravid uterus may be shifted away
from the IVC & aorta by placing in LUD orfrom the IVC & aorta by placing in LUD or
by pulling the gravid uterus to the sideby pulling the gravid uterus to the sideThis may be accomplished manually or byThis may be accomplished manually or by
placement of a rolled blanket or otherplacement of a rolled blanket or other
object under the right hip and lumbar areaobject under the right hip and lumbar area
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Modifications of Basic Life SupportModifications of Basic Life Support
AirwayAirway
Hormonal changes promote insufficiencyHormonal changes promote insufficiency
of the gastroesophageal sphincter,of the gastroesophageal sphincter,
increasing the risk of regurgitation.increasing the risk of regurgitation.Apply continuous cricoid pressure duringApply continuous cricoid pressure during
positive pressure ventilation for anypositive pressure ventilation for any
unconscious pregnant womanunconscious pregnant woman
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Modifications of Basic Life SupportModifications of Basic Life Support
AirwayAirway
Secure the airway early in resuscitationSecure the airway early in resuscitation
Use an ETT 0.5 to 1 mm smaller inUse an ETT 0.5 to 1 mm smaller in
internal diameter than that used for ainternal diameter than that used for anonpregnant woman of similar sizenonpregnant woman of similar size
because the airway may be narrowed frombecause the airway may be narrowed from
edemaedema
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Modifications of Basic Life SupportModifications of Basic Life Support
BreathingBreathing
Hypoxemia can develop rapidly becauseHypoxemia can develop rapidly because
of decreased FRC & increased O2of decreased FRC & increased O2
demand, so be prepared to supportdemand, so be prepared to support
oxygenation & ventilationoxygenation & ventilation
Ventilation volumes may need to beVentilation volumes may need to be
reduced because the mothers diaphragmreduced because the mothers diaphragm
is elevatedis elevated
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Modifications of Basic Life SupportModifications of Basic Life Support
CirculationCirculation
Perform chest compressions higher,Perform chest compressions higher,slightly above the center of the sternum toslightly above the center of the sternum toadjust for the elevation of the diaphragm &adjust for the elevation of the diaphragm &
abdominal contentsabdominal contentsVasopressor agents, including epinephrineVasopressor agents, including epinephrine& vasopressin, will decrease blood flow to& vasopressin, will decrease blood flow to
the uterus, but since there are nothe uterus, but since there are noalternatives, indicated drugs should bealternatives, indicated drugs should beused in recommended dosesused in recommended doses
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Modifications of Basic Life SupportModifications of Basic Life Support
DefibrillationDefibrillation
Defibrillate using standard ACLSDefibrillate using standard ACLS
defibrillation dosesdefibrillation doses
There is no evidence that shocks from aThere is no evidence that shocks from adirect current defibrillator have adversedirect current defibrillator have adverse
effects on the heart of the fetuseffects on the heart of the fetus
If fetal or uterine monitors are in place,If fetal or uterine monitors are in place,
remove them before delivering shocksremove them before delivering shocks
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Modifications of Basic Life SupportModifications of Basic Life Support
Differential DiagnosesDifferential Diagnoses
Same reversible causes of cardiac arrest thatSame reversible causes of cardiac arrest that
occur in nonpregnant women can occur duringoccur in nonpregnant women can occur during
pregnancypregnancy
Providers should be familiar with pregnancyProviders should be familiar with pregnancyspecific diseases & procedural complicationsspecific diseases & procedural complications
Use of abdominal US should be considered inUse of abdominal US should be considered in
detecting possible causes of the cardiac arrest,detecting possible causes of the cardiac arrest,but this should not delay other treatmentsbut this should not delay other treatments
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Modifications of Basic Life SupportModifications of Basic Life Support
Differential DiagnosesDifferential Diagnoses
Excess magnesium sulfateExcess magnesium sulfate
Iatrogenic overdose is possible in womenIatrogenic overdose is possible in women
with eclampsia, particularly if the womanwith eclampsia, particularly if the womanbecomes oliguricbecomes oliguric
Administration of calcium gluconate (1Administration of calcium gluconate (1
amp/1 g) is the treatment of choiceamp/1 g) is the treatment of choice
Empiric calcium administration may beEmpiric calcium administration may be
lifesavinglifesaving
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Modifications of Basic Life SupportModifications of Basic Life Support
Differential DiagnosesDifferential Diagnoses
Acute coronary syndromesAcute coronary syndromes
Pregnant women may experience ACS,Pregnant women may experience ACS,
typically in association with other medicaltypically in association with other medicalconditionsconditions
Because fibrinolytics are relativelyBecause fibrinolytics are relatively
contraindicated in pregnancy, PCI is thecontraindicated in pregnancy, PCI is the
reperfusion strategy of choice for STEMIreperfusion strategy of choice for STEMI
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Modifications of Basic Life SupportModifications of Basic Life Support
Differential DiagnosesDifferential Diagnoses
PrePre--eclampsia/eclampsiaeclampsia/eclampsia
PrePre--eclampsia/eclampsia develops aftereclampsia/eclampsia develops after
the 20th week of gestation & can producethe 20th week of gestation & can producesevere HTN & ultimate diffuse organsevere HTN & ultimate diffuse organ
system failuresystem failure
If untreated it may result in maternal andIf untreated it may result in maternal and
fetal morbidity & mortalityfetal morbidity & mortality
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Modifications of Basic Life SupportModifications of Basic Life Support
Differential DiagnosesDifferential Diagnoses
LifeLife--threateningPE & strokethreateningPE & stroke
Successful use of fibrinolytics for aSuccessful use of fibrinolytics for a
massive, lifemassive, life--threatening PE & ischemicthreatening PE & ischemicstroke have been reported in pregnantstroke have been reported in pregnant
womenwomen
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Modifications of Basic Life SupportModifications of Basic Life Support
Differential DiagnosesDifferential Diagnoses
Trauma and drug overdoseTrauma and drug overdose
Pregnant women are not exempt from thePregnant women are not exempt from the
accidents & mental illnessesaccidents & mental illnessesDomestic violence also increases duringDomestic violence also increases during
pregnancy; homicide & suicide are leadingpregnancy; homicide & suicide are leading
causes of mortality during pregnancycauses of mortality during pregnancy
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Modifications of Basic Life SupportModifications of Basic Life Support
Differential DiagnosesDifferential Diagnoses
Aortic dissectionAortic dissection
Pregnant women are at increased risk forPregnant women are at increased risk for
spontaneous aortic dissectionspontaneous aortic dissection
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Alberta woman fine after giving birth duringAlberta woman fine after giving birth during
emergency heart surgeryemergency heart surgery
Edmonton, AlbertaEdmonton, Alberta
Surgery was done Jan. 24, hours after the 35Surgery was done Jan. 24, hours after the 35week primip complained of SOB & Echo showedweek primip complained of SOB & Echo showeda thoracic aneurysma thoracic aneurysm
Cardiac Sx opened chest and monitoredCardiac Sx opened chest and monitoredmothers heart while the Obstetrical teammothers heart while the Obstetrical teamdelivered the babydelivered the baby
After the obstetrics team delivered the child,After the obstetrics team delivered the child,
Cardiac Sx completed the aorta graftCardiac Sx completed the aorta graftIt was the first such procedure carried out in theIt was the first such procedure carried out in theregion and only one of a handful done aroundregion and only one of a handful done aroundthe worldthe world
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Emergency Cesarean Delivery forEmergency Cesarean Delivery for
the Pregnant Woman in Cardiac Arrestthe Pregnant Woman in Cardiac Arrest
CPR leader should consider the need for an ERCPR leader should consider the need for an ER
cesarean delivery as soon as a pregnant womancesarean delivery as soon as a pregnant woman
develops cardiac arrestdevelops cardiac arrest
The best survival rate for infants 24The best survival rate for infants 24--25 weeks in25 weeks ingestation occurs when the delivery of the infantgestation occurs when the delivery of the infant
occurs no more than 5 minutes after theoccurs no more than 5 minutes after the
mothers heart stops beatingmothers heart stops beating
This typically requires that the provider begin theThis typically requires that the provider begin the
delivery about 4 minutes after cardiac arrestdelivery about 4 minutes after cardiac arrest
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Emergency Cesarean Delivery forEmergency Cesarean Delivery for
the Pregnant Woman in Cardiac Arrestthe Pregnant Woman in Cardiac Arrest
Delivery of the baby empties the uterus,Delivery of the baby empties the uterus,
relieving both the venous obstruction andrelieving both the venous obstruction and
the aortic compressionthe aortic compression
Delivery also allows access to the infantDelivery also allows access to the infant
so that newborn resuscitation can beginso that newborn resuscitation can begin
It is important to remember that you willIt is important to remember that you will
lose both mother & infant if you cannotlose both mother & infant if you cannot
restore blood flow to the mothers heartrestore blood flow to the mothers heart
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Decision Making for EmergencyDecision Making for Emergency
Cesarean DeliveryCesarean DeliveryConsider gestational ageConsider gestational age
Although the gravid uterus reaches a size thatAlthough the gravid uterus reaches a size that
will begin to compromise aortocaval blood flowwill begin to compromise aortocaval blood flow
at approximately 20 weeks of gestation, fetalat approximately 20 weeks of gestation, fetalviability begins at approximately 24 to 25 weeksviability begins at approximately 24 to 25 weeks
Portable US, may aid in determination ofPortable US, may aid in determination of
gestational age & positioning, but the use of USgestational age & positioning, but the use of US
should not delay the decision to perform deliveryshould not delay the decision to perform delivery
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Decision Making for EmergencyDecision Making for Emergency
Cesarean DeliveryCesarean DeliveryGestational age less than 20 weeksGestational age less than 20 weeksNeed not be considered because this size gravidNeed not be considered because this size graviduterus is unlikely to significantly compromiseuterus is unlikely to significantly compromisematernal cardiac outputmaternal cardiac output
Gestational age approximately 20 to 23 weeksGestational age approximately 20 to 23 weeks
Perform to enable successful resuscitation of thePerform to enable successful resuscitation of themother, not the survival of the delivered infant,mother, not the survival of the delivered infant,which is unlikely at this gestational agewhich is unlikely at this gestational age
Gestational age greater than 24 weeksGestational age greater than 24 weeksPerform to save the life of both the mother &Perform to save the life of both the mother &infantinfant
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Decision Making for EmergencyDecision Making for Emergency
Cesarean DeliveryCesarean DeliveryThe following can increase the infants survival:The following can increase the infants survival:
Short interval between the mothers arrest & theShort interval between the mothers arrest & the
infants deliveryinfants deliveryNo sustained prearrest hypoxia in the motherNo sustained prearrest hypoxia in the mother
Minimal or no signs of fetal distress before theMinimal or no signs of fetal distress before themothers cardiac arrestmothers cardiac arrest
Aggressive & effective resuscitative efforts forAggressive & effective resuscitative efforts forthe motherthe motherDelivery to be performed in a medical centerDelivery to be performed in a medical centerwith a NICUwith a NICU
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Decision Making for EmergencyDecision Making for Emergency
Cesarean DeliveryCesarean Delivery
Consider the professional settingConsider the professional setting
Are appropriate equipment and suppliesAre appropriate equipment and suppliesavailable?available?
Is emergency hysterotomy within the rescuersIs emergency hysterotomy within the rescuersprocedural range of experience & skills?procedural range of experience & skills?
Are skilled neonatal support personnel availableAre skilled neonatal support personnel availableto care for the infant, especially if the infant isto care for the infant, especially if the infant is
not full term?not full term?Are obstetric personnel immediately available toAre obstetric personnel immediately available tosupport the mother after delivery?support the mother after delivery?
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SummarySummary
Successful resuscitation of a pregnant woman &Successful resuscitation of a pregnant woman &
survival of the fetus require prompt & excellentsurvival of the fetus require prompt & excellent
CPR with some modifications in techniquesCPR with some modifications in techniques
By the 20th week of gestation, the gravid uterusBy the 20th week of gestation, the gravid uteruscan compress the IVC & aorta, obstructingcan compress the IVC & aorta, obstructing
venous return & arterial blood flowvenous return & arterial blood flow
Rescuers can relieve this compression byRescuers can relieve this compression by
positioning the woman on her side or by pullingpositioning the woman on her side or by pulling
the gravid uterus to the sidethe gravid uterus to the side
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SummarySummary
Defibrillation & medication doses used forDefibrillation & medication doses used forresuscitation of the pregnant woman areresuscitation of the pregnant woman arethe same as those used for other adultsthe same as those used for other adults
Rescuers should consider the need for ERRescuers should consider the need for ERCaesarian Delivery as soon as theCaesarian Delivery as soon as thepregnant woman develops cardiac arrestpregnant woman develops cardiac arrest
Rescuers should be prepared to proceed ifRescuers should be prepared to proceed ifthe resuscitation is not successful within 4the resuscitation is not successful within 4minutesminutes
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ReferenceReference
Cardiac Arrest Associated WithCardiac Arrest Associated With
Pregnancy.Pregnancy.C
irculationC
irculation 2005;112;IV2005;112;IV--150150--IVIV--153; 2005. American Heart Association153; 2005. American Heart Association