Purpose: To update established guidelines for
rapid assessment and treatment of pregnant patients in cardiac arrest
Background: Though rare, maternal cardiac arrest
can be a challenging clinical scenario. Trauma in pregnancy is a leading cause
of non-obstetric maternal death, however other causes include PE, cardiac
failure and septic shock. The management of these codes differs and depends
upon gestational age (viability) and cause of cardiac arrest. The age of viability for a fetus/neonate is
considered 23 weeks with medical advances. Maternal survival is improved by
delivery during medical causes of cardiac arrest, however the evidence is
lacking for traumatic/hemorrhagic causes of cardiac arrest. The decision to
proceed with perimortem cesarean delivery (PMCD) is best made in consultation
with MFM. Team management in any code is therefore crucial with clearly defined
roles and protocols.
Procedure: To effectively manage a maternal code,
a multidisciplinary approach is key. Maternal and fetal status are reliant upon
one another as are decisions regarding mother and fetus. Maternal status is
often reliant upon efficiency of delivery as well. Thus, early recognition of
gestational age and fetal status is useful in planning management of the
patient.
ABCs for potential mechanism of maternal cardiac
arrest:
1.
Anesthetic complication
a.
Hypotension
b.
High neuraxial block
c.
Aspiration
2.
Bleeding:
a.
Obstetric reasons: PPH. atony,
abruption, rupture
b.
Surgical
c.
Traumatic - PMCD may or may not be
indicated
3.
Cardiovascular:
a.
Arrhythmia
b.
MI, aortic dissection,
cardiomyopathy
c.
Congenital/acquired cardiac
lesions, valvular disease
4.
Drugs:
a.
Magnesium
b.
Illicit drugs
5.
Embolic:
a.
Pulmonary embolus
b.
Amniotic fluid embolus
c.
Air embolism
6.
Fever:
a.
Sepsis
7.
Neurologic:
a.
CVA: embolic or hemorrhagic
b.
Sinus venous thrombosis
Initial management:
1.
Maternal code near or > 23
weeks, call code, OB, neonatology
2.
Begin ACLS
3.
Displace uterus to the left using
2 hands or a hip bump
4.
Defibrillate if necessary
5.
Airway management/ventilation
a.
Optimize first attempt at
intubation: have difficult airway supplies and a 6-0 ET tube
b.
Second attempt: alternative
technique, cricoid pressure changed
c.
Third attempt: insert LMA or
surgical airway
6.
IV access: preferably above
diaphragm
7.
No variation in drugs given for
ACLS
8.
OB performs PMCD as code team runs
code
Published 11/12/17 (C Talley, S Priest, A Bernard); Reviewed 11/7/23 (C Reynolds, A Bernard)
