RJP Bumil

MATERNAL CARDIAC
ARREST
Obstetric and Neonatal Emergency
Multidiscipline approach
Alfan Mahdi Nugroho

Anesthesiology and Intensive Care
Department RSUPN Cipto Mangunkusumo
Thursday, February 26, 15
THE FACT
Mortality related to pregnancy in developed

countries is rare 1:30,000 deliveries.
Worldwide
2008 342,900 maternal deaths
Indonesia
2004 300 per 100.000 maternities
2010 228 per 100.000 maternities
MDG (2015) 103 per 100.000

maternities
MATERNAL MORTALITY
RATIO
UN Maternal mortality Estimation Group : WHO, UNICEF, UNFPA, World Bank

CAUSES OF MATERNAL DEATH

UK maternal deaths (2003 2005) associated with:
cardiac disease;
pulmonary embolism;
psychiatric disorders;
hypertensive disorders of pregnancy
sepsis;
hemorrhage;
amniotic-fluid embolism;
ectopic pregnancy.
PHASES OF DELAY
PHILOSOPHY
TWO
Fetal
potential patients: the mother and the fetus.
survival usually depends on maternal survival
Physiological
changes occur during pregnancy
OBJECTIVE
To review relevant maternal physiology
To review standard ACLS guidelines
To review ACLS modifications for pregnancy
Perimortem Caesarean Section
MATERNAL PHYSIOLOGY
-
CHANGES IN PREGNANCY
CARDIOVASCULAR
HEMATOLOGY
RESPIRATORY
METABOLIC
GASTROINTESTINAL
ENDOCRINOLOGY
MUSCULOSkELETAL
Anatomical Changes
Anatomical features relevant to difficult intubation

or ventilation
Large breasts
Edema or obesity of neck
Supra glottic edema
Flared ribcage
Raised diaphragm
PHYSIOLOGY CHANGES OF PREGNANCY AFFECTING

RESUSCITATION
Increased
Cardiovascular
Effect
Plasma Volume by 40 to 50 % but erythrocyte

volume only 20%
Dilutional Anemia, decreased Oxygen

Carrying Capacity
CO by 40%
Increase CPR circulation demands
HR by 15 - 20 bpm
Clotting Factors susceptible to thromboembolism
Dextrorotation of the heart
Decreased
Estrogen effect on myocardial receptors
Supraventricular Arrhythmia
Supine blood pressure and venous return with

aortocaval compression
Decreases CO by 30%
ABP by 10 - 15 mmHg
Susceptible to CV insult
SVR
Sequesters blood during CPR
Colloid oncotic Pressure
Susceptible to 3rd spacing
PCWP
Susceptible to Pulmonary Edema
PHYSIOLOGY CHANGES OF PREGNANCY AFFECTING

RESUSCITATION
Increased
Decreased
Respiratory
Effect
RR by Progesterone mediated
Decrease of buffering capacity
Oxygen consumption by 20%
Intrapulmonal shuntingby 12.8 - 15.3%
Increase the risk of hypoxemia
Tidal volume(progesterone mediated)
Minute ventilation
Compensated respiratory alkalosis
Laryngeal angle
Difficult intubation
Pharyngeal edema
Difficult intubation
Nasal edema
Difficult nasal intubation
FRC by 25%
Arterial PCO2
Serum bicarbonate
Respiratory alkalosis
PHYSIOLOGY CHANGES OF PREGNANCY

AFFECTING RESUSCITATION
Gastrointestinal
Effect
Increased
Intestinal compartmentalization
Susceptible to penetrating injury
Decreased
Peristalsis, gastric motility
Aspiration of gastric contents
Gastroesophageal sphincter tone
Aspiration of gastric content
Uteroplasental
Effect
Uteroplacental blood flow by 30% of CO
Sequesters blood in CPR
Aortocaval compression
decrease CPR effectiveness
Elevation of diaphragm by 4 to 7 cm
Uterine perfusion decreases with

drop in maternal blood pressure
Increased
Decreased
Increased
Autoregulation to blood pressure

Breast
Effect
Chest wall compliance secondary to breast

hyperthrophy
Increase CPR compression force
KEY INTERVENTIONS TO PREVENT

ARREST
Full left-lateral position
relieve possible compression of the inferior vena cava.
Give 100% oxygen.
Establish intravenous (IV) access above the diaphragm.
Assess for hypotension;
Systolic blood pressure <100 mmHg or < 80% baseline
Reduced placental perfusion.
Crystalloid and colloid increase preload
Consider reversible causes of critical illness and treat conditions as

early as possible
Immediately re-evaluate the need for any drugs being given.
Seek expert help early. Obstetric and neonatal specialists should

be involved early
The standard of care for treating the critically ill pregnant patient (Class I, LOE C):
Standard ACLS
guideline
Adult ALS 2010 Algorithm,

European Resuscitation Council
Adult ALS 2010 Algorithm,

American Heart Association
ALS MODIFICATION
IN PREGNANCY
GOAL AND OBJECTIVE

Adapt performance of Basic Life Support and Advanced Life
Support for Pregnant Woman
Airway management
Uterine displacement (patient positioning)
High quality chest compression
Deliver within 5 minutes
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Possible Modification of Resuscitative

effects in Pregnancy (BLS/primary)
Action
Rationale
Manual uterine displacement or 25 30 0 Left

lateral tilt
Decrease aortocaval compression
Increase chest wall compression force
Decreased chest wall compliance with breast

hyperthrophy and diaphragmatic elevation
Use cricoids pressure, if assistance available
Decrease gastric aspiration
Perform compression higher on sternum (Slightly Elevated diaphragm and abdominal content
above center of the sternum)
Defibrillation: remove fetal or uterine monitors
produced skin burns at monitor sites
Loss of adequate cardiac shock dose
Heimlich maneuver = chest thrust
Enlarged uterus displace diaphragm
Possible Modification of Resuscitative

effects in Pregnancy (ALS/secondary)
No
Procedures
Modification for Pregnant
Consideration
Airway
No modifications to intubation
techniques
Secure the airway early.

Use an smaller ETT
Breathing
No modifications to secondary
Clinical assessment & CO2
confirmation of successful intubation detector (ClassI)
Develop hypoxemia rapidly
Circulation
Follow standard ACLS

recommendations
Do not use lower extremity site
Differential
Diagnosis and
Decisions
Decision-making for
emergency hysterotomy.
Identity & treat reversible causes

(4Hs-4Ts)
Contributing factors ;
BEAU-CHOPS
PATIENT POSITIONING
Left Lateral Tilt
Increases
maternal stroke
volume by 30% with
decompression of the
inferior vena cava and the
aorta by the gravid uterus
Improved
fetal parameters
of oxygenation, nonstress
test, and fetal heart rate.
Manual Uterine
Displacement
Left uterine displacement
performed from the
patients left side with
the 2-handed
technique
Manual Uterine
Displacement
Left uterine displacement
performed from the the
patients right side
with the 1-handed
technique
Most common causes of cardiac arrest/

collapse in pregnancy.
Four Hs:
Hypoxia
Hypovolemia (hemorrhage or sepsis)
Hyper/hypokalemia/metabolic disorders
Hypothermia
Four Ts:
Thrombosis
Toxicity (drugs associated with regional or general anesthesia)
Tension pneumothorax
Cardiac tamponade
MATERNAL CARDIAC ARREST NOT

IMMEDIATELY REVERSED BY BLS AND
ACLS

ACLS

ACLS
EMERGENCY CESAREAN
SECTION IN CARDIAC ARREST
WHAT DEFINES A GRAVID UTERUS WITH THE

POTENTIAL TO CAUSE AORTOCAVAL
COMPRESSION?
Not every pregnant woman in cardiac arrest is a candidate for

an emergency cesarean section;
The decision depends on whether or not the gravid uterus is

thought to interfere with maternal hemodynamics.
The exact gestational age at which aortocaval compression

occurs is not consistent,
multiple-gestation pregnancies
intrauterine growth retardation,
Fundal height
Abdominal distention
Less than 20 weeks
2023 weeks,
Urgent Caesarean delivery need not be considered,

because a gravid uterus of this size is unlikely to
significantly compromise maternal cardiac output.
Initiate emergency hysterotomy to enable successful

resuscitation of the mother, not survival of the delivered
infant, which is unlikely at this gestational age.
2425 weeks, initiate emergency hysterotomy to save

the life of both the mother and the infant.
WHY PERFORM AN EMERGENCY CESAREAN

SECTION IN CARDIAC ARREST?
ROSC or improvement in maternal hemodynamic status only

after the uterus has been emptied
Pregnant women develop anoxia faster than non-pregnant

women and can suffer irreversible brain damage within
four to six minutes after cardiac arrest
One systematic review documented 38 cases of Caesarean

section during CPR, with 34 surviving infants and 13 maternal
survivors at discharge, suggesting that Caesarean section
may have improved maternal and neonatal
outcomes.
Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: were our assumptions correct? Am J Obstet Gynecol
2005;192:191620, discussion 201
THE IMPORTANCE OF TIMING WITH

EMERGENCY CESAREAN SECTION
When there is an obvious gravid uterus, the emergency

cesarean section team should be activated at the onset
of maternal cardiac arrest
Emergency cesarean section may be considered at 4

minutes after onset of maternal cardiac arrest if
there is no ROSC
The best survival rate for infants over 2425 weeks

gestation occurs when delivery of the infant is achieved
within 5 min after the mothers cardiac arrest.
THE IMPORTANCE OF TIMING WITH

EMERGENCY CESAREAN SECTION
At older gestational ages (3038 weeks), infant survival

is possible even when delivery was after 5 min from
the onset of maternal cardiac arrest
CPR must be continued throughout the caesarean

section and afterwards, as this increases the chances of a
successful neonatal and maternal outcome
WHERE THE CAESAREAN SECTION SHOULD

TAKE PLACE?
Moving the mother to an operating theatre (e.g. from a

labour room or accident and emergency department) is
not necessary.
Diathermy will not be needed initially, as there

is little blood loss if no cardiac output.
If the mother is successfully resuscitated, she can be moved

to theatre to complete the operation.
HOW SHOULD THE CAESAREAN SECTION

BE DONE?
A limited amount of equipment is required in this situation.

Sterile preparation and drapes are unlikely to
improve survival.
A surgical knife and forceps should be sufficient to effect delivery of

the baby.
There are no recommendations regarding the surgical

approach for caesarean section but
Operators should use the technique with which they are

most comfortable, and in the current context most obstetricians
can deliver a baby via a routine approach in less than a minute.
HOW SHOULD THE CAESAREAN SECTION

BE DONE?
Anesthesiologist is in attendance at the earliest opportunity.
Airway protection
Continuity of effective chest compressions and adequate ventilation breaths
Help determine and treat underlying cause (4 Hs and 4 Ts)
Should resuscitation be successful and the mother regain a cardiac output,

appropriate sedation/general anesthetic needs to be administered to
provide amnesia and pain relief.
If resuscitation is successful the mother should be moved to a theatre

to complete the operation.
FETAL OUTCOME
Timing of delivery is also important for the survival of the

infant and its normal neurological development.
In a comprehensive review of postmortem caesarean deliveries between

1900 and 1985 by Katz et al.,
70% (42/61) of infants delivered within five minutes survived and all developed
normally.
13% (8/61) of those delivered at 10 minutes and 12% (7/61) of infants delivered at
15 minutes survived.
One infant in both of these groups of later survivors had neurological sequelae.
Evidence suggests that if the fetus survives the neonatal period then the
chances of normal development are good.
INSTITUTIONAL PREPARATION FOR

MATERNAL CARDIAC ARREST
Have plans and equipment in place for

resuscitation of both the pregnant woman and newborn;
Ensure early involvement of obstetric, anesthetic

and neonatal teams;
Ensure regular training in obstetric emergencies
Team planning should be done in collaboration with the

obstetric, neonatal, emergency, anesthesiology, intensive care,
and cardiac arrest services
Essential Equipment (Should be

available in Labour ward)
Pulse oximeter
Cardiac arrest cart; defibrillator
Automatic Electric Defibrillator (AED)?
Cesarean section instruments
Difficult intubation equipment (including LMA, jet ventilator,
fiberoptic laryngoscope)
Blood warmer and rapid fluid infuser
Central venous and arterial line equipment

ELEMENT IN MANAGEMENT
Obstetrician!
Anaesthetist!
Assessment of patient condition!
Resuscitation!
General condition, BP, pulse, revealed blood Maintenance of haemodynaemic status of patient!
loss!
Fluid & blood product replacement!
Assessment of blood loss!
Estimation of blood loss!
Estimation of blood loss is notoriously
More experienced in blood loss estimation!
difficult & inaccurate!
Anaesthesia!
Control bleeding!
Induction a & maintenance of anaesthesia!
Manual pressure, oxytocic, operative
Drug administration!
procedures!
5 Elements in
management
Operating Theatre!
Preparation for emergency operation!
Assistance in operative procedures!
Scrub nurse to conduct operation!
Assist in administration of anaesthesia!
Assist in fluid, blood product and drug!
administration!
V Radiologist!
Control of haemorrhage!
Cannulisation of pelvic vessels!
Embolization of pelvic vessels to control!
bleeding!
VPaediatrican!
Resuscitation of newborn!
Stand by delivery!
Immediate resuscitation of newborn!
Escort newborn to NICU!
ELEMENT IN MANAGEMENT
Obstetrician
Hospital
Administration
Neonatology
Risk
Management
Anesthesiology
PATIENT
Blood Bank
Social Work
Nursing
Radiology
SUMMARY
Reviewed relevant maternal physiology
Reviewed standard ACLS guidelines

Reviewed modifications for pregnancy
Successful treatment requires:
-
Communication
Preparedness
Multidisciplinary Team Approach
THANK YOU FOR SAVING MY

MOM
POST CARDIAC ARREST CARE
One case report showed that postcardiac arrest

hypothermia can be used safely and effectively in
early pregnancy without emergency cesarean section (with
fetal heart monitoring), with favorable maternal and fetal outcome
after a term delivery.
No cases in the literature have reported the use of therapeutic

hypothermia with perimortem cesarean section.
POST CARDIAC ARREST CARE
Therapeutic hypothermia may be considered on an

individual basis after cardiac arrest in a comatose pregnant patient
based on current recommendations for the nonpregnant patient
(Class IIb, LOE C).
During therapeutic hypothermia of the pregnant patient, it is

recommended that the fetus be continuously monitored
for bradycardia as a potential complication, and obstetric and
neonatal consultation should be sought (Class I, LOE C).
MEDICO-LEGAL ISSUES
No
doctor has been found liable for performing a

postmortem caesarean section.
Theoretically, liability
wrongdoing.
Operating
If
may concern either criminal or civil
without consent may be argued as battery
the mother is successfully resuscitated. However, the

doctrine of emergency exception would be applied
because a delay in treatment could cause harm.
MEDICO-LEGAL ISSUES
The second criminal offense could be mutilation of corpse.
An operation performed to save the infant would not be

wrongful, because there would be no criminal intent.
The unanimous consensus of the literature is that a civil suit

for performing perimortem caesarean is very unlikely to
succeed.

RJP Bumil

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MATERNAL CARDIAC

Alfan Mahdi Nugroho

Thursday, February 26, 15

Mortality related to pregnancy in developed

2008 342,900 maternal deaths

2004 300 per 100.000 maternities

2010 228 per 100.000 maternities

MDG (2015) 103 per 100.000

Thursday, February 26, 15

UN Maternal mortality Estimation Group : WHO, UNICEF, UNFPA, World Bank

CAUSES OF MATERNAL DEATH

hypertensive disorders of pregnancy

Thursday, February 26, 15

Thursday, February 26, 15

potential patients: the mother and the fetus.

survival usually depends on maternal survival

Thursday, February 26, 15

changes occur during pregnancy

Thursday, February 26, 15

Thursday, February 26, 15

Thursday, February 26, 15

Anatomical features relevant to difficult intubation

Thursday, February 26, 15

PHYSIOLOGY CHANGES OF PREGNANCY AFFECTING

Plasma Volume by 40 to 50 % but erythrocyte

Dilutional Anemia, decreased Oxygen

Increase CPR circulation demands

Thursday, February 26, 15

Estrogen effect on myocardial receptors

Supine blood pressure and venous return with

Sequesters blood during CPR

Colloid oncotic Pressure

Susceptible to 3rd spacing

Susceptible to Pulmonary Edema

PHYSIOLOGY CHANGES OF PREGNANCY AFFECTING

Thursday, February 26, 15

Decrease of buffering capacity

Oxygen consumption by 20%

Decrease of buffering capacity

Intrapulmonal shuntingby 12.8 - 15.3%

Increase the risk of hypoxemia

Tidal volume(progesterone mediated)

Decrease of buffering capacity

Compensated respiratory alkalosis

Difficult nasal intubation

Decrease of buffering capacity

Decrease of buffering capacity

PHYSIOLOGY CHANGES OF PREGNANCY

Susceptible to penetrating injury

Peristalsis, gastric motility

Aspiration of gastric contents

Gastroesophageal sphincter tone

Aspiration of gastric content

Uteroplacental blood flow by 30% of CO

Sequesters blood in CPR

decrease CPR effectiveness

Uterine perfusion decreases with

Thursday, February 26, 15

Autoregulation to blood pressure

Chest wall compliance secondary to breast

Increase CPR compression force

KEY INTERVENTIONS TO PREVENT

Full left-lateral position