Maternal CPR 2010-1

MATERNAL CARDIAC
ARREST
Obstetric and Neonatal Emergency
R Besthadi Sukmono
Anestesiologi dan Intensive Care
FKUI-RSCM
1 Monday, April 21, 14
OVERVIEW
Maternal death during pregnancy, childbirth, or 42 days postpartum
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
OVERVIEW
2 potential patients: the mother and the fetus.
Fetal survival usually depends on maternal survival
Physiological changes occur during pregnancy
Signicant compression by the gravid uterus to the
iliac and abdominal vessels in supine position
resulting in reduced cardiac output and
hypotension.
CAUSES
UK maternal deaths (2003 - 2005)
associated with:
cardiac disease;
pulmonary embolism;
psychiatric disorders;
hypertensive disorders of pregnancy
sepsis;
hemorrhage;
amniotic-uid embolism;
ectopic pregnancy.
Cardiovascular Effect
Increased
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
Estrogen effect on myocardial receptors Supraventricular Arrhythmia
Decreased
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 3
rd
spacing
PCWP Susceptible to Pulmonary Edema
PHYSIOLOGY CHANGES OF PREGNANCY
AFFECTING RESUSCITATION
Respiratory Effect
Increased RR by Progesterone mediated Decrease of buffering capacity
Oxygen consumption by 20%
Rapid decrease of PaO2 in
hypoxia state
Intrapulmonal shunting by 12.8 -
15.3%
Increase the risk of hypoxemia
Tidal volume (progesterone mediated) Decrease of buffering capacity
Minute ventilation
Compensated respiratory
alkalosis
Laryngeal angle Difcult intubation
Decreased Pharyngeal edema Difcult intubation
Nasal edema Difcult nasal intubation
FRC by 25% Decrease of buffering capacity
Arterial PCO2 Decrease of buffering capacity
Serum bicarbonate Respiratory alkalosis
Gastrointestinal Effect
Increased Intestinal compartmentalization Susceptible to penetrating injury
Decreased Peristalsis, gastric motility Aspiration of gastric contents
Gastroesophageal sphincter tone
Uteroplasental Effect
Increased Uteroplacental blood ow by 30% of CO Sequesters blood in CPR
Aortocaval compression Aspiration of gastric content
Elevation of diaphragm by 4 to 7 cm
Uterine perfusion decreases with
drop in maternal blood pressure
Decreased Autoregulation to blood pressure
Breast Effect
Increased
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
BLS AND ACLS
MODIFICATION
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.
Chest Compression
Left-lateral tilt position are feasible in a manikin study
Less forceful chest compressions than the supine
position
30
o
angle best with a xed hard wedge with
predetermined setting
manual left uterine displacement, which is
done with the patient supine, is as good as or
better than left-lateral tilt in relieving aortocaval
compression
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
AIRWAY
Difculties
Anatomic and Physiologic changes during
pregnancy
Lateral Tilt
Increases the risks of aspiration and rapid desaturation
Optimal use of bag-mask ventilation and
suctioning, while preparing for advanced airway
AIRWAY
Issue of failed intubation in obstetric anesthesia as a
major cause of maternal morbidity and mortality.
Increased risk for pregnancy-related complications in
airway management.
Intubation with an endotracheal tube or supraglottic
airway should be performed only by experienced
providers if possible.
Bag-mask ventilation with 100% oxygen before
intubation is especially important in pregnancy
BREATHING
Hypoxemia occurs rapidly because of decreased
functional residual capacity and increased oxygen demand
Ventilation volumes may need to be reduced because the
mothers diaphragm is elevated.
Prepare to support oxygenation and ventilation and
monitor oxygen saturation closely.
CIRCULATION
Chest compressions should be performed slightly higher
on the sternum than normally recommended
DEFIBRILLATION AND DRUG
Debrillation and Drug is in accordance with ALS
recommendations.
It is difcult to apply an apical debrillator paddle
with the patient inclined laterally, ensure that the
dependent breast does not come into contact with
the hand holding the paddle.
Magnesium sulphate is used to treat and prevent
eclampsia. If a high magnesium has contributed to
the cardiac arrest, consider giving calcium chloride.
THE FIVE HS AND TS
MATERNAL CARDIAC ARREST
NOT IMMEDIATELY REVERSED
BY BLS AND 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
urgent Caesarean delivery need not be considered,
because a gravid uterus of this size is unlikely to
signicantly compromise maternal cardiac output.
2023 weeks,
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?
Return of spontaneous circulation 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 return of spontaneous
circulation
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.
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
FOUR MINUTE RULE
Maternal apnea
associated with rapid
declines in PaO2 and
arterial pH
Fetus of an apnoeic
and a systolic mother
has # 2 minutes of
oxygen reserve
After 4 minutes
without restoration of
circulation, dramatic
action must occur
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 sufcient to effect delivery of the
baby.
There are no recommendations regarding the surgical
approach for caesarean section but
Classical approach is aided by the natural diastasis of recti abdomini
that occurs in late pregnancy and a bloodless eld in this clinical
situation.
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.
Consider open cardiac massage in the context of Caesarean section
when the abdomen is already open and the heart can be reached relatively
easily through the diaphragm.
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.
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 ve 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.
FETAL OUTCOME
MEDICO-LEGAL ISSUES
No doctor has been found liable for performing a
postmortem caesarean section.
Theoretically, liability may concern either criminal
or civil wrongdoing.
Operating without consent may be argued as battery
If the mother is successfully resuscitated. However, the
doctrine of emergency exception would be applied
because a delay in treatment could cause harm.
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.
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
INSTITUTIONAL PREPARATION
FOR MATERNAL CARDIAC ARREST
POSTCARDIAC
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.
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).
THANK YOU

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MATERNAL CARDIAC

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