Video Clips on DVD
- 14-1
PowerPoint Discussion of Cardiorespiratory Arrest and Resuscitation in Pregnancy
- 14-2
A Step-by-Step Video Demonstration of How to Manage a Pregnant Patient Who Develops Cardiorespiratory Arrest
Cardiorespiratory arrest (CRA) during pregnancy or postpartum is a rare complication with unknown incidence. The onset of CRA can be abrupt and unpredictable (as in the case of a massive pulmonary or amniotic fluid embolism) or gradual and expected (as seen with hypovolemic or septic shock). Potential causes of CRA in pregnancy are described in Table 14-1 .
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Maternal and perinatal outcomes after CRA depends on the cause as well as the speed of cardiopulmonary resuscitation (CPR), including timing of delivery. Similar to nonpregnant patients, a rapid response is essential; however, in cases of pregnancy, timing is extremely important because it relates to adequate resuscitation of the mother and effects on the fetus. In addition, there are factors unique to pregnancy as it relates to physiologic and anatomic changes ( Table 14-2 ), the technique of CPR ( Table 14-3 ), and the need to empty the uterus within 5 minutes of onset of CPR if there is no response.
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Case 1: Cardiorespiratory Arrest
A 40-year-old patient is pregnant for the first time with a twin gestation as a result of in-vitro fertilization. She has a 5-year history of chronic hypertension that required two antihypertensive medications for blood pressure management during this pregnancy. At 34 weeks’ gestation, she presented to an emergency department with shortness of breath, cough, and inability to sleep flat. Her blood pressure was 180 to 200 (systolic), 105 to 115 mm Hg (diastolic), and her heart rate was 115 beats per minute (bpm) with a respiratory rate of 24 breaths/min. Pulse oximetry was between 91% and 93%. Blood tests and urine were sent to rule out superimposed preeclampsia. Heart and lung examinations were noted to be normal. The patient received 10 mg of IV labetalol with a plan to observe response to treatment. During the observation period, the blood pressures remained between 174 to 186 and 100 to 110 mm Hg, the pulse was 120 bpm, and the respiratory rate was 28 breaths/min. The pulse oximeter was reading between 90% and 91%. After 30 minutes the patient was noted to be cyanotic, agitated, and sitting up on edge of the bed; this was followed by acute CRA. The physician was called and CPR was initiated in the emergency department using standard nonpregnancy techniques. This was continued for at least 5 minutes with no response. At that time, the obstetrician in the room called for emergency cesarean delivery for which the patient was transferred to the operating room. A low-transverse uterine incision was performed 12 minutes after the arrest with delivery of two live infants that were severely depressed. Both infants had evidence of severe metabolic acidosis and developed neonatal encephalopathy. After delivery of the infants, CPR was continued, but the patient expired 30 minutes later.
Discussion
Early detection and prompt management of potential causes of CRA during pregnancy are extremely critical because they may allow for interventions that will prevent adverse maternal and fetal outcomes as was evident in this case. This patient had several risk factors for pulmonary edema, and on presentation to the emergency department, her clinical findings were suggestive of early onset heart failure. No chest x-ray was ordered, and blood pressure was not adequately controlled. She then developed unobserved progressive hypoxia leading to respiratory and then cardiac arrest. The code team was called and CPR was started promptly, but the resuscitation team was not familiar with the appropriate techniques relevant to pregnancy. As a result, CPR was performed with the patient in supine position and the uterus was not displaced from compressing the inferior vena cava and aorta, particularly in the presence of twins. In addition, after CPR for 4 minutes, no attempts were made to deliver the infants both for maternal and fetal benefits. Finally, when the decision for delivery was made, the patient was moved to the operating room resulting in additional delay in timing of delivery.
This case demonstrates the lack of knowledge of CPR in pregnancy by the various providers responding to the code, particularly as to the importance of left uterine displacement to relieve aortocaval compression, and of prompt delivery within 5 minutes into CPR. In addition, it highlights the need for development of protocols for CPR in pregnancy including mechanisms for education, training, and methods to maintain skills in CPR for all physicians and staff providing obstetric services.
Several studies have reported that most physicians that may respond to perform CPR in pregnancy lack the necessary knowledge and skills to manage maternal resuscitation. These studies have identified limited knowledge of the importance of anatomic and physiologic changes in pregnancy, the technique to be used, and the potential life-saving benefit of cesarean delivery within 5 minutes. In addition, there was a lack of knowledge among providers regarding the safety and doses of medication to be administered during CPR.
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