Cardiopulmonary Resuscitation in Pregnancy

Aka: Cardiopulmonary Resuscitation in Pregnancy, Obstetrical Resuscitation, CPR in Pregnancy, Cardiac Arrest in Pregnancy, Pregnant Women with Cardiac Arrest, Maternal Cardiac Arrest

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II. Epidemiology

  1. Cardiac Arrest Incidence: 1 in 20,000 pregnancies

III. Differential Diagnosis (Mnemonic ABCDEFG)

  1. Anesthetic Complications
  2. Bleeding
    1. Postpartum Hemorrhage
    2. Placental Abruption
    3. Placenta Previa
    4. Ruptured Ectopic Pregnancy
  3. Cardiovascular
    1. Aortic Dissection
    2. Myocardial Infarction
      1. Pregnant women are at increased risk of Acute Coronary Syndrome (ACS) despite young age
      2. Acute Coronary Syndrome was responsible for 20% of maternal deaths from 2006-2008
      3. Nelson-Piercy (2012) Heart 98(10): 760-1 [PubMed]
  4. Drugs
  5. Embolic
    1. See Pulmonary Embolism in Pregnancy
    2. Pulmonary Embolism
    3. Amniotic Fluid Embolism (Anaphylactoid Syndrome of Pregnancy)
  6. Fever
    1. Chorioamnionitis
    2. Postpartum Endometritis
    3. Pyelonephritis in Pregnancy
  7. General Non-obstetric causes of Cardiac Arrest
    1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  8. Hypertension
    1. See Severe Preeclampsia

IV. Technique: Resuscitation (as contrasted to non-pregnant Resuscitation)

  1. Similarities: Approach for most of the CPR and ACLS guidelines are the same as for non-pregnant patients
    1. CAB Approach (compressions first)
    2. Defibrillate unstable or pulseless
    3. Post-ROSC Hypothermia
      1. Case reports of improved outcomes post-Cardiac Arrest in Pregnancy
      2. Chauhan (2012) Ann Emerg Med 60(6): 786-9 [PubMed]
  2. Differences in the pregnant Cardiac Arrest patient
    1. Compression hand position
      1. Place hands 1-2 interspaces higher than in non-pregnant patient
    2. Elevate head of bed
      1. Allows better diaphragm excursion by decreasing upward abdominal pressure
    3. Perform CPR with patient still supine, but with Uterus deflected to side during CPR (second rescuer)
      1. Aorta and vena cava are compressed by gravid Uterus
        1. Venous return is reduced by up to 30% (especially after 20 weeks gestation)
      2. Uterine deflection replaces prior guidelines
        1. Previously recommended compressions with patient at 30 degrees left lateral decubitus position
        2. May place in left lateral decubitus position after Return of Spontaneous Circulation (ROSC)
    4. Heimlich Maneuver
      1. Chest thrusts may be used in place of abdominal thrusts if gravid Abdomen interferes with hand placement
    5. Avoid Amiodarone if at all possible
      1. Amiodarone is a Class D medication due to association with Fetal Bradycardia, IUGR, Preterm Labor
    6. Intravenous Access
      1. Intravenous Access is preferred above the diaphragm (due to aortocaval compression by the Uterus/fetus)
      2. Prefer large bore peripheral antecubital IVs
      3. Central Intravenous Access at the internal jugular or subclavian, or Humeral IO may be considered
      4. Avoid femoral Central Line or tibial IO (due to aortocaval compression)
    7. Early airway management is paramount
      1. Aspiration risk
        1. Pregnancy increases aspiration risk significantly
      2. Equipment modifications
        1. Estimate a smaller sized Endotracheal Tube (6.5 to 7.0)
        2. Use a short-handled Laryngoscope (in Direct Laryngoscopy)
          1. Allows for increased Breast size in pregnancy that impacts Laryngoscope maneuverability
      3. Intubation attempt time is significantly reduced
        1. See Endotracheal Intubation Preoxygenation
        2. Decreased functional reserve of oxyegn with rapid desaturation
        3. Employ Apneic Oxygenation
        4. Most experienced intubator should intubate (first attempt success is critical)
        5. May require smaller ET Tube (secondary airway edema in pregnancy)

V. Management: Perimortem Cesarean Section

  1. See Perimortem Cesarean Section (Emergency Hysterotomy)
  2. Consider for Gestational age >24 weeks
  3. Assemble Emergency Hysterotomy equipment and staff as part of initial code response

VI. References

  1. Mattu in Herbert (2013) EM:Rap 13(4):11-2
  2. Swaminathan and Mallemat (2024) EM:Rap, 9/23/2024
  3. (2022) ACLS Maternal Cardiac Arrest Guidelines, AHA
  4. Farinelli (2012) Cardiol Clin 30(3): 453-61 [PubMed]
  5. Murphy (2014) Am Fam Physician 90(10): 717-22 [PubMed]

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