Cardiac Arrest in Pregnancy

Today we discuss a topic that we hope you never encounter, but want every OB, EM, and really any other person or medical professional to be prepared for cardiac arrest in pregnancy. The American Heart Association (AHA) Scientific Statement on Cardiac Arrest in Pregnancy can be found here and is essential companion reading.

(c) AHA

In preparation for a maternal cardiac event, a cesarean delivery kit should be available as part of the adult code cart. This at minimum should have a scalpel (#10 blade), betadine splash prep, clamps for cutting the umbilical cord, sponges, absorbable suture, and additional clamps and/or retractors if feasible. A neonatal resuscitation cart should accompany the adult cart if a maternal code is ongoing.

BLS is not different from standard for any other adult resuscitation, except for one key component: leftward displacement of the uterus. This allows for improved venous return to the right heart via the inferior vena cava, which may be compressed to some degree as early as 12 weeks gestation. Otherwise hand positioning, compression technique, and ventilation considerations in the BLS portion do not have any differences.

The ACLS algorithm also proceeds as usual, with the notable exception being performance of resuscitative hysterotomy (aka, peri-mortem cesarean section) at 4 minutes of pulseless arrest. This should be performed at any gestation above 20 weeks (i.e., fundal height at or above the umbilicus). It serves the dual purpose of improving maternal venous return, as well as protecting the fetus from consequences of prolonged anoxia.

Otherwise, ACLS algorithms use the same medications and doses, the same indications for shocks, and actually many times the same etiologies for arrest. However there are some pregnancy-specific considerations all physicians should recall, in a simple mnemonic:

(c) Society of Obstetric Anesthesia and Perinatology