Maternal Cpr 2010-1

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MATERNAL CARDIAC

ARRESTObstetric and Neonatal Emergency

R Besthadi Sukmono

Anestesiologi dan Intensive Care

FKUI-RSCM

1Monday, April 21, 14

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OVERVIEW

2 potential patients: the mother and the fetus.

Fetal survival usually depends on maternal survivalPhysiological changes occur during pregnancy

Signicant compression by the gravid uterus to the

iliac and abdominal vessels in supine positionresulting in reduced cardiac output andhypotension.


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CAUSESUK maternal deaths (2003 - 2005)associated with:

cardiac disease;

pulmonary embolism;

psychiatric disorders;

hypertensive disorders of pregnancy

sepsis;hemorrhage;

amniotic-uid embolism;

ectopic pregnancy.


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Cardiovascular Effect Increased Plasma Volume by 40 to 50 % but erythrocyte volume only 20%

Dilutional Anemia, decreasedOxygen 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 withaortocaval 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 PREGNANCYAFFECTING RESUSCITATION


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Respiratory Effect

Increased RR by Progesterone mediated Decrease of buffering capacity

Oxygen consumption by 20% Rapid decrease of PaO2 inhypoxia state

Intrapulmonal shunting by 12.8 -15.3% Increase the risk of hypoxemia

Tidal volume (progesterone mediated) Decrease of buffering capacity

Minute ventilation Compensated respiratoryalkalosis

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


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Gastrointestinal Effect

Increased Intestinal compartmentalization Susceptible to penetrating injuryDecreased 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 cmUterine perfusion decreases withdrop in maternal blood pressure

Decreased Autoregulation to blood pressure

Breast Effect Increased Chest wall compliance secondary to breasthyperthrophy

Increase CPR compression force


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KEY INTERVENTIONS TOPREVENT 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

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BLS AND ACLSMODIFICATION


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PATIENT POSITIONING

Left Lateral Tilt

Increases maternal stroke volume by 30% withdecompression of theinferior vena cava and theaorta by the gravid uterus

Improved fetalparameters ofoxygenation, nonstresstest, and fetal heart rate.


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Chest Compression

Left-lateral tilt position are feasible in a manikin studyLess forceful chest compressions than the supineposition

30 o angle best with a xed hard wedge withpredetermined setting

manual left uterine displacement , which isdone with the patient supine, is as good as orbetter than left-lateral tilt in relieving aortocavalcompression


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Manual UterineDisplacement

Left uterine displacementperformed from the

patients left side withthe 2-handed technique


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Manual UterineDisplacement

Left uterine displacementperformed from the the

patients right side withthe 1-handed technique


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AIRWAY

Difculties

Anatomic and Physiologic changes duringpregnancy

Lateral Tilt

Increases the risks of aspiration and rapid desaturationOptimal use of bag-mask ventilation andsuctioning , while preparing for advanced airway


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AIRWAY

Issue of failed intubation in obstetric anesthesia as amajor cause of maternal morbidity and mortality.

Increased risk for pregnancy-related complications inairway management.

Intubation with an endotracheal tube or supraglotticairway should be performed only by experiencedproviders if possible.

Bag-mask ventilation with 100% oxygen beforeintubation is especially important in pregnancy


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BREATHING

Hypoxemia occurs rapidly because of decreasedfunctional 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 andmonitor oxygen saturation closely.

CIRCULATIONChest compressions should be performed slightly higheron the sternum than normally recommended


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DEFIBRILLATION AND DRUG

Debrillation and Drug is in accordance with ALSrecommendations.

It is difcult to apply an apical debrillator paddle

with the patient inclined laterally, ensure that thedependent breast does not come into contact withthe hand holding the paddle.

Magnesium sulphate is used to treat and preventeclampsia. If a high magnesium has contributed tothe cardiac arrest, consider giving calcium chloride.


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THE FIVE HS AND TS


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MATERNAL CARDIAC ARRESTNOT IMMEDIATELY REVERSED

BY BLS AND ACLS

EMERGENCY CESAREANSECTION IN CARDIAC ARREST


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WHAT DEFINES A GRAVID UTERUS WITH THEPOTENTIAL TO CAUSE AORTOCAVAL

COMPRESSION?

Not every pregnant woman in cardiac arrest is a candidate for anemergency cesarean section;

The decision depends on whether or not the gravid uterus isthought to interfere with maternal hemodynamics .

The exact gestational age at which aortocaval compression occurs isnot consistent ,

multiple-gestation pregnancies

intrauterine growth retardation,

Fundal height

Abdominal distention


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Less than 20 weeks

urgent Caesarean delivery need not be considered ,because a gravid uterus of this size is unlikely tosignicantly compromise maternal cardiac output.

2023 weeks,

initiate emergency hysterotomy to enablesuccessful resuscitation of the mother , notsurvival of the delivered infant, which is unlikely at

this gestational age.

" 2425 weeks, initiate emergency hysterotomy to savethe life of both the mother and the infant.


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WHY PERFORM AN EMERGENCYCESAREAN SECTION IN CARDIAC ARREST?

Return of spontaneous circulation or improvement in maternalhemodynamic status only after the uterus has beenemptied

Pregnant women develop anoxia faster than non-pregnantwomen and can suffer irreversible brain damage withinfour to six minutes after cardiac arrest

One systematic review documented 38 cases of Caesarean

section during CPR, with 34 surviving infants and 13 maternalsurvivors at discharge, suggesting that Caesarean section mayhave 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


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THE IMPORTANCE OF TIMING WITHEMERGENCY CESAREAN SECTION

When there is an obvious gravid uterus, the emergency cesarean sectionteam 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 spontaneouscirculation

The best survival rate for infants over 2425 weeks gestation occurswhen delivery of the infant is achieved within 5 min after the motherscardiac arrest.

At older gestational ages ( 3038 weeks ), infant survival is possible evenwhen delivery was after 5 min from the onset of maternal cardiac arrest

CPR must be continued throughout the caesarean section andafterwards, as this increases the chances of a successful neonatal andmaternal outcome


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FOUR MINUTE RULE

Maternal apneaassociated with rapiddeclines in PaO2 and

arterial pH

Fetus of an apnoeicand a systolic motherhas # 2 minutes ofoxygen reserve

After 4 minuteswithout restoration ofcirculation, dramaticaction must occur


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WHERE THE CAESAREAN SECTIONSHOULD 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 thereis little blood loss if no cardiac output.

If the mother is successfully resuscitated, she can bemoved to theatre to complete the operation.


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HOW SHOULD THE CAESAREANSECTION BE DONE?

A limited amount of equipment is required in this situation. Sterilepreparation 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 surgicalapproach 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 clinicalsituation.

Operators should use the technique with which they are mostcomfortable , and in the current context most obstetricians can deliver ababy via a routine approach in less than a minute.


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Consider open cardiac massage in the context of Caesarean sectionwhen the abdomen is already open and the heart can be reached relativelyeasily 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 beadministered to provide amnesia and pain relief.

If resuscitation is successful the mother should be moved to atheatre to complete the operation.


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Timing of delivery is also important for the survival of the infantand 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 alldeveloped normally.

13% (8/61) of those delivered at 10 minutes and 12% (7/61) of infantsdelivered at 15 minutes survived.

One infant in both of these groups of later survivors had neurologicalsequelae.

Evidence suggests that if the fetus survives the neonatal period then thechances of normal development are good.

FETAL OUTCOME


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MEDICO-LEGAL ISSUES

No doctor has been found liable for performing apostmortem caesarean section.

Theoretically, liability may concern either criminalor civil wrongdoing.

Operating without consent may be argued as battery

If the mother is successfully resuscitated. However, thedoctrine of emergency exception would be appliedbecause a delay in treatment could cause harm.


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The second criminal offense could bemutilation of corpse.

An operation performed to save the infant

would not be wrongful, because there would beno criminal intent.

The unanimous consensus of the literature is

that a civil suit for performing perimortemcaesarean is very unlikely to succeed.


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have plans and equipment in place for resuscitation ofboth the pregnant woman and newborn;

ensure early involvement of obstetric, anesthetic andneonatal teams;

Ensure regular training in obstetric emergencies

Team planning should be done in collaboration withthe obstetric, neonatal, emergency, anesthesiology,intensive care, and cardiac arrest services

INSTITUTIONAL PREPARATIONFOR MATERNAL CARDIAC ARREST


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POSTCARDIACARREST CARE


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One case report showed that postcardiac arrest hypothermiacan 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 therapeutichypothermia with perimortem cesarean section.

Therapeutic hypothermia may be considered on anindividual basis after cardiac arrest in a comatose pregnant patientbased on current recommendations for the nonpregnant patient(Class IIb, LOE C).

During therapeutic hypothermia of the pregnant patient, it isrecommended that the fetus be continuously monitored forbradycardia as a potential complication, and obstetric and neonatalconsultation should be sought (Class I, LOE C).


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