8/11/2019 Maternal Cpr 2010-1
1/40
MATERNAL CARDIAC
ARRESTObstetric and Neonatal Emergency
R Besthadi Sukmono
Anestesiologi dan Intensive Care
FKUI-RSCM
1Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
2/40
8/11/2019 Maternal Cpr 2010-1
3/40
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.
3Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
4/40
CAUSESUK maternal deaths (2003 - 2005)associated with:
cardiac disease;
pulmonary embolism;
psychiatric disorders;
hypertensive disorders of pregnancy
sepsis;hemorrhage;
amniotic-uid embolism;
ectopic pregnancy.
4Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
5/40
5Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
6/40
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
6Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
7/40
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
7Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
8/40
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
8Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
9/40
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
8/11/2019 Maternal Cpr 2010-1
10/40
BLS AND ACLSMODIFICATION
10Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
11/40
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.
11Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
12/40
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
12Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
13/40
Manual UterineDisplacement
Left uterine displacementperformed from the
patients left side withthe 2-handed technique
13Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
14/40
Manual UterineDisplacement
Left uterine displacementperformed from the the
patients right side withthe 1-handed technique
14Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
15/4015Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
16/4016Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
17/40
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
17Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
18/40
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
18Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
19/40
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
19Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
20/40
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.
20Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
21/4021Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
22/4022Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
23/40
THE FIVE HS AND TS
23Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
24/40
24Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
25/40
MATERNAL CARDIAC ARRESTNOT IMMEDIATELY REVERSED
BY BLS AND ACLS
EMERGENCY CESAREANSECTION IN CARDIAC ARREST
25Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
26/40
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
26Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
27/40
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.
27Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
28/40
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
28Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
29/40
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
29Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
30/40
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
30Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
31/40
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.
31Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
32/40
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.
32Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
33/40
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.
33Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
34/40
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
34Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
35/40
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.
35Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
36/40
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.
36Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
37/40
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
37Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
38/40
POSTCARDIACARREST CARE
38Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
39/40
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).
39Monday, April 21, 14
8/11/2019 Maternal Cpr 2010-1
40/40
THANK YOU