ACLS for Cardiac Arrest in Pregnancy

9/7/2023

ACLS for In-Hospital Cardiac Arrest in Pregnancy

IHCA in pregnancy

In-Hospital Cardiac Arrest (IHCA) in pregnancy is a medical emergency that affects both the mother and the fetus.
The management of these patients requires a rapid and coordinated response from a multidisciplinary team of healthcare professionals, including obstetricians, anesthesiologists, cardiologists, neonatologists, and cardiothoracic surgeons.
The basic and advanced cardiac life support (BLS and ACLS) algorithms should be implemented as usual.
However, the physiologic and anatomic changes of pregnancy require some modifications to these protocols.
Randomized trials of approaches to the management of pregnant patients with IHCA are lacking.
Therefore, recommendations for modifications to BLS and ACLS protocols are based on expert opinion and data from small case series and small cohort studies.

ACLS algorithm for IHCA in pregnancy

The ACLS algorithm for IHCA in pregnancy includes the following steps:
Perform BLS and ACLS as would occur in any adult patient.
Chest compression and ventilation recommendations for the pregnant patient are the same as nonpregnant patients.
The mother should be placed supine for chest compressions.
Manual left uterine displacement (LUD) should be used to relieve aortocaval compression during resuscitation.
The energy required for defibrillation during cardiac arrest in pregnancy would be the same as for the nonpregnant patient.
If magnesium is being administered, stop it, and provide calcium gluconate or calcium chloride.
Fetal assessment should not be performed during resuscitation.
Fetal monitors should be removed or detached as soon as possible to facilitate perimortem Cesarean delivery (PMCD) without delay or hindrance.
If ROSC (return of spontaneous circulation) occurs, move to post-cardiac arrest care.
Pregnant women who remain comatose after resuscitation from cardiac arrest should receive targeted temperature management and fetal heart rate monitoring with OB/GYN support.
If ROSC does not occur within 5 minutes, consider perimortem Cesarean delivery.
The neonate should be evaluated for neonatal resuscitation.

Advanced Airway for IHCA in pregnancy

In pregnancy, a difficult airway is common.
Use the most experienced provider.
Provide endotracheal intubation or supraglottic advanced airway.
Perform waveform capnography or capnometry to confirm and monitor endotracheal tube placement.
Once an advanced airway is in place, give 1 breath every 6 seconds (10 breaths per minute) with continuous chest compressions.

Potential Etiology of Maternal Cardiac Arrest

Perimortem Cesarean Delivery (PMCD)

PMCD is a surgical delivery of a fetus from a mother in cardiac arrest.
It is performed when the mother has not responded to CPR after 4 minutes.
The goal of PMCD is to increase the chances of survival for both the mother and the fetus.
PMCD is recommended for fetuses at least 20 weeks gestation.
The decision to perform PMCD is made on a case-by-case basis, considering the fetus’ gestational age, the mother's medical condition, and the availability of resources, and skill of the medical team.
PMCD should be performed as quickly as possible.
Maternal and fetal survival rates following PMCD vary greatly based on multiple factors.

Take Home Message

In conclusion, in-hospital cardiac arrest in pregnancy requires a specialized approach to resuscitation.
The primary focus is on resuscitating the mother, and fetal monitoring should not be used during the resuscitation.
Oxygenation and airway management is crucial in the resuscitation of a pregnant woman.
Amiodarone should be avoided due to the risk of fetal thyroid and neurodevelopmental complications.

Perimortem Cesarean delivery should be considered if ROSC does not occur within 5 minutes.

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