Cardiac Arrest in Pregnancy

🚨 Cardiac Arrest in Pregnancy

Maternal cardiac arrest is rare but critical. Management = standard ALS + pregnancy-specific modifications. Saving the mother gives the fetus the best chance of survival.

⚡ Causes (Reversible – “BEAU-CHOPS”)

• 🩸 Bleeding (PPH, abruption, uterine rupture) • Shock, vaginal bleeding, uterine tenderness. • 🚑 Mx: ABC, massive transfusion protocol, uterotonics, surgical repair/hysterectomy.
• 🫁 Embolism (PE, amniotic fluid, air) • Sudden collapse, hypoxia, coagulopathy (AFE). • 🚑 Mx: O₂, ALS, thrombolysis/thrombectomy (PE), supportive fluids/vasopressors/blood products (AFE).
• 💉 Anaesthetic complications (high spinal, aspiration, anaphylaxis) • Hypotension, hypoventilation, desaturation. • 🚑 Mx: Intubate + 100% O₂, stop offending agent, anaphylaxis protocol (adrenaline, fluids, antihistamines, steroids).
• 🧷 Uterine atony (major PPH cause) • Boggy enlarged uterus, postpartum haemorrhage. • 🚑 Mx: Uterotonics (oxytocin, ergometrine, carboprost, misoprostol), uterine massage, balloon tamponade, surgery ± hysterectomy.
• ❤️ Cardiac disease (MI, arrhythmia, cardiomyopathy) • Chest pain, palpitations, cardiac history. • 🚑 Mx: PCI (MI), defibrillation/anti-arrhythmics, inotropes/ECMO for cardiomyopathy.
• ⚡ Hypertension (eclampsia, HELLP) • Seizures, headache, visual changes, RUQ pain. • 🚑 Mx: IV MgSO₄, antihypertensives (labetalol/hydralazine), expedite delivery if viable.
• 🚑 Other causes (trauma, metabolic, anaphylaxis) • Trauma → bleeding, pelvic injury; Sepsis → fever, hypotension. • 🚑 Mx: ATLS (trauma), IV antibiotics + source control (sepsis), adrenaline + airway support (anaphylaxis).
• 🧬 Placentation problems (previa, accreta, percreta) • Massive obstetric haemorrhage, shock. • 🚑 Mx: ABC, massive transfusion, surgical control ± hysterectomy, IR if available.
• 🦠 Sepsis (chorioamnionitis, puerperal sepsis, septic abortion) • Fever, tachycardia, hypotension, confusion. • 🚑 Mx: IV broad-spectrum antibiotics within 1 hr, fluids, vasopressors if refractory, surgical source control.

🍼 Perimortem Caesarean Delivery (PMCD)

• Start PMCD if no ROSC within 4 min → deliver by 5 min.
• Improves maternal venous return & cardiac output, plus chance of neonatal survival if ≥24 weeks.
• Perform on site during resuscitation – do not delay for theatre.

👩‍⚕️ Team & Logistics

• Call obstetrics, anaesthetics, neonatology, ICU early.
• Prepare neonatal resus if viable gestation (>24 wks).
• Post-ROSC → ICU + definitive management of underlying cause.

📌 Key Takeaways

• ALS with pregnancy modifications.
• Always think BEAU-CHOPS (reversible causes).
• 4–5 minute rule: PMCD if no ROSC by 4 min.
• Maternal survival = best fetal outcome.

🧭 Practical Modifications (UK ALS)

• 🤰 Prefer manual left uterine displacement (LUD) with patient supine; use 15–30° tilt only if LUD compromises compressions.
• 💓 CPR mechanics: hands slightly higher on sternum; depth 5–6 cm, rate 100–120/min; defib energies & drug doses unchanged (e.g., adrenaline 1 mg IV every 3–5 min).
• 🫁 Difficult airway: early RSI, smaller ETT (6.5–7.0), ramped position, continuous ETCO₂; avoid hypo-/hyperventilation post-ROSC.
• 🍼 PMCD trigger: if no ROSC by 4 min → incise immediately; do not transfer. If gestation uncertain, proceed when fundus ≥ umbilicus (~≥20 wks).
• 🫀 PE arrest: consider systemic thrombolysis in maternal arrest; evaluate for ECMO where available.
• ⚡ Magnesium toxicity (eclampsia Rx): treat with IV calcium if respiratory depression or arrest occurs.

📚 References

• Resus Council UK – Cardiac Arrest in Pregnancy
• ACOG – Cardiac Arrest in Pregnancy
• LITFL – Perimortem C-section