Scribd
Upload
69 views24 pages

Resuscitation in Pregnancy

Physiological changes in pregnancy can affect resuscitation efforts. A multidisciplinary team is needed when responding to maternal cardiac arrest, including obstetrics, neonatology, anesthesia, and intensive care specialists. High quality CPR and relief of aortocaval compression through left uterine displacement are priorities. Oxygenation and securing the airway are also important early steps given increased risk of hypoxia in pregnant patients. Perimortem cesarean section should be considered early to attempt rescue of both mother and fetus.

Uploaded by

Hassan Al Sinan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
69 views24 pages

Resuscitation in Pregnancy

Physiological changes in pregnancy can affect resuscitation efforts. A multidisciplinary team is needed when responding to maternal cardiac arrest, including obstetrics, neonatology, anesthesia, and intensive care specialists. High quality CPR and relief of aortocaval compression through left uterine displacement are priorities. Oxygenation and securing the airway are also important early steps given increased risk of hypoxia in pregnant patients. Perimortem cesarean section should be considered early to attempt rescue of both mother and fetus.

Uploaded by

Hassan Al Sinan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 24

RESUSCITATION

IN PREGNANCY
HASSAN ALSINAN – SBEM R2

SUPERVISED BY : DR ABDULLAH ALSHIHRI


OBJECTIVES

• Physiologic Changes in Pregnancy Affecting


Resuscitation
• Resuscitation variation and considerations in
Pregnancy
• Cardiac Arrest in pregnancy
PHYSIOLOGIC CHANGES IN PREGNANCY AFFECTING
RESUSCITATION

Cardiovascular system
Cardiac Output increases 30-50%
Peripheral Vascular resistance decrease by 20%
Plasma volume increase 30-50%
Systolic Blood pressure only decreased in first half of pregnancy
25% of blood flow directed to uteroplacental unit
Gravid uterus compress Vena cava and vessels below diaphragm
PHYSIOLOGIC CHANGES IN PREGNANCY AFFECTING
RESUSCITATION

Respiratory system
Upper airway edema , hyperemia and friability
Decreased Functional residual capacity
Increased metabolic oxygen consumption
Increased tidal volume and minute ventilation
Respiratory alkalosis
Diaphragm elevates approximately 4 cm
PHYSIOLOGIC CHANGES IN PREGNANCY AFFECTING
RESUSCITATION

Hematological
Increase risk of thromboembolism in second half of pregnancy

Genitourinary
Dilated renal collecting system , decrease ureteral peristalsis

GI
Bile more lithogenic (stone forming)
Decrease lower esophageal tone and gastric emptying
HOW WOULD THIS CHANGE OUR
APPROACH?
AIRWAY & INTUBATION

Difficult airway
- Landmark distortion ( weight gain)
- Edema of upper airway (fluid retention)
- Decreased safe apnea time ( oxygen consumption, FRC)
- Higher incidence of Mallampati Class III airway
- Airway bleeding ( Capillary friability)
- Higher likelihood of gastric aspiration
AIRWAY & INTUBATION
Approach
- Intubation by most experienced physician
- Minimize intubation attempts and manipulation
- Avoid blind nasotracheal intubation
- Smaller sized ET tube (0.5 to 1.0 mm smaller)
- Short laryngoscope handle
- Bougie and stylet ready
- VL facilitate first pass success
- Supraglottic devices
- Elevate head and shoulder with pillow to achieve sniffing position
- Consider semi-upright intubation
- Standard dosing RSI
RESUSCITATION VARIATION AND CONSIDERATIONS
IN PREGNANCY : BREATHING

• Vulnerable to the development of hypoxia ( decreased FRC , increase O2 consumption)

• In severe respiratory distress, might require PPV ( increased airway resistance)

• Consider high flow cannula in patient with intact respiratory drive


• Chest tubes should be placed in a relatively higher location

• IF Mechanical Ventilaiton, set to match pre-intubation MV

• Avoid hyperventilation : CO , cerebral perfusion, cause fetal acidosis


RESUSCITATION VARIATION AND CONSIDERATIONS
IN PREGNANCY : CIRCULATION
- IV access above diaphragm : Aortocaval compression compromise drug delivery during resuscitation of
pregnant woman >20 wks.

- Resuscitative fluids increase by 50% : accommodate blood and plasma volume increase

- Physiologic hypervolemia of pregnancy can mask acute blood loss, and hypotension may be a late
finding.

- Patient in left lateral position or manual left uterine displacement : aortocaval compression increase
afterload and decrease preload

- Volume adequately replaced before considering vasopressors: All pressors category C, decrease
uterine blood flow.
MANUAL LEFT UTERINE
DISPLACEMENT
SUPINE HYPOTENSION SYNDROME
• Hypotension ,tachycardia, dizziness, pallor, nausea
• After 30 minutes in supine position
• Mmx : place any patient in third trimester of
pregnancy in full left lateral position
SEPSIS

• Pregnant women More likely to develop complications from infections


• Differentiate sepsis from normal pregnancy (Leukocytosis, HR, Diastolic BO)
• Symptoms : Fever, rigors, diarrhea or vomiting, rash, abdo/pelvic pain , PV discharge, urinary sx, cough
• Most common causes : Pyelonephritis, pelvic inflammation
• Antibiotics : Beta lactams, Aminoglycosides and macrolides preferred
• Pyelonephritis most common cause of Septic shock ( MC organism : E.coli, Klebsiella, proteus)
– Need to hospitalize patient
• Pneumonia : rapid decline in O2 sats. Select Category B agents for treatment
• Influenza : high mortality and morbidity than non pregnant
– Lower severity in those vaccinated ( safe in pregnancy) & antivirals within 2 days of symptoms
CARDIAC ARREST IN PREGNANCY

• Quickly assess fetal viability as approach differs slightly


– Below Umbilicus : no Modifications, approach as non pregnant as per ACLS guidelines
– Above umbilicus :
• Manual left lateral displacement throughout CPR
• Consider Perimortem Cesearean delivery early

• Defibrillation is safe, no need to change shock doses


• IV access above diaphragm
• No Change in ACLS Medication
• Fetal monitoring?
Causes of Maternal cardiac arrest
Anesthetic Causes High Neuroaxial block
Aspiration
Respiratory distress
LA systemic toxicity

Bleeding Uterine Atony


Placental Abruption
Placenta previa
Coagulopathy
Trauma

Cardiovascular MI
Aortic Dissection
Arrhythmia

Drugs Anaphylaxis
Illicit (opioid , Cocaine , Benzodiazepine )
Mg Toxicity

Embolic PE
Amniotic fluid Embolism
Fever Sepsis
General non obstetric Hs & Ts
Hypertension Pre-eclampsia
Eclampsia
ICH
PERIMORTEM CESAREAN DELIVERRY
(RESUSCITATIVE HYSTEROTOMY )
- Emergent surgical procedure performed to rescue both a
potentially viable fetus and the mother during
cardiopulmonary arrest

- PMCD should begin at 4 minutes to effect delivery at 5


minutes after failed resuscitative efforts

- Delivery provides the mother with improved cardiac venous


return and upwards of one-third increase to cardiac output

- CPR should be initiated before and continue during and


after the procedure.

- Continuous manual LUD should be performed


throughout the PMCD until the fetus is delivered (
MEDICATIONS CATEGORIES AND
SAFETY
• Vasopressors all potentially increase uterine vascular resistance = decrease in placental blood
flow
• All pressors are category C during pregnancy
• ACOG recommends Epinephrine as vasopressor of choice for vascular collapse
• Atropine, Magnesium Sulfate and Lidocaine are Category B
• Fentanyl may cross placenta and may cause neonatal respiratory depression
• Data for RSI agents is limited, animal studies showing Etomidate and Succinylcholine to be
safe options
POST CARDIAC ARREST ECMO AND TTM

• TTM • ECMO
– Targeted temperature management – patients developing refractory arrest with
should be considered in pregnancy on reversible causes like local anesthetic
an individual basis toxicity, amniotic fluid embolism,
– Follow the same current protocol as for cardiogenic shock
the nonpregnant patient – Hysterectomy may be needed to control
– Fetal monitoring should be performed massive bleeding
throughout
MATERNAL CARDIAC ARREST TEAM?

• An adult resuscitation team (potentially composed of critical care physicians and nurses,
and/or emergency physicians and nurse , with respiratory therapy )
• Obstetrics: 1 obstetric nurse, 1 obstetrician
• Anaesthesia care provider
• Neonatology team: 1 nurse, 1 physician, 1 neonatal respiratory therapist
SUMMARY

• Consider physiological changes when approaching pregnant patient


• Call for help in cardiac arrest : Multi-team approach with assistance of Obstetrics,
Neonatologists, Anesthetist and and Intensive care.
• Priority of high quality CPR , and relief of aortocaval compression
• Oxygenation and airway management early as pregnant patient more prone to hypoxia
• Anticipate difficult airway
• Consider Perimortem CS early as resuscitative measure of both mother and fetus
REFERENCES
THANK YOU

Questions ??

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy