Cardiac disease in pregnancy resuscitation strategies

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Cardiovascular Drugs in Pregnancy

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Resuscitation in Late Pregnancy

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Special Scenarios:

I. Pre-existing Cardiac Disease:
Congenital Heart Disease
Repaired Congenital Heart Disease
Pulmonary Hypertension
Rheumatic Heart Disease
Connective Tissue Disorders
II. Valvular Heart Disease:
Mitral Stenosis
Mitral Regurgitation
Aortic Insufficiency
Aortic Stenosis
Mechanical Prosthetic Valves
Tissue Prosthetic Valves
III. Cardiomyopathy:
Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Peripartum Cardiomyopathy
IV. Cardiac diseases that may develop During Pregnancy:
Arrhythmias
Acute Myocardial Infarction
Hypertension

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Cardiac arrest occurs in approximately one in 30,000 women in late pregnancy.[1] Maternal mortality is caused by venous thromboembolism, severe preeclampsia or eclampsia, sepsis, amniotic fluid embolism, haemorrhage, trauma, iatrogenic causes including anaesthesia and drug errors or allergy, and congenital or acquired heart disease.[2]

Urgent hysterotomy or Caesarean section should be considered in the pregnant woman who has a cardiac arrest. If early resuscitation fails, birth of the fetus may improve both the maternal and the fetal chances of survival. Infants over 24-25 weeks gestation have the best chance of survival if birthed within 5 minutes of maternal cardiac arrest. It is recommended that hysterotomy or Caesarean section be initiated within 4 minutes after a cardiac arrest unless there has been a successful resuscitation and maternal perfusion restored within that time.[3]

Resuscitation Strategies

Position of the Pregnant Women

  • Position the women on her back with the shoulders flat. Place padding/wedge under the right buttock to give an obvious pelvic tilt to the left.[4]
  • The thighs of a rescuer may be used for resting the women on, and providing a lateral tilt.[1]
  • An assistant may move the uterus further off the vena cava by lifting the uterus with two hands to the left and towards the woman’s head.[1]

Airway Management

  • The woman should be inclined laterally for suction, removing ill-fitting dentures or foreign bodies, and inserting airways.[1]
  • Mouth to mouth or bag and mask ventilation is done with a pillow; the head and neck are fully extended.
  • Apply cricoid pressure until the airway is protected by a cuffed tracheal tube if sufficient staff are available to do this – this decreases the risk of gastric aspiration.[3]
  • A soon as possible tracheal intubation should be inserted – ensures adequate ventilation with increased intra-abdominal pressure.<[3]
  • Consider using a smaller tracheal tube if the airway is narrowed due to edema and swellling.[3]
  • Positioning for intubation - using one pillow helps to flex the neck and extend the head.[1]

Circulation Management

  • Adhesive defibrillator pads attachment are used to assist contact which may be difficult due to the larger breasts in the pregnant woman.[3]
  • Hand position higher than the normal position for chest compressions may be needed to adjust for the elevation of the diaphragm and abdominal contents due to the gravid uterus.[3]
  • Raising the woman’s legs will assist venous return.[1]

Gastrointestinal Management

Early intubation decreases the risk of gastric aspiration.[3]

Intiating Caesarean Section

If a pregnant woman collapses and requires resuscitation then a staff member should immediately collect the Caesarean Section Perimortem pack.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Morris S, Stacey M (2003). "Resuscitation in pregnancy". BMJ (Clinical Research Ed.). 327 (7426): 1277–9. doi:10.1136/bmj.327.7426.1277. PMC 286253. PMID 14644974. Retrieved 2012-04-16. Unknown parameter |month= ignored (help)
  2. Mallampalli A, Powner DJ, Gardner MO (2004). "Cardiopulmonary resuscitation and somatic support of the pregnant patient". Critical Care Clinics. 20 (4): 747–61, x. doi:10.1016/j.ccc.2004.05.005. PMID 15388200. Retrieved 2012-04-16. Unknown parameter |month= ignored (help)
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Soar J, Deakin CD, Nolan JP, Abbas G, Alfonzo A, Handley AJ, Lockey D, Perkins GD, Thies K (2005). "European Resuscitation Council guidelines for resuscitation 2005. Section 7. Cardiac arrest in special circumstances". Resuscitation. 67 Suppl 1: S135–70. doi:10.1016/j.resuscitation.2005.10.004. PMID 16321711. Retrieved 2012-04-16. Unknown parameter |month= ignored (help)
  4. Australian Resuscitation Council. Guideline 7 Cardiopulmonary resuscitation. In: Australian Resuscitation Council Guidelines; 2006.


Cardiology