ALERT

ETIOLOGY

• Trauma (penetrating or blunt):
  • Major cause of maternal mortality
• Pulmonary embolus:
  • Thromboembolism is most common cause of nontraumatic maternal mortality
• Cerebral vascular accident
• Amniotic fluid embolism
• DIC
• Placenta previa
• Eclampsia
• Miscellaneous medical disorders:
  • Asthma
  • CHF
  • MI
  • Drug overdose

SIGNS AND SYMPTOMS

History

Gravid female (> 24 wk gestation determined by uterine fundal height) who is in cardiopulmonary arrest

Physical Exam

Patient is determined to be > 24 wk gestation if uterus is at least 4 finger breadths above umbilicus

ESSENTIAL WORKUP

• Physical exam for apnea and pulselessness in obviously gravid female:
  • Quickly evaluate for reversible causes of cardiopulmonary arrest:
    • Hypoxia
    • Hypovolemia
    • Hydrogen ion (acidosis)
    • Hypokalemia/hyperkalemia
    • Hypoglycemia
    • Hypothermia
    • Trauma
    • Thromboembolism
    • Toxins/poisons
    • Tension pneumothorax
    • Tamponade (pericardial)
  • Supine hypotension syndrome (compression of inferior vena cava by enlarged uterus)
• Assess gestational age by uterine fundal height
  • Distance from pubis to fundus in centimeters is roughly equivalent to gestational age in weeks, i.e., 24 cm = 24 wk
• US is beneficial if immediately available to assess fetus.

DIAGNOSIS TESTS & INTERPRETATION

Imaging

• None necessary to establish cardiopulmonary arrest
• Do not use valuable time attempting to determine fetal heart tones

DIFFERENTIAL DIAGNOSIS

Cardiopulmonary arrest is final common pathway:

• Evaluate for underlying cause

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

Cautions:

• Minimal scene time, "scoop and run"
• Place the patient in the left lateral decubitus position to avoid compression of inferior vena cava (supine hypotension syndrome)
• Trauma patient requiring spinal immobilization:
  • Uterus can be manually displaced to left
  • Backboard can be wedged to keep right hip elevated 45°

INITIAL STABILIZATION/THERAPY

• Standard resuscitation measures:
  • Emergency intubation
    • Use a smaller endotracheal tube (0.5–1 mm less in internal diameter compared to that used for nonpregnant women)
  • High-flow oxygen
  • Cardiac and BP monitoring
  • 2 large-bore peripheral IV lines:
    • Fluid resuscitation
    • O-negative blood if indicated
• Fetal survival correlates with maternal survival and adequacy of initial maternal resuscitation
• If patient is at < 24 wk gestation, use advanced cardiac life support (ACLS) and advanced trauma life support protocols directed at maternal resuscitation
  • Do not perform emergent cesarean section
• If patient is > 24 wk gestation, use 4-min rule:
  • Perform ACLS or advanced trauma life support for 4 min
  • If no response, proceed to immediate emergency cesarean section
  • Goal is to deliver fetus within 1 min
  • If it is obvious there is no chance for maternal survival, begin perimortem cesarean section immediately

ED TREATMENT/PROCEDURES

• Call for immediate obstetric, surgical, and pediatric consultations:
  • Do not delay performing procedure while waiting for consultants
• Ensure a Foley catheter has been inserted to decompress bladder, but do not delay procedure
• Perform cesarean section:
  • Use linea nigra as landmark for vertical midline incision
  • Incise abdominal wall from pubic hairline to 5 cm above umbilicus.
  • This incision should pass through fascial and peritoneal layers
  • Retract urinary bladder inferiorly against pubic symphysis
  • Make small vertical incision in lower uterine segment, just cephalad to urinary bladder
  • Extend incision cephalad with scissors:
    • Insert your free hand into uterus
    • Lift uterine wall away from fetus to avoid fetal injury
  • Deliver fetus
  • Clamp umbilical cord in 2 places and cut between the 2 clamps
  • Manually deliver placenta
  • Perform neonatal resuscitation, as indicated
  • Immediately reassess maternal vital signs because occasionally spontaneous circulation may return
  • Continue maternal resuscitation as appropriate
  • Suture uterus with running lock stitch using no. 0 polyglactin suture
  • Suture fascia and peritoneum with running stitch using no. 0 polyglactin suture
  • Close the skin with staples or suture
  • Administer broad-spectrum antibiotics
• If maternal return of circulation is obtained, consider starting therapeutic hypothermia protocol

MEDICATION

First Line

Resuscitative measures/ACLS medications directed at mother:

• Treatment of underlying cause

Second Line

Neonatal resuscitation should be anticipated:

• Oral tracheal intubation

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• The infant should be admitted to NICU
• If maternal resuscitation is successful, patient should be admitted to appropriate ICU

Discharge Criteria

Neither infant nor mother should be discharged from ED

• Only females > 24 wk pregnant in cardiopulmonary arrest qualify for the procedure.
• Decision to perform perimortem cesarean section must be made quickly (within 4 min of maternal cardiopulmonary arrest)
• Procedure must be done quickly (< 1 min).

ICD9

• 427.5 Cardiac arrest
• 659.83 Other specified indications for care or intervention related to labor and delivery, antepartum condition or complication

ICD10

• I46.9 Cardiac arrest, cause unspecified
• O99.419 Diseases of the circ sys comp pregnancy, unsp trimester

[Outline]

• ICD9
• ICD10

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Jonathan B. Walker

James S. Walker