Circulation

High-quality chest compressions.

Perform continuous manual left uterine displacement (LUD)

Follow ACLS medication guidelines. Give typical drugs and dosages.

Vasopressors, if used, may cause fetal demise.

Defibrillate as indicated.

Place intravenous access line above the diaphragm.

Manual LUD needed to relieve aortocaval compression and improve maternal cardiac output.

These drugs cause decreased uterine blood flow; no alternatives exist.

No modification of currently recommended defibrillation protocol is needed.

Airway

Secure airway with continuous cricoid pressure before and during endotracheal intubation.

Plan to use smaller (0.5-1mm) endotracheal tube.

Gastroesophageal sphincter insufficiency.

Airway edema.

Breathing

Support oxygenation and ventilation (100% oxygen supplementation).

Verify tube placement with exhaled CO2 detector and clinical assessment.

Reduced ventilatory volumes should be used.

Decreased functional residual capacity, increased oxygen demand.

Esophageal detector devices can fail to detect proper placement in late pregnancy.

Elevated diaphragm reduces lung capacity.

Differential Diagnosis

Same reversible causes as in nonpregnant patients, also look for pregnancy-specific diseases and procedural complications.

Review possible causes: anesthetic complications/accidents; bleeding; cardiovascular; drugs; embolic; fever; general nonobstetric causes of cardiac arrest (Hs & Ts); hypertension.

Magnesium sulfate overdose: Treat with calcium gluconate (1 ampule/1g).

Acute coronary syndromes: Fibrinolytics are relatively contraindicated; choice is percutaneous coronary intervention for ST-elevation myocardial infarction.

Preeclampsia/eclampsia: Untreated, increased risk of maternal and fetal morbidity and mortality.

Aortic dissection: Increased risk for spontaneous aortic dissection.

Life-threatening massive pulmonary embolism and ischemic stroke: Use fibrinolytics.

Amniotic fluid embolism: Use cardiopulmonary bypass. Trauma and drug overdose.