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92
CHAPTER 11 Resuscitation in Pregnancy
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SECTION I RESUSCITATION SKILLS AND TECHNIQUES
starts with the ABCs (airway, breathing, and circulation). One Defibrillation energy requirements remain the same (Fig.
hundred percent oxygen should be administered to the mother 11.2).9 Defibrillation will not harm the fetus. ACLS medica-
early. Hypoxia should be treated aggressively in this patient tions should be used as needed. It is reasonable to remove
population because when the mother is hypoxic, oxygen is external or internal fetal monitoring devices during electrical
shunted away from the fetus. Additionally, preoxygenation is shock of the mother because of the possibility of creating
important because apnea results in more rapid hypoxia in the an electrical arc to the monitoring equipment, but this is
setting of pregnancy. Rapid-sequence induction with precau- unlikely with the electrical current applied to the maternal
tions for aspiration is essential before intubation. Aggressive thorax. Box 11.2 lists the U.S. Food and Drug Administra
volume resuscitation, administration of vasopressors if needed, tion categories for the various ACLS drug options during
and close attention to the patients body position are all very pregnancy.
important in the treatment of hypotension in a pregnant In pregnant patients with trauma who are in need of a tho-
patient. Fetal heart monitoring and, ideally, cardiotocographic racostomy, the chest tube must be placed one or two intercos-
monitoring should be initiated as soon as possible for patients tal spaces higher than normal to avoid diaphragmatic injury.
in the second or third trimester of pregnancy.8 An open supraumbilical approach should be used for diagnos-
A commercially produced wedge called a Cardiff wedge tic peritoneal lavage in a pregnant patient, with the gravid
is available to aid in the resuscitation of pregnant women. uterus palpable on abdominal examination.
It can be placed under the womans right side to support her If return of spontaneous circulation (ROSC) is achieved,
back while she lies in the preferred left lateral tilt position. In effort must be directed at further hemodynamic stabilization.
the absence of a wedge, a human wedge can be used, with Postcardiac arrest therapeutic hypothermia has been success-
the patient being tilted on the bent knees of a kneeling ful in the setting of early pregnancy and is recommended as
rescuer. Pillows, towel rolls, and blanket rolls are readily for nonpregnant patients.10 In a comatose postcardiac arrest
available in EDs and accomplish the same purpose of patient with ROSC, the patient should be cooled as soon as
angling the womans back 30 to 45 degrees from the floor possible and within 4 to 6 hours to 32 C to 34.8 C for a
(Fig. 11.1). If for some reason the patient must lie on her back, 12-to 24-hour duration to gain the best possible neurologic
as in the case for adequate cardiopulmonary resuscitation outcome. If a perimortem cesarean section has not been per-
(CPR), a member of the health care team should manually formed because of gestational age less than 24 weeks, fetal
displace the uterus to the left so that it does not rest on the monitoring should be performed during hypothermia in anti
great vessels. cipation of bradycardia.11
The American Heart Association (AHA) basic life support
guidelines should be followed with two modifications: IMAGING
Ultrasonography is an important method for assessment of
Move the uterus off the great vessels. both the mother and fetus, but additional radiographic studies
Adjust the hand position for CPR cephalad to account for are often required. Shielding can ensure that exposure even
displacement of the thoracic contents by the gravid uterus. with maternal head and chest computed tomography (CT) can
be kept below the 1-rad (1000-millirad) limit. Intrauterine
The AHA advanced cardiac life support (ACLS) guidelines exposure to 10 rad (10,000 millirad) produces a small increase
for medications, intubation, and defibrillation for patients in in childhood cancer; exposure to 15 rad creates a risk for
cardiac arrest should be followed for gravid females with one mental retardation, childhood cancer, and a small head. A
simple exceptiona change in placement of the defibrillation head or chest radiograph delivers less than 1 millirad to the
paddles and pads: shielded gravid uterus. A lumbar spine, hip, or kidneys-
ureters-bladder radiograph delivers more than 200 millirad. A
Place one paddle below the right clavicle in the midclavicu- CT scan of the head delivers less than 50 millirad to the
lar line. shielded uterus, and a chest CT scan provides an exposure of
Position the second paddle outside the normal cardiac apex less than 1000 millirad. In sum, important radiographic studies
so that it avoids breast tissue.7 of the head, neck, and chest can safely proceed if the uterus
is shielded.
FETOMATERNAL TRANSFUSION
After the 12th week of pregnancy, when the uterus rises
above the pelvic rim and becomes susceptible to trauma, fetal
blood can theoretically cross into the maternal circulation
after significant trauma. A 50-mcg dose of Rh immuno
globulin (RhoGAM) is used when the mother is Rh negative.
During the second and third trimesters a 300-mcg dose is
administered, which protects against 30mL of fetomaternal
hemorrhage. A 16-week fetus has about a 30-mL volume
of blood, so the entire blood volume is covered by the 300-
mcg dose.
Pregnant patients in the second or third trimester who suffer
Fig. 11.1 Blanket roll technique to tilt the patient. major traumatic injury could theoretically have fetomaternal
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CHAPTER 11 Resuscitation in Pregnancy
Airway
Breathing
Circulation
Defibrillation/definitive care
Fig. 11.2 Algorithm for resuscitation of a pregnant patient. CPR, Cardiopulmonary resuscitation.
transfusion that exceeds the coverage provided by the 300-mcg morbidity and mortality in the child. If resuscitative efforts,
dose. This situation is rare and occurs in less than 1% of including ACLS algorithms and alleviation of aortocaval com-
pregnant patients after trauma. In patients with major trauma pression, fail to improve maternal hemodynamics, perimor-
and advanced pregnancy, the Kleihauer-Betke test should be tem cesarean section must be considered. The likelihood that
considered, especially when significant vaginal bleeding is perimortem cesarean section will result in a living and neu-
present. Rh immunoglobulin is effective when administered rologically normal infant is related to the interval between
within 72 hours, so the test does not have to be performed in onset of maternal cardiac arrest and delivery of the infant.12,13
the ED. The gestational age of the neonate is also critical. If cesarean
section is performed in the ED, it should be done rapidly. Time
is of the essence. Fetal viability outside the uterus is best
PERIMORTEM CESAREAN SECTION beyond 24 weeks gestation, but it is not always possible to
know the exact gestational age in the ED. On the basis of case
The two goals of perimortem cesarean section are to improve reports, it is recommended that cesarean section be performed
the unstable hemodynamics of the mother and minimize in the ED if the gestational age is believed to be more than
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SECTION I RESUSCITATION SKILLS AND TECHNIQUES
BOX 11.2 Classification of Drugs Used During BOX 11.3 Technique for Perimortem
Pregnancy Cesarean Section
The U.S. Food and Drug Administration categories for the NOTE: Have suction available for this procedure because
various advanced cardiac life support drug options during bleeding can be excessive.
pregnancy are as follows: 1. Ideally, while the emergency physician is preparing for
Category B the procedure, a catheter is placed in the bladder and
Definition the abdominal wall is prepared with povidone-iodine.
Animal studies have revealed no evidence of harm to the However, do not delay the procedure for these
fetus, although no adequate and well-controlled studies in activities.
pregnant women have been conducted. 2. Using a No. 10 scalpel, make a midline vertical incision
OR from the umbilicus to the pubis along the linea nigra.
Animal studies have shown an adverse effect, but adequate 3. Once the peritoneal cavity is open, use bladder retrac-
and well-controlled studies in pregnant women have failed to tors and Richardson retractors to improve access to the
demonstrate a risk to the fetus in any trimester. uterus.
4. Make a short vertical incision in the lower uterine segment
Agents
just cephalad to the bladder.
Atropine
5. Extend the uterine incision cephalad with blunt scissors.
Magnesium
Place a hand in the uterus to keep the baby from
Category C being cut.
Definition 6. Deliver the baby.
Animal studies have shown an adverse effect, and no ade- 7. Suction the mouth and nose, cut and clamp the umbilical
quate and well-controlled studies in pregnant women have cord, and resuscitate the baby.
been conducted. 8. Document Apgar scores at 1, 5, and 10 minutes.
OR 9. If the mother regains vital signs, remove the placenta and
No animal studies have been conducted, nor have ade repair the uterus and abdominal wall.
quate and well-controlled studies in pregnant women been 10. Consider intramuscular injection of oxytocin into the
conducted. bleeding uterus.
Agents
Epinephrine
Lidocaine that published and anecdotal reports describe return of mater-
Bretylium nal blood pressure and maternal survival after perimortem
Bicarbonate cesarean section.14 Successful resuscitation of a pregnant
Dopamine woman and her unborn child requires a coordinated team
Dobutamine approach.
Adenosine
Category D
Definition CONCLUSION
Adequate well-controlled or observational studies in preg-
nant women have demonstrated a risk to the fetus. The In the setting of resuscitation, a pregnant woman poses chal-
benefits of therapy may outweigh the potential risk. For lenges given the physiologic and anatomic changes associated
example, the drug may be acceptable if needed in a life- with pregnancy. Remembering these normal adjustments that
threatening situation or for serious disease for which safer occur in gravid women is critical. Aortocaval compression
drugs cannot be used or are ineffective. must be avoided during resuscitation of a pregnant woman.
Agent Appropriately diagnosing the cause of the patients medical
Amiodarone problem while being mindful of the ABCs of resuscitation is
a must. Thankfully, cardiac arrest is an uncommon event in
pregnant women. When it occurs later in pregnancy, perimor-
tem cesarean section may improve the outcome of the infant
and mother if performed in a timely manner. As with all
20 weeks. At this stage of pregnancy, the fundus is likely to resuscitations, a team effort is mandatory, but possibly even
be palpable at or above the level of the umbilicus. more so in this setting because the emergency practitioner is
The child should be delivered within 5 minutes of maternal caring for two patients whose lives are very tenuous and time
cardiac arrest, so the procedure should be initiated within 4 is of the essence.
minutes of failed CPR of the mother. The procedure is sum-
marized in Box 11.3. Maternal CPR should be maintained
throughout the procedure to optimize blood flow to the uterus REFERENCES
and the mother and should be continued after cesarean
section. Once delivery is accomplished, ED personnel should References can be found on Expert Consult @
be prepared to resuscitate the neonate. It is important to note www.expertconsult.com.
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CHAPTER 11 Resuscitation in Pregnancy
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