Cardiac arrest Fig 181

Cardiopulmonary resuscitation (CPR) is not only difficult to administer but is particularly inefficient in the pregnant patient due to:

• difficulties in performing CPR on a tilted patient;

• increased oxygen requirement in pregnancy (20% increase in resting oxygen consumption);

Approaching and treating the apparently lifeless patient

Approaching and treating the apparently lifeless patient

Uterine Hyperstimulation

Table 18.1 Causes, features and initial treatment of collapse in the obstetric patient (distinguishing features in bold)

(alphabetical order)

Cause/risk factors

Specific clinical features

Specific treatment points: all need ABC + lateral tilt if undelivered

Adrenal insufficiency

Amniotic fluid embolism [13]

Anaphylaxis [12,14]

Aspiration (Mendelson's syndrome)

Bacteraemic shock

Cardiogenic shock Eclampsia

Hyperglycaemia

Hypoglycaemia

Intracerebral bleed

Massive PE

Neurogenic

Oligaemic [16] Pneumo: thorax/mediastinum

Inadequate or absent steroid cover in Drug history someone previously taking steroids Hypotensive collapse

Metabolic imbalance

Uterine tachysystole Syntocinon hyperstimulation Previous uterine surgery Multiparity Polyhydramnios

Drug administration, e.g. antibiotics, voltarol, anaesthetic agents, haemocell Latex

Inhalation after vomiting/passive regurgitation (reduced consciousness with unprotected airway)

Overwhelming sepsis due to esp. Gram negative rods or strep. B

Congenital or acquired disease

Cardiomyopathy Associated with cerebrovascular events or pulmonary oedema or Mg toxicity

Diabetes

Diabetes, Addison's hypopituitary, hypothyroid a-v malformation

Usually deep pelvic thrombosis

Vasovagal (uterine inversion)

Haemorrhage (can be concealed) Previous history of labour/pushing

Restless, shortness of breath and cyanosis Vaginal bleeding follows within 30 min due to disseminated intravascular coagulation [15] History of drugs/latex Rash Stridor Oedema

Shortness of breath, restlessness cyanosis Bronchospasm

Hypotensive Warm/fever/blotchy

History

Restless SOB/chest pain

Hypertensive Proteinuria

Hyperventilation and ketosis Sweating/clammy loss of consciousness Fits, CNS signs and neck stiffness Restless/cyanosis elevated JVP

Vaginal examination

Tachycardia, pale and cold

Chest pain SOB

Supportive with IV fluids (check electrolytes especially sodium may be low)

Hydrocortisone (200 mg IV stat) check BM - may need glucose O2 + ventilate Deliver the baby ASAP Hydrocortisone (200 mg IV stat)

* (aminophylline, diuretics, adrenaline morphine)

Adrenaline* (1 ml of 1 in 10,000 IV repeated as needed) with IV fluids Hydrocortisone (200 mg IV stat) Chlorpheniramine (20 mg IV) O2 + ventilate

* (aminophylline, steroids, diuretics and antibiotics)

Replenish circulation, systems support Antibiotics IV (e.g. Imipenem) Sit up

O2 + frusemide Magnesium sulphate

(antidote = calcium gluconate) Control blood pressure with hypotensives

IV fluids, Insulin (and potassium)

IV glucose

Supportive

fluids + anticoagulate IV fluids ± atropine/reduce uterine inversion Restore circulation and treat Aspirate/drain

*These treatments should be undertaken under anaesthetic supervision on high dependancy unit (HDU)/intensive care unit (ITU).

• decreased chest compliance due to splinting of the diaphragm (20% decrease in functional residual capacity);

• reduced venous return due to caval compression limiting cardiac output from chest compressions (stroke volume 30% at term compared to non-pregnant state);

• risk of gastric regurgitation and aspiration (relaxation of cardiac sphincter).

For these reasons it is considered appropriate to empty the uterus to aid maternal survival by performing a perimortem Caesarean section if CPR performed with lateral tilt is ineffective after 5 min [5,10]. To achieve this the obstetrician at such an arrest should therefore be preparing for Caesarean section almost immediately. It is reiterated that the point of emptying the uterus is to aid in the resuscitation of the mother and is not for fetal reasons. Fetal viability issues should not delay this procedure which is worthwhile when the pregnancy is of sufficient size to compromise resuscitation: as a guide, if the uterus has reached the level of the umbilicus it should be considered.

To perform a perimortem Caesarean section rapidly the skin incision should be that with which the operator is most familiar, and the uterine incision will be influenced by the gestation of the pregnancy. These details matter little compared to the pressing need to evacuate the uterus and render the mother more receptive to life-saving resuscitation techniques. A large Caesarean section pack is unnecessary and in extremis all the obstetrician needs is a scalpel to commence the procedure while other instruments are being collected.

It is stressed again that this is not done for fetal reasons but there is no doubt that fetal viability is more likely the more quickly the baby is delivered: 70% survive intact if delivered within 5 min, falling to 13% after 10 min [11].

To detail the management of each possible condition which can cause maternal collapse is beyond the scope of this chapter, but Table 18.1 summarizes the different possibilities and those features specific to them in terms of risk factors, clinically distinguishing features and specific points of treatment. More detailed accounts are referenced for further reading [12-16], but a few summary points are highlighted here.

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Pregnancy Diet Plan

Pregnancy Diet Plan

The first trimester is very important for the mother and the baby. For most women it is common to find out about their pregnancy after they have missed their menstrual cycle. Since, not all women note their menstrual cycle and dates of intercourse, it may cause slight confusion about the exact date of conception. That is why most women find out that they are pregnant only after one month of pregnancy.

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