Advanced Cardiac Life Support in Pregnancy

Abstract

Cardiopulmonary arrest during pregnancy is a rare occurrence. Approximately 10% of maternal deaths are attributed to cardiopulmonary arrest. The AHA guideline advises manually placing the uterus in the left lateral position during pregnant resuscitation and perimortem cesarean section. While there are many causes of cardiopulmonary arrest in the general population, in pregnant patients, causes can arise from pre-existing conditions as well as physiopathological conditions induced by pregnancy. Managing cardiopulmonary arrest during pregnancy is a challenging clinical situation. While maternal resuscitation shares many aspects with standard adult resuscitation, there are some differences, with the most significant being the presence of two patients, the mother and the fetus. Equipment and personnel for emergency cesarean section and neonatal resuscitation should be readily available. When a pregnant patient experiences arrest, they should be placed on a stretcher, and chest compressions should be initiated. Chest compressions should be performed at a rate of 100-120 compressions per minute and to a depth of at least 2 inches, in the middle of the chest, just below the sternum, with minimal interruption. Airway management and basic life support should be provided, and the time of arrest should be noted. If the pregnancy is beyond 20 weeks or if the uterus is above the level of the umbilicus, manual displacement of the uterus to the left should be performed to reduce aortocaval compression. Bag-mask ventilation with 100% oxygen at a rate of at least 15 L/min should be initiated immediately with a compression-ventilation ratio of 30:2. If the patient is suitable for defibrillation, it should be administered without altering the shock energy. Studies have shown that transthoracic impedance does not change in pregnant women. Defibrillation in the mother should not be delayed due to fetal safety concerns, as minimal energy is transferred to the fetus during defibrillation. Due to physiological changes, the oxygen reserve in the pregnant woman’s lungs is limited, necessitating rapid and effective airway intervention. Therefore, intubation should be attempted using an endotracheal tube with an inner diameter of 6.0-7.0 mm by the most experienced rescuer. Multiple laryngoscopy attempts-more than twice- should be avoided, and if airway intervention fails and mask ventilation is not possible, emergency invasive airway should be established. Medical drug therapy is no different from standard adult resuscitation, and there is no need for dose adjustment in the drugs administered. Drug administration should not be stopped due to fetal teratogenicity.