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Latest and Greatest: Overview 2015 American Heart Association Emergency Cardiovascular Care Updates

New Basic Life Support Algorithm for Cardiac Arrest in Pregnancy

Pregnancy is accompanied by a variety of cardiovascular changes in normal women and these can cause clinical decompensation in patients with structural heart disease. These changes, combined with and triggered by several factors may predispose a pregnant woman to cardiac arrest.

            Cardiac arrest during pregnancy is a very challenging occurrence. In the United States, this occurs in approximately 1:12 000 admissions for delivery. The steps followed in resuscitating a pregnant woman are similar to those in a non-pregnant adult. However, in addition to the woman’s life, the life of the fetus is also considered. In order to save both the mother and the fetus, a healthcare provider should be effective in the management and prevention of cardiac arrest during pregnancy. To be able to accomplish this, he or she must be educated with the guidelines established by the American Heart Association.

The American Heart Association provides algorithms for the management of cardiac arrest in pregnancy. Through application of physiologic principles and on close examination of observational studies, updates on Emergency Cardiovascular Care has been made recently in order to achieve the best outcome for both the mother and the fetus.

The 2015 guidelines feature updates on Patient Positioning during Cardiopulmonary Resuscitation (CPR) and performing Perimortem Cesarean Delivery (PMCD).

The 2010 guidelines for Patient Positioning during Cardiopulmonary Resuscitation, stated that manual left uterine displacement (LUD) should be performed while the woman in the supine position. Should this fail, there should be an available wedge that would support the patient’s pelvis and thorax while health care providers place the patient in a left lateral tilt at 27° to 30°.

The basis for this is that at about 20 weeks age of gestation, when the fundus is at the level or above the umbilicus the enlarged gravid uterus compresses the two large vessels namely the abdominal aorta and the inferior vena cava. This decreases the cardiac output and the stroke volume, eventually leading to hypotension.

In the 2015 update, if the fundic height is at or above the level of the umbilicus, manual LUD can be beneficial in relieving aortocaval compression during chest compressions. The force applied in performing CPR is stronger when the patient is in the supine position as compared to when the patient is in a left lateral tilt. Proper execution of CPR is vital in ensuring the patient’s survival and while it is possible to perform a CPR with a patient in a left lateral tilt, it may be less affective. Also, there has been no studies focusing on the effect of left uterine displacement or other methods in relieving aortocaval compression while resuscitating the patient that has been published.

In addition, the New Basic Life Support Algorithm for Cardiac Arrest in Pregnancy also made changes regarding the algorithm for performing Perimortem Cesarean Delivery (PMCD). In the 2010 update, delivery of the fetus via Emergency cesarean section may be done 4 minutes after onset of maternal cardiac arrest if there is no Return of Spontaneous Circulation (ROSC), with delivery aimed within 5 minutes of resuscitative efforts.

The 2015 update on the other hand recommends that there is no reason to postpone Perimortem Cesarean Delivery (PMCD) in situations such as trauma or prolonged pulselessness. Cesarean delivery may be considered as part of maternal resuscitation, regardless of fetal viability in the latter half of pregnancy. It must be considered 4 minutes after onset of maternal cardiac arrest, while putting into consideration the personnel capacity as well as other resources needed. This is supported by case series in which 12 out of 20 women who underwent PMCD during resuscitation and had Return of Spontaneous Circulation Immediately. In addition, fetal survival has been recorded when PMCD was performed up to 30 minutes after the onset of cardiac arrest. Postmortem Cesarean Section is advantageous as it enables the healthcare practitioner as it increases the success of resuscitation by relieving aortocaval compression and at the same time enables the healthcare practitioner to resuscitate the viable fetus.

 

 

References:

Jeejeebhoy, F., et al. (2015, October 6). Cardiac Arrest in Pregnancy. Retrieved May 30, 2016, from http://circ.ahajournals.org/content/132/18/1747.full?sid=cb3f4dc9-5a8e-4837-8d63-ebe046dfb3ca .

Rashba, E., et al. (n.d.). Influence of Pregnancy on the Risk for Cardiac Events in Patients With Hereditary Long QT Syndrome. Retrieved May 30, 2016, from http://circ.ahajournals.org/content/97/5/451.full?sid=cb3f4dc9-5a8e-4837-8d63-ebe046dfb3ca