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EDITORIAL
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 1-2

Maternal cardiac arrest and resuscitation: Some burning issues!


Department of Anaesthesia, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India

Date of Web Publication1-Jul-2013

Correspondence Address:
Sunanda Gupta
Geetanjali Medical College and Hospital, Udaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.114250

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How to cite this article:
Gupta S. Maternal cardiac arrest and resuscitation: Some burning issues!. J Obstet Anaesth Crit Care 2013;3:1-2

How to cite this URL:
Gupta S. Maternal cardiac arrest and resuscitation: Some burning issues!. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2019 Oct 21];3:1-2. Available from: http://www.joacc.com/text.asp?2013/3/1/1/114250

Cardiac arrest during the pregnancy has shown an increase in incidence from 1:30,000 [1] to 1:20,000, [2] which is much higher than the incidence of cardiac arrest in athletes (1:200,000) [3] considering that both sub groups are young in age and have a healthy baseline. The major concern of course is that in pregnant patients, there are two lives involved. The improved survival and quality of life due to advances in medical care have increased the chances of successful pregnancies in women with underlying medical conditions. Cardiac arrest in such situations can pre-dispose to a negative outcome. Thus, the Current Resuscitation Guidelines, [4],[5] have specifically formulated and defined modifications to advanced care life support resuscitation for the pregnant women. [4],[5]

Some of the key steps in resuscitating a pregnant woman are: timely initiation of uninterrupted chest compressions, left lateral displacement of uterus, midsternal hand positioning, use of small size endotracheal tube, continuous cricoid pressure, and intravenous access above the uterine level; but there are many roadblocks in proper implementation of these protocols, which need urgent attention.

First and foremost, since cardiac arrest is such a rare occurrence on labor and delivery floors, obstetric care providers have infrequent exposure to this catastrophic situation. There is also a paucity of evidence-based recommendations, which leaves them often unprepared to address this unexpected event. Current advanced cardiac life support (ACLS) requirements and training have been found to be insufficient for sustaining resuscitation skills. [6] Surveys conducted on obstetric anesthesiologists, obstetricians, and emergency care physicians have found the knowledge regarding basic concepts of cardiopulmonary resuscitation (CPR) in pregnant women to be grossly inadequate. [7],[8] They recommend that ACLS and CPR for parturients should be taught in a better manner and repeated at regular intervals to practitioners at all levels. Thus, all obstetric care providers, whether at the primary or tertiary level, should be trained on a simulation-based, pregnancy focused ACLS educational program. Recently, [9] significant benefit of a simulation-based training program in improving performance, knowledge, and confidence of maternal-fetal medicine staff, in the management of maternal cardiac arrest has been demonstrated.

Secondly, timely initiation of uninterrupted chest compressions is considered the single most important step in successful resuscitation [9] along with recognition of a cardiac rhythm and timely use of the defibrillator. Until an experienced resuscitation team with equipments arrives at the site chest compressions should continue unabated since interruptions in chest compressions have been found to have a negative impact on coronary perfusion pressures. [10] To save time and take a definitive action, the multidisciplinary team should quickly spring into action. An interesting article [11] in this issue, has highlighted the importance of a public addressal system, activating code blue and code green in their hospital, which assembles the multidisciplinary team along with resources and provides facilities for perimortem cesarean delivery at the patient's bedside to improve the survival rates in both mother and fetus. Valuable time should not be lost trying to shift the patient to the operation theatre. This will not only delay caesarean delivery, but would also compromise the quality of chest compressions during the move. [9] Further, tilting the pregnant patient during the cardiac arrest will take time resulting in interruption in chest compressions. Supine manual leftward displacement of the uterus has been found to be as effective as a left lateral tilt to counter aortocaval compression during the cesarean delivery. [12] This position could also prove to be better for rescuers to perform high quality supine chest compressions, [13] through, a recent simulation study [14] comparing quality of chest compressions in both a 30˚ inclined lateral position and supine position showed no significant difference between the two positions.

Thirdly, current science, emphasizes the importance of initiating caesarean delivery within 4 min of maternal cardiac arrest. Since, 30% of the cardiac output is shunted to the gravid uterus and unless the fetus is delivered within this time period, cardiac compressions may not be effective in maintaining the maternal cardiac output. A significant review [15] of all published maternal cardiac arrests prior to delivery, from 1980 to 2010, highlights several important findings: maternal outcomes may not be as poor as those of other cardiac arrest populations, mortality rates were higher among women who underwent post mortem cesarean delivery (PMCD) compared to those who did not, the 4 min time frame advocated for PMCD usually remains unmet yet neonatal survival is still likely, (especially in-hospital) if delivery occurs within 10-15 min of arrest. Thus, fixation on specific time frames for PMCD needs to be revised and more stress should be laid on recommendations which are evidence-based. This would only be possible if we have our own national registry to follow experiences of other professionals across the country, which would help us make future recommendations according to the available resources.

To conclude, locally applicable guidelines with easy recall, need to be formulated, which could be implemented by grassroot physicians at the primary level, with mandatory up gradation of skills at regular intervals. Tertiary level hospitals should have regular simulation-based training programs focused on resuscitation in the pregnant patients, for all obstetric care providers to sustain their resuscitation skills.

 
  References Top

1.Lewis. Why mothers die 2000-2002: Confidential enquiry into maternal and child health. London, UK: Centre for Maternal and Child Enquiries; 2004.  Back to cited text no. 1
    
2.Lewis GE. The confidential enquiry into maternal and child health (CEMACH). Saving mothers' lives: Reviewing maternal deaths to make motherhood safer 2003-2005. The seventh confidential enquiry into maternal deaths in the United Kingdom. RCOG Press; 2007.  Back to cited text no. 2
    
3.Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: Endorsed by the American College of Cardiology Foundation. Circulation 2007;115:1643-455.  Back to cited text no. 3
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4.Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJ, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010;81:1400-33.  Back to cited text no. 4
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5.Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, et al. Part 12: Cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S829-61.  Back to cited text no. 5
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6.Seethala RR, Esposito EC, Abella BS. Approaches to improving cardiac arrest resuscitation performance. Curr Opin Crit Care 2010;16:196-202.  Back to cited text no. 6
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7.Cohen SE, Andes LC, Carvalho B. Assessment of knowledge regarding cardiopulmonary resuscitation of pregnant women. Int J Obstet Anesth 2008;17:20-5.  Back to cited text no. 7
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8.Lipman SS, Daniels KI, Carvalho B, Arafeh J, Harney K, Puck A, et al. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises. Am J Obstet Gynecol 2010;203:179.e1-5.  Back to cited text no. 8
    
9.Fisher N, Eisen LA, Bayya JV, Dulu A, Bernstein PS, Merkatz IR, et al. Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based training. Am J Obstet Gynecol 2011;205:239.e1-5.  Back to cited text no. 9
    
10.Berg RA, Sanders AB, Kern KB, Hilwig RW, Heidenreich JW, Porter ME, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation 2001;104:2465-70.  Back to cited text no. 10
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11.Mathur D, Sng BL. Perimortem caesarean section: Rethinking the resuscitation codes. J Obstet Anaesth Crit Care 2013;3;35-6.  Back to cited text no. 11
    
12.Kundra P, Khanna S, Habeebullah S, Ravishankar M. Manual displacement of the uterus during Caesarean section. Anaesthesia 2007;62:460-5.  Back to cited text no. 12
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13.Jeejeebhoy FM, Zelop CM, Windrim R, Carvalho JC, Dorian P, Morrison LJ. Management of cardiac arrest in pregnancy: A systematic review. Resuscitation 2011;82:801-9.  Back to cited text no. 13
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14.Kim S, You JS, Lee HS, Lee JH, Park YS, Chung SP, et al. Quality of chest compressions performed by inexperienced rescuers in simulated cardiac arrest associated with pregnancy. Resuscitation 2013;84:98-102.  Back to cited text no. 14
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15.Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: Evidence or expert-based? Resuscitation 2012;83:1191-200.  Back to cited text no. 15
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