First series for Resuscitation in difficult situations.

1. RESUSCITATION TECHNIQUES IN
PREGNANCY
BY
ANUGOM EMEKA M B B C H , D I P. P H , A D V. D I P. O C C M E D , I G C N E B O S H

2. WELCOME & INTRODUCTIONS
 Logistics
 Emergency exits
 Restrooms
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3. AGENDA
 Introduction
 Epidemiology
 Causes of Cardiac Arrest in Pregnancy
 Changes in Pregnancy
 Modifications To Resuscitation in Pregnancy
 Conclusion
 References
 Q&A
3

4. INTRODUCTION
 Various difficult situations may arise that lead to
cardiac arrest.
 The skill of bystanders is paramount for outcome
of survival.[1]
 Resuscitation will need to be modified in these
situations depending on their peculiarities and
reversible causes.
 Early recognition and proper management of
Airway Breathing Circulation Disability and
Exposure (ABCDE) is very important for
survival.[2]
 Image: http://www.sundaymercury.net/news/midlands -news/2011/01/16/poor-maternity-care-blamed-for-deaths-of-21-
west-midlands-babies-66331-27993368/ 4

5. INTRODUCTION
 This presentation is a review based on 2010
Guidelines by American Heart Association and
European Resuscitation Council.
 Prior Knowledge of current BLS/ACLS guidelines
or resuscitation is assumed.
 I m a g e : h t t p : // www. t h e b a b yp l a n n e r s . c o . u k/ b i r t h i n g - c h o i c e s - p r i va t e - h o s p i t a l s 5

6. EPIDEMIOLOGY
 Maternal mortality is rare in
developed nations, with a
prevalence of 1:30,000
maternities and a maternal
mortality rate of 13.95 deaths
per 100,000maternities in
developing nations.[3,4,5]
 Image:
http:// www.byregi on.net/c gibin/us ers /profiles.pl?s ubdomai n=bebebirth 6

7. CAUSES OF CARDIAC ARREST IN PREGNANCY
 The following can lead to cardiopulmonary
collapse in pregnancy:
 Sepsis
 Cardiac disease
 Haemorrhage,
 Amniotic fluid embolism
 Ectopic pregnancy
 Pre-eclampsia and Eclampsia etc.[2,3,4]
 Image 2: http://www.sc ribd.com/doc /45492814/Resus citation -of-the-
Pregnant -Pati ent 7

8. CHANGES IN PREGNANCY
 There are increases in:
 - cardiac output
 - blood volume and
 - oxygen consumption,
 However with increase in uterine size up to
20weeks gestational age, impinging on iliac
and abdominal vessels this leads to
 - hypotension and
 - cardiac arrest.[3,4]
 Image 1: http://www.quantummetta.co.uk/?p=tab&s=courses&f=cpd
 Image 2: http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=21&seg_id=345 8

9. MODIFICATIONS TO RESUSCITATION IN PREGNANCY
 In cardiopulmonary arrest certain modifications
are made to the BLS/ACLS guidelines for the
pregnant woman.[2,3,4,5]
 Image 1: http://www.sciencedirect.com/science/article/pii/S096880800627229X
 Image 2: http://www.dailymail.co.uk/health/article -2034160/Do-resuscitate-Theyre-fateful-words- 9
meaning-doctors-wont-try-save-you-collapse-hospital.html

10. MODIFICATIONS TO RESUSCITATION IN PREGNANCY
 1. Ask for expert help immediately
 - To rule out and treat cause or
 - Decide on caesarean section if required.[3,4,5]
 2. Put in left lateral position at 15 to 30 degrees
either on the rescuer’s knee or using a wedge
or
 Displace the uterus manually and gently left
laterally while lying supine
(This enables better chest compression than when in
the left lateral tilt position)
to relieve obstruction on the iliac and abdominal
vessels .[3,4,5]
 Image 1 & 2: Stephen Morris,Mark Stacey ABC of Resuscitation:Resuscitation in pregnancy;BMJ 2003;327,1278 10

11. MODIFICATIONS TO RESUSCITATION IN PREGNANCY
 3. - Good ventilation with bag valve mask and
high flow oxygen,
 - Suctioning to keep the airway clear.[3,4,5]
 4. IV Fluid bolus to correct:
 - hypotension or
 - hypovolaemia,
while monitoring the oxygen saturation.[3,4,5]


Image 1: http://www.scienceandsensibility.org/?tag=midwife
Image 2: http://drhem.com/2012/04/02/intern -report-5-20/
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12. MODIFICATIONS TO RESUSCITATION IN PREGNANCY
 5. Chest compressions are done slightly
higher on the sternum as abdominal
contents and diaphragm are elevated.
Use of AED if indicated is still under review
but is not discouraged if required.[3,4,5]
 I m a g e 1 : h t t p : / / www. s c i e n c e d i r e c t .c o m / sc i e n c e / a r t i c l e / p i i / S 0 3 0 0 9 5 7 2 1 2 0 0 2 9 8 5 12

13. MODIFICATIONS TO RESUSCITATION IN PREGNANCY
 6. Endotracheal intubation should be: - Done
early and
 - By an expert
Because the upper airway narrows in third trimester
and so it gets more difficult to intubate,
 - Apply cricoid pressure to avoid aspiration that
has a higher risk of occurrence in pregnant
women due to gastro-esophageal sphincter
insufficiency.[3,4]
 I m a g e : h t t p : // www. s c i e n c e d i r e c t . co m/ s ci e n c e / a r t i c l e /p i i / S 0 3 0 0 9 5 7 2 11 0 0 0 8 3 9 13

14. MODIFICATIONS TO RESUSCITATION IN PREGNANCY
 7. Manage all reversible causes as they present.
 If non-responsive to resuscitation

  Plan emergency caesarean section
 - within 4minutes of determining the cardiac arrest
and
 - delivery of fetus within 5minutes of initiating
resuscitation.

  Therapeutic hypothermia may also be used for
comatose patients as indicated for regular non-
pregnant patients.[3,4,]


Image 1: http://www.sciencedirect.com/science/article/pii/S0300957211000839
Image 2: http://circ.ahajournals.org/content/102/suppl_1/I -229.full
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15. CONCLUSION
 Difficult situations may arise or lead to need
for resuscitation.
 Modifications and consideration of
reversible factors, including importance of
making early decisions to
- initiate resuscitation
- invite expert and
- manage the patient accordingly
is paramount to survival in these situations.
 Image: http://www.alsg.org/en/files/MOET_Ch3_CPR.pdf 15

16. CONCLUSION
 Mastery and awareness of the basic
techniques and guidelines for BLS/ACLS by
everyone is crucial to success in resuscitation
in theses situations.
 Get Trained to save lives.
 Image: http://healthyhous tonkids .com/2011/07/how -to-choos e -bes t -
infant-cpr-class -for/ 16

17. REFERENCES
 1. J.R Casal Codesido, y M.J. Vazquez Lima, 2007; Out-of Hospital Cardiopulmonary
Resuscitation: Where are We now? Emergencias 2007;19:295-297.
 2. Australian Resuscitation Council; New Zealand Resuscitation Council, 2011; Guideline
11.10 Resuscitation in Special Circumstances: 1-14
 3. Jasmeet Soar et al,2010, European Resuscitation Council Guidelines for 2010 Section 8.
Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning,
accidental hypothermia, hyperthermia, asthma,anaphylaxis, cardiac surgery, trauma,
pregnancy, electrocution; Elsevier Ireland Ltd, Resuscitation 81(2010)1400-1433,
doi:10.1016/j.resuscitation.2010.08.015
 4. Terry L. Vanden Hoek et al, 2010, Cardiac Arrest in Special Situations: 2010 American
Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care; Circulation.2010:122:S829-S861;
doi:10.1161/CIRCULATIONAHA.110.971069; Online ISSN:1524-4539
 5. OGCCU, 2010, 11.1 Resuscitation in Late Pregnancy, Section B, Clinical Guidelines. King
Edward Memorial Hospital Perth Western Australia. DPMS Ref: 5334
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18. .
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19. QUESTIONS
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