This document discusses the management of critically ill pregnant patients and cardiac arrest in pregnancy. It recommends placing pregnant patients in the left lateral decubitus position for oxygen delivery and intravenous access above the diaphragm. For cardiac arrest, it advises starting chest compressions supine and considering perimortem cesarean delivery after 4 minutes without signs of recovery. Common causes of maternal arrest include anesthesia complications, bleeding, cardiovascular issues, embolism, infection, and preeclampsia.

1. Paleerat Jariyakanjana, MD
Emergency physician
19 Oct 2015

2. The Critically Ill
Pregnant Patient

3. Severity of Illness and Early Warning Scores
 obstetric early warning score (Class I; Level of
Evidence C)

5. Management of the Unstable Pregnant
Patient
 full left lateral decubitus position (Class I;
Level of Evidence C)
 100% oxygen by face mask (≥15 L/min)
(Class I; Level of Evidence C)
 Intravenous access: above the diaphragm
(Class I; Level of Evidence C)

6. Cardiac Arrest
Management

9. Chest Compressions in Pregnancy
 placed supine for chest compressions(Class I;
Level of Evidence C)
 mechanical chest compressions: not advised

10. Factors Affecting Chest Compressions
in the Pregnant Patient
 Continuous manual LUD: uterus ≥ umbilicus
(Class I; Level of Evidence C)

11. Factors Affecting Chest Compressions
in the Pregnant Patient

14. Advanced Cardiovascular Life Support

15. Advanced Cardiovascular Life Support

16. Special Equipment Required for a Maternal Cardiac
Arrest

18. Special Equipment Required for a Maternal
Cardiac Arrest

19. Breathing and Airway Management in
Pregnancy
 Management of Hypoxia
 Airway Management

20. Management of Hypoxia
 early ventilatory support (Class I; Level of
Evidence C)

21. Airway Management
 Endotracheal intubation should be performed
by an experienced laryngoscopist (Class I;
Level of Evidence C).
A. ETT with a 6.0-7.0 mm ID (Class I; Level of
Evidence C)
B. ≤2 laryngoscopy attempts (Class IIa; Level of
Evidence C)
C. Supraglottic airway placement: failed intubation
(Class I; Level of Evidence C)
D. airway control fail and mask ventilation is not
possible → emergency invasive airway access

22. Airway Management
 Cricoid pressure: not routinely recommended
(Class III; Level of Evidence C)

23. Delivery

24.  PMCD: after ≈4 minutes of resuscitative
efforts (Class IIa; Level of Evidence C)

25.  When PMCD is performed
A. not be transported to OR (Class IIa; Level of
Evidence B)
B. not wait for surgical equipment; only a scalpel is
required (Class IIa; Level of Evidence C)
C. not spend time on lengthy antiseptic procedures
(Class IIa; Level of Evidence C)
D. Continuous manual LUD until the fetus is
delivered (Class IIa; Level of Evidence C)

26. EMS Considerations

27.  If available, transport should be directed
toward a center that is prepared to perform
PMCD, but transport should not be prolonged
by >10 minutes to reach a center with more
capabilities (Class IIb; Level of Evidence C).

30. Cause of the Cardiac
Arrest

32. Table 5. Most Common Etiologies of Maternal
Arrest and Mortality
Letter Cause Etiology
A Anesthetic complications High neuraxial block
Hypotension
Loss of airway
Aspiration
Respiratory depression
Local anesthetic systemic toxicity
Accidents/trauma Trauma
Suicide
B Bleeding Coagulopathy
Uterine atony
Placenta accreta
Placental abruption
Placenta previa
Retained products of conception
Uterine rupture
Surgical
Transfusion reaction
C Cardiovascular causes Myocardial infarction
Aortic dissection
Cardiomyopathy
Arrhythmias
Valve disease
Congenital heart disease

33. Table 5. Most Common Etiologies of Maternal
Arrest and Mortality
Letter Cause Etiology
D Drugs Oxytocin
Magnesium
Drug error
Illicit drugs
Opioids
Insulin
Anaphylaxis
E Embolic causes Amniotic fluid embolus
Pulmonary embolus
Cerebrovascular event
Venous air embolism
F Fever Sepsis
Infection
G General H’s and T’s
H Hypertension Preeclampsia
Eclampsia
HELLP syndrome, intracranial
bleed

34. Point-of-Care
Instruments

35.  point-of-care checklists (Class I; Level of
Evidence B)

37. Immediate
Postarrest Care

38.  still pregnant: full left lateral decubitus position
 not in full left lateral tilt: manual LUD (Class I;
Level of Evidence C)