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Some guidance questioned on managing cardiac arrest in pregnancy

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – A recommended maneuver in resuscitating pregnant women in cardiac arrest may be counterproductive, according to the authors of a systematic review of the topic. Furthermore, they found that perimortem cesarean section as a last resort is not being utilized optimally in this situation.

Writing in Resuscitation online May 9, Dr. Laurie J. Morrison at the University of Toronto in Ontario, Canada, and colleagues note that cardiac arrest occurs in about 1 in 20,000 pregnancies. Although rare, the incidence is 10 times higher than the rate of cardiac arrest in young athletes.

There are published recommendations for managing cardiac arrest in pregnancy, the authors note, but these are based on “very little science.” One recommendation is to place the women in a left lateral tilt during chest compressions to relieve aortocaval compression. Another guideline indicates that perimortem cesarean section should be performed within 5 minutes of maternal cardiac arrest.

In conducting a review of the literature on these issues, the team identified three studies dealing with resuscitation technique and two with perimortem c-section.

These data indicated that it is feasible to apply chest compressions with the patient tilted to the left, but the compression force is only about 80% of that delivered in the supine position. Given that, and considering the time spent positioning the patient, the team believes that a better strategy is to displace the uterus leftward manually while the patient is supine during chest compressions.

As for defibrillation, the evidence supports usual energy settings, since transthoracic impedance is not changed in pregnancy, according to the report.

Regarding the performance of perimortem cesareans, a series of 38 cases showed that it was undertaken within 5 minutes in only 8 instances. Nonetheless, 17 infants survived without sequelae.

Furthermore, in 22 cases with sufficient information, “twelve women had sudden and often dramatic improvement in their clinical status immediately after the uterus was emptied including a return of the pulse and blood pressure,” Dr. Morrison and colleagues report.

Summing up, they conclude, “Perimortem cesarean section is rarely done within 5 min from cardiac arrest. Maternal and neonatal survival has been documented with the use of perimortem cesarean section; however, there is not enough information about its optimal use.”

They continue, “Chest compressions in a left lateral tilt from the horizontal are feasible but less forceful compared to the supine position, and there are good theoretical arguments to use left lateral uterine displacement rather than lateral tilt from the horizontal during maternal resuscitation.”

The authors suggest that an international registry would help frame future recommendations for managing cardiac arrest in pregnancy.

Reference:
Management of cardiac arrest in pregnancy: A systematic review
Resuscitation 2011.