Rosen & Barkin's 5-Minute Emergency Medicine Consult (148 page)

• Trauma (penetrating or blunt):
  
  • Major cause of maternal mortality
    
• Pulmonary embolus:
  
  • Thromboembolism is most common cause of nontraumatic maternal mortality
    
• Cerebral vascular accident
  
• Amniotic fluid embolism
  
• DIC
  
• Placenta previa
  
• Eclampsia
  
• Miscellaneous medical disorders:
  
  • Asthma
    
  • CHF
    
  • MI
    
  • Drug overdose
    

DIAGNOSIS

Gravid female (>24 wk gestation determined by uterine fundal height) who is in cardiopulmonary arrest

Patient is determined to be >24 wk gestation if uterus is at least 4 finger breadths above umbilicus

• Physical exam for apnea and pulselessness in obviously gravid female:
  
  • Quickly evaluate for reversible causes of cardiopulmonary arrest:
    
    • Hypoxia
      
    • Hypovolemia
      
    • Hydrogen ion (acidosis)
      
    • Hypokalemia/hyperkalemia
      
    • Hypoglycemia
      
    • Hypothermia
      
    • Trauma
      
    • Thromboembolism
      
    • Toxins/poisons
      
    • Tension pneumothorax
      
    • Tamponade (pericardial)
      
  • Supine hypotension syndrome (compression of inferior vena cava by enlarged uterus)
    
• Assess gestational age by uterine fundal height
  
  • Distance from pubis to fundus in centimeters is roughly equivalent to gestational age in weeks, i.e., 24 cm = 24 wk
    
• US is beneficial if
  immediately
  available to assess fetus.
  

• None necessary to establish cardiopulmonary arrest
  
• Do
  not
  use valuable time attempting to determine fetal heart tones
  

Cardiopulmonary arrest is final common pathway:

• Evaluate for underlying cause
  

TREATMENT

Cautions:

• Minimal scene time, “scoop and run”
  
• Place the patient in the left lateral decubitus position to avoid compression of inferior vena cava (supine hypotension syndrome)
  
• Trauma patient requiring spinal immobilization:
  
  • Uterus can be manually displaced to left
    
  • Backboard can be wedged to keep right hip elevated 45°
    

• Standard resuscitation measures:
  
  • Emergency intubation
    
    • Use a smaller endotracheal tube (0.5–1 mm less in internal diameter compared to that used for nonpregnant women)
      
  • High-flow oxygen
    
  • Cardiac and BP monitoring
    
  • 2 large-bore peripheral IV lines:
    
    • Fluid resuscitation
      
    • O-negative blood if indicated
      
• Fetal survival correlates with maternal survival and adequacy of initial maternal resuscitation
  
• If patient is at <24 wk gestation, use advanced cardiac life support (ACLS) and advanced trauma life support protocols directed at maternal resuscitation
  
  • Do
    not
    perform emergent cesarean section
    
• If patient is >24 wk gestation, use 4-min rule:
  
  • Perform ACLS or advanced trauma life support for 4 min
    
  • If no response, proceed to immediate emergency cesarean section
    
  • Goal is to deliver fetus within 1 min
    
  • If it is obvious there is no chance for maternal survival, begin perimortem cesarean section immediately
    

• Call for immediate obstetric, surgical, and pediatric consultations:
  
  • Do
    not
    delay performing procedure while waiting for consultants
    
• Ensure a Foley catheter has been inserted to decompress bladder, but do not delay procedure
  
• Perform cesarean section:
  
  • Use linea nigra as landmark for vertical midline incision
    
  • Incise abdominal wall from pubic hairline to 5 cm above umbilicus.
    
  • This incision should pass through fascial and peritoneal layers
    
  • Retract urinary bladder inferiorly against pubic symphysis
    
  • Make small vertical incision in lower uterine segment, just cephalad to urinary bladder
    
  • Extend incision cephalad with scissors:
    
    • Insert your free hand into uterus
      
    • Lift uterine wall away from fetus to avoid fetal injury
      
  • Deliver fetus
    
  • Clamp umbilical cord in 2 places and cut between the 2 clamps
    
  • Manually deliver placenta
    
  • Perform neonatal resuscitation, as indicated
    
  • Immediately reassess maternal vital signs because occasionally spontaneous circulation may return
    
  • Continue maternal resuscitation as appropriate
    
  • Suture uterus with running lock stitch using no. 0 polyglactin suture
    
  • Suture fascia and peritoneum with running stitch using no. 0 polyglactin suture
    
  • Close the skin with staples or suture
    
  • Administer broad-spectrum antibiotics
    
• If maternal return of circulation is obtained, consider starting therapeutic hypothermia protocol
  

Resuscitative measures/ACLS medications directed at mother:

• Treatment of underlying cause
  

Neonatal resuscitation should be anticipated:

• Oral tracheal intubation
  

FOLLOW-UP

• The infant should be admitted to NICU
  
• If maternal resuscitation is successful, patient should be admitted to appropriate ICU
  

Neither infant nor mother should be discharged from ED

• Only females >24 wk pregnant in cardiopulmonary arrest qualify for the procedure.
  
• Decision to perform perimortem cesarean section must be made quickly (within 4 min of maternal cardiopulmonary arrest)
  
• Procedure must be done quickly (<1 min).
  

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CODES

• 427.5 Cardiac arrest
  
• 659.83 Other specified indications for care or intervention related to labor and delivery, antepartum condition or complication