Challenges Of Cardiopulmonary Resuscitation During
Published online: 2019-07-16THIEME32Review ArticleChallenges of Cardiopulmonary Resuscitation duringPregnancyPadmaja Durga1Shibani Padhy1Anupama Bardaa21 Anesthesiology and Intensive Care Nizam’s Institute of MedicalSciences, Panjagutta, Hyderabad, India2 Medicine China Medical University, ChinaAddress for correspondence Padmaja Durga, MD, DNB, Anesthesiologyand Intensive Care, Nizam’s Institute of Medical Sciences, Panjagutta500082, Hyderabad, India (e-mail: padmajanims@yahoo.com).Ind J Car Dis Wom 2019;4:32–39AbstractKeywords pregnancy cardiac arrest resuscitation perimortem cesareansectionCardiac arrest, though rare, is the most feared complication in the pregnant womanas it involves two lives. Most arrests occur because of conditions that result from thepregnancy itself or from preexisting medical conditions exacerbated by the pregnancy.Prompt resuscitative efforts are crucial for favorable outcomes for the mother and fetus.The basic principles of resuscitation during pregnancy such as airway, breathing, andcirculation are similar to the resuscitation in a cardiopulmonary arrest in any patient;however, certain modifications are necessary to account for the physiologic changesthat occur during the pregnancy. Cardiopulmonary resuscitation (CPR) of the parturientshould include uterine tilt or displacement to relieve the compression of the inferior venacava and aorta by the gravid uterus, intubation using rapid sequence intubation with cricoid pressure, and timely perimortem cesarean section (PMCS). Ideally, the PMCS mustbe performed within 5 minutes of cardiac arrest if the pregnant woman does not have areturn of spontaneous circulation, and resuscitation is deemed unsuccessful. The PMCSis performed if the gestational age is at least 20 weeks or the gravid uterus is evident. Ahigh-quality CPR and multispecialty team approach, consisting of obstetricians, cardiologists, anesthesiologists, neonatologists, and nursing staff, is essential for survival.IntroductionCardiac arrest, though rare, is the most feared complication in the peripartum period. The incidence of cardiacarrest during pregnancy is 2.78 per 100,000 maternities,and mortality is about 42%.1 Resuscitation of the cardiacarrest in parturient aims at both the maternal and thefetal well-being. Survival rates are lower in the pregnant cardiac victim though younger than the patient withtraditional cardiac arrest. The number of women with highrisk attaining pregnancy is increasing, and so is the risk ofpossibility of cardiac arrests during pregnancy.2 There is anincreasing need for improving the knowledge deficits, andresuscitation skills are among physicians for cardiac arrestduring pregnancy.3Causes of Cardiac Arrest in PregnancyThe causes of cardiac arrest in a parturient are numerous( Table 1). Most deaths result from acute conditions that aredirectly related or consequent to pregnancy. The cardiac arrestsDOI https://doi.org/10.1055/s-0039-1692304also occur due to indirect causes resulting from worsening ofpreexisting comorbid conditions that could be further exacerbated by changes resulting from pregnancy. The majority of theserious cardiac complications of pregnancy occur in women notTable 1 Causes of cardiac arrest during pregnancyCauses of pregnancy-related deathsCardiovascularCongenital heart diseaseIschemic heart diseaseValvular heart diseaseCardiomyopathyOther acquired cardiac ageThromboticAmniotic fluid embolismHypertensiveCerebrovascularAnesthetic causesOthers 2019 Women in Cardiology andRelated Sciences
Challenges of CPR during Pregnancyrecognized as having heart disease before pregnancy. About 25%of cardiac arrests in pregnancy are related to anesthesia, whichis potentially preventable.1,4 It is imperative for physicians to beable to diagnose and manage pregnancy-associated diseasesand reversible causes of cardiac arrest in pregnancy.Cardiac DiseaseWith an incidence on the rise, cardiac disease presentlyaccounts for about 2.27 deaths for every 100,000 pregnantpatients. Rheumatic heart disease continues to be the mostcommon cardiac disease during pregnancy in India.5 Thereis an aggravation of underlying symptoms in patients withthe rheumatic mitral disease during pregnancy. About 50%of patients with mitral stenosis and 23% of mitral regurgitation decompensate during pregnancy and develop heartfailure.6 In the United States, myocardial infarction andaortic dissection are the leading cardiac causes of maternaldeath. As compared with women of similar age, pregnantwomen have around three to four times higher risk of myocardial infarction.7 There are no known risk factors in mostpatients. The common causative factor is coronary arterydissection. The mechanisms are similar to aortic dissection.8More women are now deferring pregnancy to a higher agethat increases the chance of atherosclerosis-induced cardiacdisease in parturients.9,10 Nearly 20% of women have intracoronary thrombus or arteriosclerosis on angiography.8 Withfibrinolytics being relatively contraindicated, percutaneouscoronary intervention (PCI) remains the managementstrategy of choice for reperfusion in ST-elevation myocardialinfarction in pregnancy. Advances in the medical fieldhave now made it possible to witness many patients withcongenital cardiac disease surviving into adulthood. It is,therefore, possible that they suffer a higher risk of cardiac events during pregnancy.11 Pulmonary hypertension,12either primary or as a complication related to congenitalheart disease,13 ranks third in the causes of maternal cardiacdeaths. Table 2 shows the high-risk conditions leading tocardiac morbidity and resultant maternal cardiac arrest.14Noncardiac Diseases Eclampsia: Pregnancy-induced hypertension developsafter 20 weeks, and eclampsia and multiorgan failure insevere cases complicate pregnancy. Maternal and fetalmorbidity and mortality may result.15,16 Pulmonary embolism (PE): Pregnancy is a hypercoagulablestate, and it also aggravates the preexisting hypercoagulableconditions. PE is a significant complication in pregnancy.A high index of suspicion is required for diagnosis.Management of PE is according to the advanced cardiaclife support (ACLS) guidelines.17 Massive PE is usually fatalthough there have been few reports of successful use offibrinolytics for massive, life-threatening PE.18 Amniotic fluid embolism (AFE): The most feared anddeadly cause of arrest in parturient is AFE. There arereports of high morbidity and mortality rates withthe condition.19,20 The presentation of AFE is varied.Hypotension, bronchospasm, coagulopathy, fetal distress,and even cardiac arrest can occur. There are reportsDurga et al.Table 2 High-risk cardiac conditions during pregnancyHigh-risk cardiac conditionsMyocardial infarctionMechanical valveComplex CHD Systemic RV Fontan circulationAortic dilatation Marfan’s syndrome 40-45 mm Bicuspid AV 45–50Highest risk NYHA class III or IV Severe pulmonary hypertension Significant LV dysfunction Severe aortic or mitral stenosis Severe coarctationAbbreviations: AV, aortic valve; CHD, congenital heart disease; LV, leftventricular; NYHA, New York Heart Association; RV, right ventricular.of the use of cardiopulmonary bypass for successfulmanagement massive embolism in the peripartum period.21Perimortem cesarean section (PMCS) can improve thechances of maternal and neonatal survival. Hemorrhagic shock: Hemorrhagic shock is an oftenencountered cause of cardiac arrest in the parturient. Theplacental pathologies such as abruptio placentae, placentaprevia, or abnormalities of placental implantation posea high risk for significant hemorrhage during labor. Theother common causes of massive bleeding are surgicalcomplications and persistent atonic uterus. Massive hemorrhage could culminate in cardiac arrest.22 Iatrogenic: There are several preventable iatrogenic causesof cardiac arrest. They may be as simple as lack of properinstructions to avoid supine position. Patients may not havebeen instructed to return to their side after performingcervical examination or placement of monitoring devicesin lithotomy or supine position. The venous return candecrease due to compression of the great vessels by graviduterus, resulting in hypotension and possibly cardiac arrest,especially in the presence of epidural anesthesia.Complications of therapy: Administration of tocolyticdrugs, oxytocic drugs such as oxytocin, ergots, and medicationssuch as magnesium is common in parturients. The adverseeffects of these drugs can sometimes be fatal. Tocolytic drugscan cause cardiac rhythm disturbances, myocardial ischemia,and heart failure.23 There are reports of myocardial ischemiaand consequent cardiac arrest with ergot derivatives in theparturient. The number of parturients with advanced age isincreasing, and so would the coexisting medical problems.The presence of comorbidities may complicate treatment ofpremature labor with tocolysis or management of preeclampsia.The iatrogenic overdose of magnesium can occur inpatients receiving magnesium sulfate for treatment ofeclampsia. Toxicity can develop even after low doses ofmagnesium if the woman becomes oliguric. Magnesiumtoxicity can result in cardiac effects. Electrocardiogram(ECG) interval changes such as prolonged conductiontimes resulting in PR, QRS, and QT interval prolongationIndian Journal of Cardiovascular Disease in Women WINCARS Vol. 4No. 1/201933
34Challenges of CPR during PregnancyDurga et al.occur at levels of magnesium between 2.5 and 5 mmol/L.Further, an increase in magnesium levels to 6 to 10 mmol/Lcan cause atrioventricular (AV) nodal block, hemodynamicabnormalities, and cardiac arrest. Calcium administrationcan be helpful in reversing the effects of magnesium.Complications of anesthesia: They are the important andpreventable causes of cardiac arrest in labor and delivery.24Local anesthetic toxicity can occur from drug overdosage.This complication is seen more often during prolongedlabor when patients receive multiple top-up doses of localanesthetics. Occasionally, there can be complications evenwith regular dosing and testing. Intravascular migration ofepidural catheters can lead to systemic toxicity, or migrationinto the subarachnoid space can cause total spinal anesthesia.Severe hypotension could result in hypovolemic patientsreceiving either regional or general anesthesia. Cardiac arrest from other etiology: Cardiac arrest canoccur during pregnancy due to causes that are also seen innonpregnant individuals such as trauma and anaphylaxis.Why Is Resuscitation in Parturient Different?Physiologic changes of pregnancy that influence cardiacarrest and resuscitation in a parturient: Compensatoryphysiologic changes occur in pregnancy to accommodatethe needs for the growing fetus and uterus. These changesnot only influence recommendations and guidelines formanagement of the pregnant cardiac arrest patient butalso make the diagnosis and treatment difficult duringemergencies. Management of such cases requires a completeunderstanding of these physiologic changes that occur inpregnancy. Fig. 1 summarizes the implications of thesephysiologic changes.Aortocaval compression in the supine position candecrease cardiac output by 30 to 40%, resulting in supinehypotension syndrome. Supine position is often not toleratedafter 30 weeks’ gestation. It is therefore advised to maintaina position that produces the displacement of the uterus tothe left, especially during the third trimester to relieve theaortocaval compression ( Fig. 2).The cardiac output increases by 1 to 1.5 L/min afterthe 10th week of gestation. Maternal heart rate increasesby 15 to 20 beats above nonpregnant values throughoutpregnancy. Maternal blood pressure is lower than nonpregnant values by 10 to 15 mm Hg. Therefore, severe bleeding canoccur without the usually seen physical signs of hypovolemiasuch as hypotension and tachycardia. Physiologic anemiawith low hematocrit occurs at about 34 weeks’ gestation dueto an increase in plasma volume by 40 to 50% accompaniedby a lesser increase in the volume of red blood cells. A lowerFig. 1 Cardiorespiratory changes in pregnancy and their effects on resuscitation. CPR, cardiopulmonary resuscitation; FRC, functional residual capacity.Indian Journal of Cardiovascular Disease in Women WINCARS Vol. 4No. 1/2019
Challenges of CPR during PregnancyFig. 2Durga et al.Left uterine tilt and its effect on aortocaval compression.hematocrit in the cases of hypovolemia and acute hemorrhagemay be misinterpreted as physiologic anemia. Moreover,during hypovolemia, the blood flow tends to be shunted fromthe placenta and uterine circulation. Therefore, even thoughthe parturient appears stable, the fetal blood flow is severelyreduced and there can be a fetal compromise. Hence, it shouldbe assessed without delay. It is essential to understand thatthere can be a blood loss of up to 35% of the blood volume inthe absence of any overt signs of hemodynamic instability in apregnant patient. Volume replacement should be commencedearly and the intravenous fluid site should be secured abovethe level of the diaphragm for resuscitation.There is an increase in oxygen consumption, tidal volume,and minute ventilation in the pregnant state. These changescause a faster desaturation rate during periods of apnea insuch patients. A decrease in functional residual capacity(FRC) is seen consequent to the expanding gravid uterus,elevation of the diaphragm, and reduction in thoracicvolume. These changes result in more rapid developmentof hypoxemia necessitating the early establishment of oxygenation and ventilation. The consequences of hormonalchanges of pregnancy such as upper airway edema, increasedsize of the breast, and weight gain can result in difficult aswell as a delayed establishment of ventilation and intubation.Further, delayed gastric emptying caused by increased levelsof progesterone increases the risk of aspiration during maskventilation and intubation. The NPO (nil per oral) status isnot always ensured as many patients are encountered afterthe consumption of a large meal. Hence, it is essential tomaintain cricoid pressure during intubation. Starling forcesnarrow oncotic pressure-wedge pressure gradient increasingthe risk of pulmonary edema. The O2 dissociation curve isshifted to the right; hence, a higher O2 partial pressure isrequired for adequate maternal oxygenation. Thus, pregnancycomplicates airway management during resuscitation due toa potential full stomach, the risk of regurgitation, difficultventilation, and intubation compounded by reduced safeapnea time and rapid desaturation.The changes in pharmacokinetics may occur due to changesin plasma volume and increase in the glomerular filtrationrate (GFR). However, there is no evidence that modificationof the doses of medications used during resuscitation isrequired.25 Defibrillation is an essential component of cardiacresuscitation. The amniotic fluid transmits current. Therecould be a potential for fetal burns or adverse outcome if thecurrent travels through the uterus. However, there are nostudies on the fetal risk during maternal defibrillation. Therisk of inducing fetal complications such as inducing fetalarrhythmias is small,26 and defibrillation is proven to be safeat all stages of pregnancy. There is a risk of electric arcing tomonitors of the fetus, though low. Hence, it is advisable toremove internal or external fetal monitors before defibrillationin a pregnant woman.Management of Critically Ill Pregnant PatientThe risk of cardiac arrest in a critically ill pregnant patientis very high.27,28 The hypotension is compounded by uterine obstruction of venous return that may even precipitatean arrest. The parturient patient should be placed in thefull left-lateral position to relieve possible compressionof the inferior vena cava. Oxygen should be administeredearly in the course as deterioration can be rapid. Maternalhypotension should be assessed and expeditiously treatedas it not only affects the mother but also reduces placentalperfusion. It is crucial to identify and address reversiblecauses of critical illness that contribute to deterioration asearly as possible.Management of Cardiac ArrestThe basics of basic life support (BLS) and ACLS protocol arethe same as for nonpregnant victims of cardiac arrest, witha few necessary modifications. The physiologic and physicalchanges that accompany pregnancy mandate certain modifications during resuscitation of cardiac arrest in the parturient.Indian Journal of Cardiovascular Disease in Women WINCARS Vol. 4No. 1/201935
36Challenges of CPR during PregnancyDurga et al.The essential modifications are relieving aortocaval compression by the gravid uterus, performing rapid sequenceintubation, and proceeding to timely perimortem cesareandelivery when indicated. A high-quality CPR is critical forsurvival. The algorithm for the management of cardiac arrestin pregnancy is shown in Fig. 3.Recommended Modifications to ResuscitationProtocols Applied to Pregnant PatientsThe compression rate, depth, hand placement, backboard,and minimal interruptions in compressions are the sameas nonpregnant adults. The gravid uterus causes elevationof the diaphragm; hence, the chest compressions shouldbe performed slightly higher on the sternum than typicallyrecommended. In late pregnancy, the gravid uterus actslike a binder for the abdomen that results in increased inintrathoracic pressure, reduced venous return, and reduction in the forward flow of blood through the abdominalaorta rendering successful resuscitation difficult. The bestcardiac output that can be generated by external cardiacmassage is only 30% of a nonpregnant patient. Besides,10% of cardiac output is shunted to the gravid uterus. Theincreased oxygen requirements during pregnancy makethe parturient more vulnerable to hypoxia.Adequate left uterine displacement must be maintainedduring chest compressions. Large doses of α-adrenergicmay reduce uterine blood flow, but the use of these drugsis essential to restoring maternal circulation. If the efforts toresuscitate using chest compressions and medications arenot successful, it is now recommended that cesarean sectionis performed within 4 to 5 minutes of the arrest. One must bevigilant about the time. Shorter intervals between the onsetof maternal cardiac arrest and commencement of CPR, andshorter time taken to deliver the fetus once CPR commences,are associated with better maternal and fetal outcomes.Management decisions depend on gestational age. Forexample, avoidance of aortocaval compression is essential after15 weeks of gestation or when the fundal height is more thanone handbreadth below the umbilicus. If brain death occursbefore fetal maturation, continued somatic support of the mothercan be done to extend the pregnancy until fetal maturation.Methods of Displacing UterusThe quality of CPR and resultant compression force and output are dependent on the position. The left-lateral tilt shouldbe maximized to improve maternal hemodynamics duringcardiac arrest. There are several practical issues regarding theleft lateral tilt. It is not practical to apply a full lateral rotationFig. 3 Modifications for resuscitation of cardiac arrest in pregnancy. ACLS, advanced cardiac life support; BLS, basic life support; CPR, cardiopulmonary resuscitation; DIC, disseminated intravascular coagulation; MI, myocardial infarction; PTE, pulmonary thromboendarterectomy;ROSC, return of spontaneous circulation.Indian Journal of Cardiovascular Disease in Women WINCARS Vol. 4No. 1/2019
Challenges of CPR during Pregnancyduring resuscitation. There is no improvement in maternalhemodynamic or fetal parameters with 10 to 20 degreesleft-lateral tilt, and the patient may roll off the inclined planeif the slope exceeds 30 degrees.29,30 Moreover, the degree oftilt is difficult to estimate reliably. Hence, using a fixed, hardwedge with a predetermined angle is helpful. The Cardiffwedge provides both relief of aortocaval compression and a firmsurface for performing cardiac compressions during resuscitation. When a wedge is not available, rolling up blankets totilt the right hip or even a simple maneuver of tipping thepatient on the bent knees of a kneeling rescuer (“humanwedge”) is useful. Although the left-lateral tilt position isvital to reduce aortocaval compression by gravid uterus,the chest compressions are less forceful than in the supineposition. Manual left uterine displacement with the patientsupine is comparable to left-lateral tilt in relieving aortocavalcompression.31 Therefore, one can commence resuscitationwith manual left uterine displacement in the supine position,using a two-handed technique from the patient’s left sideor the one-handed technique from the patient’s right sidedepending on the location of the resuscitation team.32 If this isunsuccessful and an appropriate wedge is available, the patientshould be placed in a left-lateral tilt of about 30 degrees usinga firm wedge. If chest compressions remain inadequate evenafter lateral uterine displacement or left-lateral tilt, consideran immediate emergency cesarean section.Arrhythmia-specific recommendations: Amiodarone 300 mgrapid infusion followed by 150 mg doses as needed is used totreat refractory Vfib, although fetal safety is questionable.33Epinephrine is recommended over vasopressin. Atropineis administered only for bradycardia. Calcium is helpful toreverse magnesium toxicity. There is no need to alter drugdoses or withhold emergency medications out of concerns forfetal teratogenicity.Perimortem Cesarean SectionIndicationsEmergency cesarean section in cardiac arrest resuscitationshould be prepared in every cardiac arrest in a pregnantwoman, with an evident gravid uterus large enough to causematernal hemodynamic changes due to aortocaval compressionregardless of fetal viability.Timing of Perimortem C-Section: 4-Minute RulePerimortem C-section is lifesaving and should be performedat the site of arrest within 5 minutes. Maternal resuscitationefforts should be continued during the procedure. Earlydelivery decreases the risk of neurologic damage to the baby.If the fetus is viable, but the maternal prognosis is grave, andresuscitative efforts appear futile, it may be appropriate toperform an immediate emergency cesarean section withoutdelay. Even if the emergency cesarean section cannot beperformed by the 5-minute mark, it may be advisable toevacuate the uterus while the resuscitation continues(class IIb, LOE C).34 The emergency cesarean section teamshould be activated at the onset of maternal cardiac arrestif the gravid uterus is visible (class I, LOE B). An emergencyDurga et al.cesarean section may be considered 4 minutes after onset ofmaternal cardiac arrest if there is no return of spontaneouscirculation (class IIb, LOE C).34Expected Fetal and Maternal Outcomes of PerimortemCesarean SectionThere is increasing use of PMCS due to the training(0.36/year before training to 1.6/year after training,p 0.01). Although the timing of PMCS is the mostcrucial factor for both maternal and fetal outcomes, itwas possible to perform PMCS within the recommended5 minutes of commencing resuscitation in very few cases.35The mean times to delivery in survivors 14.1 11 minutesand 22 13 minutes in nonsurvivors.36 There are reportsof maternal survival of the mother with a PMCS performedup to 15 minutes after the onset of cardiac arrest. A studyhas shown that of the 12 women who underwent PMCS,(67%) regained cardiac output, but only 2 mothers and5 neonates survived. Maternal mortality rate was 83%. Ameta-analysis of maternal outcome after PMCS shows that54.3% (51/94) of mothers survived to hospital discharge,78.4% (40/51) with a cerebral performance category (CPC)of 1/2. PMCS is shown to be beneficial to the mother in 31.7%of cases and was not harmful in any case. The maternaloutcomes were better with in-hospital arrest (odds ratios[ORs] 5.17) and PMCD within 10 minutes of arrest (ORs7.42).37 Therefore, a low admission threshold for pregnantwomen with cardiorespiratory decompensation is recommended. They should be admitted to a high dependencyor intensive care unit with facilities for the performance ofresuscitation and delivery within 10 minutes of arrest. Theneonatal case fatality rate was 58%.37 The fetal outcomesdepend on gestational age. At 24 to 25 weeks of gestation,delivery within 5 minutes of maternal arrest results in bestfetal outcome, whereas at a gestational age of 30 weeks,every delivery that occurs after 5 minutes of maternalcardiac arrest is associated with good outcomes. There arereports of neonatal survival even when delivery occurredwithin 30 minutes after onset of maternal cardiac arrest.38Postcardiac Arrest CareThe recommendation for therapeutic hypothermia incomatose pregnant patients after cardiac arrest is based onoccasional case reports39 and current recommendations forthe nonpregnant patients. Therapeutic hypothermia maybe considered on an individual basis (class IIb, LOE C).34The fetus should be continuously monitored for potentialcomplications such as bradycardia.Extended Somatic Support after Brain Death duringPregnancyBrain death declaration is rarely done in pregnant patients. Itis generally considered unethical and futile to support vitalorgans once brain death is diagnosed. However, in pregnancy,the issues of brain death are more complex.40 The issue of theappropriateness of continuing maternal somatic support toprolong gestation until delivery is debatable. The expectedIndian Journal of Cardiovascular Disease in Women WINCARS Vol. 4No. 1/201937
38Challenges of CPR during PregnancyDurga et al.physiologic changes after brain death also pose challenges tosuccessful organ system support and fetal well-being. Since1979, there have been only 43 cases of maternal brain death,and most of them had normal fetal outcomes.41Challenges of Resuscitation of PregnantPatients in Resource-Constrained CountriesSeveral pregnant patients have limited access to health care,and most deliveries continue to be performed by midwiveswith inadequate skills in resuscitation. It is important toidentify high-risk patients for cardiac arrest and treat themin specialized centers. Physicians, paramedical staff, andmidwives need to be trained in CPR and understand themodifications required for pregnant patients. Training ofall the staff involved in the care of pregnant patients forbasic and advanced obstetric life support is essential. Thereis still a big gap between the requirements and availabilityof advanced health care facilities and trained personnel toprevent and resuscitate cardiac arrests in pregnant patients.Maternal deaths continue to plague the resource-constrainedcountries such as India.ConclusionAlthough cardiopulmonary arrest rarely occurs in the pregnantwoman, the knowledge of principles of resuscitation ina parturient in the health care team is vital to facilitatepositive outcomes for both the mother and the fetus. Theprinciples of the airway, breathing, and circulation usedin cardiopulmonary arrest are similar to any other CPR;however, the team must be familiar with the modificationsthat must be made because of the physical and physiologicchanges that occur during pregnancy. If resuscitation is notsuccessful within 5 minutes of cardiac arrest, a cesareandelivery must be attempted if uterine size indicates gestationalage of at least 20 weeks. A coordinated team consisting ofobstetricians, anesthesiologists, neonatologists, and nursingstaff must work in an organized fashion for efficient andsuccessful resuscitation of the pregnant patient and goodfetal outcomes.Conflict of InterestNone declared.References1 Beckett VA, Knight M, Sharpe P. The CAPS study: incidence,management and outcomes of cardiac arrest in pregnancy inthe UK: a prospective, descriptive study. BJOG 2017;124(9):1374–13812 Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancyrelated mortality in the United States, 2011-2013. ObstetGynecol 2017;130(2):366–3733 Lipman S, Cohen S, Einav S, et al; Society for ObstetricAnesthesia and Perinatology. The Society for ObstetricAnesthesia and Perinatology consensus statement on themanagement of cardiac arrest in pregnancy. Anesth Analg2014;118(5):1003–1016Indian Journal of Cardiovascular Disease in Women WINCARS Vol. 4No. 1/20194 McQUAID E, Leffert LR, Bateman BT. The role of theanesthesiologist in preventing severe maternal morbidity andmortality. Clin Obstet Gynecol 2018;61(2):372–3865 Subbaiah M, Sharma V, Kumar S, et al. Heart disease in pregnancy: cardiac and obstetric outcomes. Arch Gynecol Obstet2013;288(1):23–276 van Hagen IM, Thorne SA, Taha N, et al; ROPAC Investigatorsand EORP Team. Pregnancy outcomes in women with rheumatic mitral valve disease: results from the registry of pregnancy and cardiac disease. Circulation 2018;137(8):806–8167 Honigberg MC, Scott NS. Pregnancy-associated myocardialinfarction. Curr Treat Options Cardiovasc Med 2018;20(7):588 Kealey A. Coronary artery disease and myocardial infarctionin pregnancy: a review of epidemiology, diagnosis, andmedical and surgical management. Can J Cardiol 2010;26(6):185–1899 Burchill LJ, Lameijer H, Roos-Hesselink JW, et al. Pregnancyrisks in women with pre-existing coronary artery disease,or following acute coronary syndrome. Heart 2015;101(7):525–52910 Furenäs E, Eriksson P, Wennerholm UB, Dellborg M. Effectof maternal age and cardiac disease severity on outcome ofpregnancy in women with congenital heart disease. Int JCardiol 2017;243:197–20311 Kampman MA, Valente MA, van Melle JP, et al; ZAHARA IIinvestigators. Cardiac adaption during pregnancy in womenwith congenital heart disease and healthy women. Heart2016;102(16):1302–130812 Sliwa K, van Hagen IM, Budts W, et al; ROPAC investigators.Pulmonary hypertension and pregnancy outcomes: datafrom the Registry Of Pregnancy And Cardiac
Jul 16, 2019 · Cardiac arrest, though rare, is the most feared complica-tion in the peripartum period. The incidence of cardiac arrest during pregnancy is 2.78 per 100,000 maternities, and mortality is about 42%.1 Resuscitation of the cardiac arrest in parturient aims at both the maternal and th
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