CARDIAC ARREST IN PREGNANCY
CARDIAC ARREST IN PREGNANCYA LIYA D ABBOUS * AND FOUAD SOUKI **Cardiac arrest occurs only about once in every 30.000 latepregnancy, and survival from such an event is exceptional1. Not only iscardiac arrest a feared entity in this population, but it is also unexpectedand catastrophic2. For this reason, it is necessary that the obstetricanesthesiologist be knowledgeable about the risk factors for cardiacarrest, the physical changes in the parturient and the management of CPRduring pregnancy.There are multiple etiologies of cardiac arrest during pregnancy.Some are pregnancy-associated, and others result form conditions thatexisted before pregnancy (Table 1).Table 1Obstetric causesHemorrhagePreeclampsiaHELLP syndromeAmniotic fluid embolusAnesthetic complicationsNonobstetric causesPulmonary embolusSeptic shockCardiovascular diseaseMyocardial infarctionTraumaObstetric CausesHemorrhageObstetric hemorrhage can be massive and may lead to maternalcardiac arrest. Causes of obstetric hemorrhage include abruptio placenta,placenta previa, uterine rupture, and uterine atony3. Postpartum bleedingFrom the American University of Beirut, Dept of Anesthesia, Beirut, Lebanon.* MD, Lecturer.**MD, MS, Chief Resident449M.E.J. ANESTH 19 (2), 2007
450ALIYA DABBOUS & FOUAD SOUKItends to be underestimated. Early diagnosis, identification, and treatmentof the source of bleeding with volume resuscitation may help avertcardiac arrest. If hemorrhage is suspected, adequate intravenous accessshould be immediately obtained. Blood is typed and cross-matched, andthe source of bleeding identified and treated. Uterine atony is the mostcommon etiology. It is important to restore adequate blood volume whenhemorrhage is the etiology of cardiac arrest.Preeclampsia and HELLPPreeclampsia is a significant contributor to maternal and fetal deathand complications. The complications of preeclampsia which precipitatecardiac arrest include: eclampsia, pulmonary edema, cardiac dysfunction,stroke cerebral edema and the HELLP syndrome; the latter beingassociated with 40% incidence of cardiac arrest. latrogenic complicationsof preeclampsia, such as magnesium toxicity and fluid overload, alsocontribute to maternal cardiac arrest3,4.If cardiac arrest complicates preeclampsia, it may also be due todecreased intravascular volume, which is part of the pathophysiology ofpreeclampsia. Hypovolemia makes cardiac compressions less efficient,than the nonpregnant resuscitation efforts that yield 30% of the cardiacoutput. Therefore volume repletion is an important part of theresuscitation of preeclampsia3.Amniotic Fluid EmbolusAmniotic fluid embolus is a devastating complication of pregnancythat causes maternal death rate as high as 50%5. The cause of death inamniotic fluid embolus is likely to be cardiac arrest5. The use ofcardiopulmonary bypass for women with life threatening amniotic fluidembolism during labor and delivery has been reported with successfuloutcome6.
CARDIAC ARREST IN PREGNANCY451Anesthetic ComplicationsComplications of regional and general anesthesia are anothercause of cardiac arrest in labor and delivery. Even with routine dosingand testing, epidural catheters can migrate into the intravascular orsubarachnoid space, leading to systemic toxicity or total spinalanesthesia, respectively. Drug overdosage can lead to local anesthetictoxicity, particularly in patients who have received multiple top-updoses of local anesthetics during a prolonged labor. Unlike theoperating room, patients in the delivery suite receive regionalanesthesia for prolonged periods of time without the continuouspresence of anesthesiologist. It is therefore essential that the amountof local anesthetic the patient receives be monitored from shift toshift. Finally, it is critical to remember that induction of eitherregional or general anesthesia can lead to severe hypotension inpreviously hypovolemic patients 3.The effective treatment of cardiac arrest during pregnancyrequires a complete understanding of the physiologic changes seen inthe parturient. These physiologic changes can make the diagnosis andtreatment of emergent situations difficult in the labor suite. Cardiacoutput is greatly influenced by the patient’s position, especiallyduring the third trimester. The supine hypotension syndrome candecrease cardiac output by 30-40% 3. Many women cannot tolerate thesupine position, especially after 30 weeks of gestation. For safety,women are encouraged to maintain left uterine displacement either byelevation of the right hip or by positioning themselves on their sides.In the labor suite, patients are frequently positioned on their back tofacilitate cervical exams and placement of monitoring devices. If thepatients are not reminded to return to their side, especially in thepresence of epidural anesthesia, there can be a rapid decrease invenous return, leading to hypotension and possibly cardiac arrest.M.E.J. ANESTH 19 (2), 2007
452ALIYA DABBOUS & FOUAD SOUKINonobstetric CausesPulmonary EmbolusPulmonary embolus (PE) is a leading cause of maternal death. Ahigh index of suspicion should exist when a pregnant woman presentswith deep vein thrombosis or PE3. Immediate institution ofanticoagulation therapy with heparin and diagnostic workup willmarkedly decrease the risk of maternal death in patients who havethromboembolic disease. When massive pulmonary embolus leads tocardiac arrest, thrombolytic therapy or thrombectomy should beconsidered7.Septic ShockOccurs in 1 per 5000 gestations and may result in maternal death.Sepsis can result from antepartum infections, including chorioamnionitis,pneumonia, and urinary tract infections. Endomyocarditis in thepostpartum period can likewise lead to sepsis. Infections must thereforebe treated aggressively3.Cardiac DiseaseCardiac disease complicating pregnancy contributes to antepartumand postpartum maternal death. The risk of death is directly related to theNew York Heart Associations status. Women with stage III or IV have ahigh risk of death3. In these patients. pulmonary artery catheters arerecommended for tight regulations intravascular volume, cardiac outputand oxygen delivery3.Myocardial InfarctionMay complicate pregnancy and is more likely to occur in women
CARDIAC ARREST IN PREGNANCY453with underlying conditions such as diabetes mellitus, chronichypertension, morbid obesity and ventricular hypertrophy. Pregnancywithin 6 months of myocardial infarction is also associated with maternalcomplications and death3.Severe asthma and other chronic pulmonary disease may worsenduring gestation and likewise lead to respiratory failure and cardiacarrest3.Trauma or Drug OverdoseDomestic violence increases during pregnancy. Homicide andsuicide are leading causes of mortality. Accidental intravenous boluses ofmedications have been reported7; magnesium or vancomycin can lead tosevere consequences, like hypotension and cardiac arrest4,7. Case reportshave linked ergot derivatives with myocardial infarction and cardiacarrest in the parturient7.Maternal Physiologic Changes in PregnancyCardiovascular ChangesAfter the 10th week of gestation, cardiac output is increased by 1.0 to1.5 liters per minute8. Maternal heart rate increases throughout pregnancy,reaching a peak of 15-20 beats above nonpregnant values during the thirdtrimester8. Maternal blood pressure is less than nonpregnant values, withsystolic pressures typically about 10-15 mmHg lower than non-pregnantvalues. Because of these cardiac changes, patients can bleed extensivelybefore the normally recognizable physical signs, such as tachycardia andhypotension, occurs. In addition, at about 34 weeks gestation, plasmavolume is increased by 40-50%. A smaller increase in red blood cellvolume occurs, resulting in a decreased hematocrit and the physiologicanemia of pregnancy8. Often, a lower hematocrit can be misinterpreteddue to this phenomenon, especially in the case of hypovolemia and acutehemorrhage. Because of these compensatory mechanisms, and theM.E.J. ANESTH 19 (2), 2007
454ALIYA DABBOUS & FOUAD SOUKItendency for blood flow to be shunted from the uteroplacental circulationunder conditions of hypovolemia, the pregnant patient can lose 35% ofher blood volume before tachycardia, hypotension, and other signs ofhemodynamic instability can be identified7. A parturient may appearstable while the fetus is severely deprived of blood flow and the patient isgreatly compromised7.Respiratory ChangesTidal volume increases during pregnancy and may cause an increasein minute ventilation. Increased oxygen consumption leads to increasedrates of arterial oxygen desaturation in the parturient that becomesapneic8. The expanding uterus and consequent diaphragmatic elevationdecreases thoracic volume leading to a decrease in functional residualcapacity (FRC)8. Due to the hormonal and physical changes of pregnancy,patients are at increased risk for difficult ventilation and failedintubation7. Increased levels of progesterone leads to delayed gastricemptying, increasing the risk for aspiration during mask ventilation andintubation1,7. Though many centers require that patients remain fastingduring labor, many patients will present in spontaneous labor afterconsuming a large meal. Edema of the upper airway, increased breast sizeand generalized weight gain can delay the establishment of adequateventilation and intubation. Therefore, it is essential that oxygenation andventilation be restored expeditiously while maintaining cricoid pressure7.Resuscitation of the Pregnant Woman During Cardiac ArrestSuccessful resuscitation in late pregnancy is difficult because thegravid uterus acts like an abdominal binder producing an increase inintrathoracic pressure, diminished venous return, and obstruction toforward flow of blood into the abdominal aorta, especially in the supineposition2,7. In addition, the gravid uterus accounts for 10% of cardiacoutput and this massive shunting of blood may hinder efforts at CPR.External cardiac massage can at best generate only 30% of a non-pregnantpatient’s normal cardiac output and increased oxygen requirements during
CARDIAC ARREST IN PREGNANCY455pregnancy make the parturient much less tolerant to hypoxia2. Tosuccessfully resuscitate a parturient in late pregnancy, a coordinated teamapproach is essential. Obstetricians, anesthesiologists, neonatologists andnursing staff must work efficiently and in an organized fashion toresuscitate these patients. As these events happen unexpectedly,cooperation is essential to assemble needed equipment and performresuscitation efforts in the labor suite1.Modifications in emergency cardiac care for the pregnant uterusconsist of:1- Left uterine displacement.2- Aggressive airway management (see section airway under BLS andACLS).3- Chest thrust instead of abdominal thrust in case of foreign bodyairway obstruction (see BLS).4- Aggressive restoration of circulatory volume (ACLS).5- Perimortem Cesarean delivery – Delivery within 5 minutes if fetus isviable.Left Uterine DisplacementTo perform chest compressions one must ensure that left uterinedisplacement is adequately maintained9. The Cardiff wedge, which ismade of hard laminated wood on casters, provides both relief ofaortocaval compression and a firm surface upon which to performcompressions (Fig. 1 & 2).Fig. 1The Cardiff wedge(Ref. 1)M.E.J. ANESTH 19 (2), 2007
456ALIYA DABBOUS & FOUAD SOUKIFig. 2Patient inclined laterallyby using Cardiff wedge(Ref. 1)Patient inclined laterally by using Cardiff wedgeFig. 3(Ref. 1)If the Cardiff resuscitation wedge is not available, other techniquesneed to be used. A human wedge is useful by tilting the patient on thebent knees of a kneeling rescuer1. An upturned chair, a cushion, a rolledup blanket or pillow can be used to wedge the patient into the left inclinedposition1 (Fig. 3). If the compressions are performed in a hospital bed, theplacement of a hard wooden board beneath the patient is also essential forsuccessful compressions.Standard algorithms should be used according to ACLS protocol;they are unaltered by pregnancy3,7. To perform chest compressions ensureleft uterine displacement is adequately maintained1,3,7,9.
457CARDIAC ARREST IN PREGNANCYAggressive Airway ManagementModifications of BLS in PregnancyPrimary ABCD SurveyNo modifications (Table 2).Table 2(Basic BLS) life supportPrimary ABCD Survey Check responsiveness Activate emergency response system Call for defibrillatorA. Airway: open the airwayB. Breathing: provide positive-pressure ventilationsC. Circulation: give chest compressionsD. Defibrillation: assess for and shock VF/pulseless VTA. AirwayNo modifications.B. BreathingNo modifications. Hormonal changes promote insufficiency of thegastroesophageal sphincter, increasing the risk of regurgitation. Applycontinuous cricoid pressure during positive pressure ventilation for anyunconscious pregnant woman7.C. CirculationPlace the woman on her left side with her back angled 15 to 30 back from the left lateral position. Then start chest compressions. Orplace a wedge under the woman’s right side (so that she tilts toward herleft side) (Fig. 2). or have one rescuer kneel next to the woman’s left sideand pull the gravid uterus laterally. This maneuver will relieve pressureon the inferior vena cava.Perform chest compressions higher on the sternum, slightly aboveM.E.J. ANESTH 19 (2), 2007
458ALIYA DABBOUS & FOUAD SOUKIthe center of the sternum. This will adjust for the elevation of thediaphragm and abdominal contents caused by the gravid uterus7.The Heimlich maneuver for the pregnant woman with airwayobstruction is modified in the second half of pregnancy. Abdominal thrustmay cause rupture of the pregnant uterus (and/or the liver or spleen) andwill probably not be effective. Chest thrusts should be substituted in themiddle sternum, avoiding the xyphoid process7.D. DefibrillationNo modifications in dose or pad position. Defibrillation shocks transfer no significant current to the fetus. Remove any fetal or uterine monitors before shock delivery. Modifications of ACLS in pregnancyThe treatments listed in the secondary ABCD survey (Table 3),standard ACLS, Pulseless Arrest Algorithm, including recommendationsand doses for defibrillation, medications, and intubation; apply to cardiacarrest in the pregnant woman (Table 3). There are importantconsiderations to keep in mind, however, about airway, breathing,circulation, and the diferential diagnosis7.Table 3Advanced Cardiac Life Support (ACLS)A. Airway: place airway deviceB. Breathing: confirm airway device placement by exam plusconfirmation deviceB. Breathing: secure airway device; purpose-made tube holders preferredB. Breathing: confirm effective oxygenation and ventilationC. Circulation: establish IV accessC. Circulation: identify rhythm and monitorC. Circulation: administer drugs appropriate for rhythm and conditionC. Circulation: assess for occult blood flow (pseudo-EMD)D. Differential Diagnosis: search for and treat identified reversiblecauses
CARDIAC ARREST IN PREGNANCY459A. Airway Secure the airway early in resuscitation. Because of the potential forgastroesophageal sphincter insufficiency with an increased risk ofregurgitation, use continuous cricoid pressure before and duringattempted endotracheal intubation. Be prepared to use an endotracheal tube 0.5 to 1 mm smaller ininternal diameter than that used for a nonpregnant woman of similarsize because the airway may be narrowed from edema. Monitor for excessive bleeding following insertion of any tube intothe oropharynx or nasopharynx. No modifications to intubation techniques. A provider experienced inintubation should insert the tracheal tube. Effective preoxygenation is critical because hypoxia can developquickly. Agents for anesthesia or deep sedation should be selected to minimizehypotension.B. Breathing Pregnant patients can develop hypoxemia rapidly because theyhave decreased functional residual capacity and increased oxygendemand, so rescuers should be prepared to support oxygenationand ventilation. Verify correct endotracheal tube placement using clinical assessmentand a device such as an exhaled CO2 detector. In late pregnancy theesophageal detector device is more likely to suggest esophagealplacement (the aspirating bulb does not reinflate after compression)when the tube is actually in the trachea. This could lead to theremoval of a properly placed endotracheal tube. Ventilation volumes may need to be reduced because the mother’sdiaphragm is elevated by the uterus.M.E.J. ANESTH 19 (2), 2007
460ALIYA DABBOUS & FOUAD SOUKIC. Circulation Follow the ACLS guidelines for resuscitation medications.Vasopressor agents such as epinephrine, vasopressin, and dopaminewill decrease blood flow to the uterus. There are no alternatives,however, to using all indicated medications in recommended doses.The mother must be resuscitated or the chances of fetal resuscitationvanish. Do not use the femoral vein or other lower extremity sites for venousaccess. Drugs administered through these sites may not reach thematernal heart unless or until the fetus is delivered. D. Differential Diagnosis The same reversible causes of cardiac arrest that occur in nonpregnantwomen can occur during pregnancy. But providers should be familiarwith pregnancy-specific diseases and procedural complications.Providers should try to identify these common and reversible causesof cardiac arrest in pregnancy during resuscitation attempts anddecide whether to perform emergency hysterotomy. The use ofabdominal ultrasound by a skilled operator should be considered indetecting pregnancy and possible causes of the cardiac arrest, but thisshould not delay other treatments8. Excess magnesium sulfate as atreatment in women with eclampsia can lead to cardiac arrest,particularly if the woman becomes oliguric. Empiric calciumadministration may be life saving. A case was reported by Swartjes etal. (1992) of successful resuscitation with calcium gluconate of aneclamptic who received magnesium overdose4.ACLS DrugsCurrent recommendations are that ACLS protocols be followed inpregnancy as they are in nonpregnant individual. Vasopressor agents suchas epinephrine, dopamine, and vasopressin will decrease uterine bloodflow. There are, however, no alterations to using all indicated medications
461CARDIAC ARREST IN PREGNANCYin recommended doses. The mother must be resuscitated even if thechances of fetal resuscitation vanish7.Epinephrine 1 mg IV q3-5 min. High dose epinephrine is no longer recommended.Vasopressin 40 U IV. One time dose (wait 5-10 minutes before starting epinephrine). Can replace first or second dose of epinephrine in all ACLSalgorithms. Vasopressin can only be given once.Amiodarone (class 2b) 300 mg IV push. May repeat once at 150 mg in 3-5 min. Max cumulative dose 2.2g IV/24 hours.Lidocaine 1-1.5 mg/kg IV q3-5 min. Max 3 mg/kg.Magnesium Sulfate 1-2g IV (over 2 min) for suspected hypomagnesemia or torsades depointes (polymorphic VT).Bicarbonate 1 meq/kg IV for reasons below. Class 1: hyperkalemia. Class 2a: bicarbonate responsive acidosis, tricyclic overdose, toalkalize urine for aspirin overdose. Class 2b: prolonged arrest.M.E.J. ANESTH 19 (2), 2007
462 ALIYA DABBOUS & FOUAD SOUKINot for hypercarbia related acidosis, not for routine use in cardiacarrest.Transcutaneous pacing (TCP) has not been shown to improvesurvival in asystole and is therefore not recommended to be used. TCP isonly used in symptomatic bradycardia, second and third degree AV blockwhen signs and symptoms of poor perfusion are present. Also in newlyacquired left, right or alternating bundle branch block or bifasicular blockin the setting of acute myocardial infarction. Signs of poor perfusioninclude: orthostatic hypotension, diaphoresis, pulmonary congestion onphysical examination or chest x-ray, frank congestive heart failure orpulmonary edema; and bradycardia related escape rhythm, frequentpremature ventricular complexes.Terminating In-hospital Resuscitation EffortsIf a reversible cause is not rapidly identified and the patient fails torespond to the BLS primary survey and ACLS secondary surveymanagement, termination of resuscitation efforts may be appropriate. Thedecision to terminate resuscitation efforts rests with the treating physicianin the hospital and is based on consideration of many factors: Time to CPR. Time to defibrillation. Comorbid disease. Prearrest state. Initial arrest rhythm. Response to resuscitation measures.None of these factors alone or in combination is clearly predictive ofoutcome. The duration of resuscitative efforts, however, is an importantfactor associated with poor outcome.Duration of Resuscitative EffortsAvailable scientific studies have shown that in the absence ofmitigating factors, prolonged resuscitative efforts are unlikely to be
CARDIAC ARREST IN PREGNANCY463successful and they can be discontinued if there no return of spontaneouscirculation (ROSC) at anytime during or following 20 minutes ofcumulative BLS and ACLS. If ROSC of any duration occurs, it may beappropriate to consider extending the resuscitative efforts. It may also beappropriate to consider other causes such as, drug overdose, and severeprearrest hypothermia (e.g. submersion in icy water) when decidingwhether to extend resuscitative efforts. Think of potentially reversiblecauses.Perimortem Cesarean Delivery and Delivery Within 5 MinutesAttempts at resuscitation in the pregnant patients are unfortunatelymet with failure secondary to negative impact of the anatomic andphysiologic changes of pregnancy11-15. If cardiac arrest occurs in the firsthalf of gestation, the purpose of CPR is to resuscitate the mother. If she isresuscitated, it is likely that the pregnancy will proceed and the fetalviability will not be compromised. In this setting, emergency delivery ofthe fetus is not likely to improve the mother’s chances of survival andcertainly the fetus will not survive. However, beyond the threshold ofviability (24 weeks of gestation or greater) there are data to suggest thatdelivery may actually improve maternal survival. Delivery of the fetuswill decrease aortocaval compressions and therefore improve venousreturn and cardiac output. In addition, the cardiac output will increasesecondary to the 25-56% increase in intravascular volume that occurswhen the uterus is emptied and autotransfusion occurs11-14. An additionalbenefit is that chest compressions will be more effective once the graviduterus is evacuated. The functional residual capacity will likewiseincrease, improving oxygenation during resuscitation efforts11-14.Several case reports document the successful resuscitation ofpregnant women in cardiac arrest after perimortem cesarean delivery11,15.The time interval from cardiac arrest to delivery is probably thesingle most important prognostic factor for fetal survival. If the fetus isdelivered within 5 minutes of maternal cardiac arrest, intact neurologicalsurvival is markedly increased. Therefore, during CPR, to maximizeM.E.J. ANESTH 19 (2), 2007
464ALIYA DABBOUS & FOUAD SOUKImaternal and fetal survival the 4-minute interval from arrest to initiatingdelivery should be considered (Table 4). Whitten and Irvine in 200014reported 56 post mortem cesarean section with 6 fetal survivors. Althoughbest fetal survival rates when delivery is within 5 minutes of arrest,cesarean section after prolonged arrest may result in fetal survival.Successful resuscitation of a neonate after 47 minutes of fatal maternalinjury have been reported16.Time Interval(min)0–56 – 1516-2526-3536 Table 4Neonatal Outcome following C-sectionSurvivingIntact neurologicInfantsStatus of Survivors451894198%83%33%25%0%ConclusionOne must be aware of the impact of the physiologic and anatomicchanges that occur during normal pregnancy on attempts to provideresuscitation during maternal cardiac arrest. Chest thrusts rather thanabdominal thrusts should be used during maternal resuscitation for airwayobstruction. The maternal airway should be rapidly secured and stabilizedwith endotracheal intubation when possible. Care should be taken toavoid maneuvers that will lead to maternal vomiting and aspiration.Intravascular volume should be replaced rapidly with packed red bloodcells, if indicated. ACLS protocols should be followed as they would bein the nonpregnant individual; however doses of drugs should beincreased if there is no maternal response. If the gestation age is thoughtto be at least 24 weeks and maternal resuscitation is unsuccessful,cesarean delivery should be started within 4 minutes of cardiac arrest andaccomplished within 5 minutes to optimize maternal and fetal survival.
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468ALIYA DABBOUS & FOUAD SOUKIReferences1. STEPHEN MORRIS, MARK STACEY: ABC of Resuscitation in pregnancy. BMJ; 327, 1277-79, 2003.2. Cardiac Arrest in Labor and Delivery: A current Review SOAP Newsletter winter, 2003.3. WHITTY JE: Maternal cardiac arrest during pregnancy. Clinical J Obstet Gynec; 45(2), 377-92,2003.4. SWARTJES JM, SCHUTTLE MF, ET AL: Management of eclampsia: cardiopulmonary arrest resultingfrom magnesium sulfate overdose. Eur Obstet Gynecol Reprod Biol; 47(1):73-75, 1992.5. CLARK S, HANKIN G, DUDLEY D: Amniotic fluid embolism: Analysis of the national registry. Am JObstet Gynecol; 172:1158-69, 1995.6. Amniotic fluid embolism causing catastrophic pulmonary vasoconstriction: Diagnosis bytransesophageal echocardiogram and treatment by cardiopulmonary bypass. Obst and Gynecol;102:496-498, 2003.7. Cardiac Arrest Associated with Pregnancy: Circulation; 112:150-163, 2005.8. CHESTNUT, DAVID H: Obstetric Anesthesia Principles and Practice 2nd Ed, p. 17-42, 1999.9. KINSELLA SM: Lateral tilt for pregnant women: why 15 degrees? Anesthesia; 58(9):835-6, 2003.10. American Heart Association Guidelines for Cardiopulmonary Resuscitation and EmergencyCardiovascular Care: Circulation; 2005, 112, Issue 24 Supplement; December 13, 2005.11. KATZ VL, DOTTERS DJ, ET AL: Perimortem cesarean delivery. Obstet Gynecol; 68:571, 1986.12. LANOIX R, AKKAPED V, ET AL: Perimortem cesarean section: case reports and recommendations.Acad Emerg Med; 2(12):1063-7, 1995.13. FINEGOLD H, DARWICH, ET AL: Successful resuscitation after maternal cardiac arrest by immediatecesarean section in the labor room. Anesthesiology; 96(5):1278, 2002.14. WHITTEN M AND IRVINE LM: Postmortem and perimortem cesarean section: what are theindications? J R Soc Med; 93(1):6-9, 2000.15. POOLE JH, LONG J: Maternal mortality-a review of current trends. Crit Care Nurs Clin North Am;16:227-230, 2004.16. LOPEZ-ZENO JA, CARLO WA, ET AL: Infant survival following delayed postmortem cesareandelivery. Obstet Gynecol; 76(5):991-992, 1990.
Preeclampsia is a significant contributor to maternal and fetal death and complications. The complications of preeclampsia which precipitate cardiac arrest include: eclampsia, pulmonary edema, cardiac dysfunction, . tendency for blood flow to be shunted from the uteroplacental circulation under conditions of hypovolemia, the pregnant patient .
Systems of Care for Improving Post–Cardiac Arrest Outcomes Post–cardiac arrest care is a critical component of advanced life support (Figure). Most deaths occur during the first 24 hours after cardiac arrest.5,6 The best hospital care for patients with ROSC after card
Advanced cardiac life support (ACLS) is a two day course that teaches students to recognize and treat cardiac arrest, arrhythmias, acute coronary syndromes, stroke, cardiac arrest in the pregnant woman, and cardiac arrest in situations involvi
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
US intrauterine pregnancy: reproducible loss heart activity, failure increase CRL over 1 w or persisting empty sac at 12 w Ectopic pregnancy blood/urine hCG, gestational sac outside uterus Heterotopic pregnancy Intrauterine ectopic pregnancy Pregnancy of unknown location (PUL) No identifiable pregnancy on US with blood/urine hCG
Discuss prevalence of teenage pregnancy. 2. Discuss pregnancy screening in teen population. 3. Identify pregnancy risks associated with teenage pregnancy for the mother. 4. Discuss medical impacts associated with teenage pregnancy for the fetus/infant. 5. Discuss social implications of teenage pregnancy. 6. Discuss risk for repeat unintended .
arrest will receive bystander CPR. It offers the advantage of consistency in teaching rescuers, whether their patients are infants, children, or adults.” Part 13: Pediatric BLS: 2010 AHA Guidelines for CPR and ECC. Circulation. 2010;122:S862-S875 ABC vs CAB Cardiac arrest due to respiratory arrest is more
What is Sudden Cardiac Arrest (SCA) Sudden Cardiac Arrest (SCA) is an arrhythmia- abnormal heartbeat- which causes the heart [s normal rhythm to suddenly become chaotic. The heart can no longer pump oxygenated blood effectively around the body and the victim collapses, becomes unresponsive, and stops breathing.
Safety Code for Elevators and Escalators, ASME A17.1-2013, as amended in this ordinance and Appendices A through D, F through J, L, M and P through V. Exceptions: 1.1. ASME A17.1 Sections 5.4, 5.5, 5.10 ((and)) , 5.11, and 5.12 are not adopted. 1.2. ASME A17.1 Section 1.2.1, Purpose, is not adopted. 2015 SEATTLE BUILDING CODE 639 . ELEVATORS AND CONVEYING SYSTEMS . 2. Safety Standard for .
