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Optimizing antepartum maternal resuscitation during cardiac arrest after 20 weeks estimated gestational age: a pragmatic approach
Abstract Number: T1H-447
Abstract Type: Original Research
Resuscitation of antepartum maternal cardiac arrest (AMCA) for EGA >20 weeks is distinct from management of postpartum arrest, due to need for perimortem delivery (PD) within 4 minutes if return of spontaneous circulation (ROSC) is not achieved [1,2]. This gives a narrow window of 4 minutes during which a team must identify reversible causes and initiate empiric treatments to improve chances of survival and maintenance of pregnancy if maternal ROSC is attained. Because of this limited time frame during which maternal ROSC would alter the course of mother and fetus by obviating the need for PD, we sought a pragmatic approach to empirically treating etiologies which could be reversed within the first 4 minutes after AMCA.
AHA/ACC guidelines for maternal cardiac arrest were reviewed, for a total of 37 etiologies for all arrest conditions . Etiologies were analyzed by the following criteria: 1) direct causality vs indirect causality for cardiac arrest; and 2) potentially reversible in the first 4 minutes, given ideal conditions with ready access to all needed resources. In addition to accepted ACLS guidelines, including initiation of high-quality chest compressions with manual left uterine displacement, early defibrillation, and administration of 1mg epinephrine IV at the 4 minute mark if no maternal ROSC was achieved , specific treatment options were identified that would be helpful for reversible causes, and would not be contraindicated in or worsen other conditions, for potential empiric treatments during the first 4 minutes in an AMCA (>20 wks EGA).
24 etiologies were identified as direct causes of cardiac arrest; 9 of those were deemed to be treatable within 4 minutes in “best” circumstances: local anesthetic toxicity, hypoxemia/respiratory depression, hypotension (all-cause), hypovolemia, anaphylaxis, arrhythmia, magnesium toxicity, cardiac tamponade, and tension pneumothorax. For all but 2 conditions, the following treatments were deemed to have favorable risk/benefit ratios as empiric treatments for AMCA within the first 4 minutes after ACLS initiation (in addition to ACLS as described above): intubation with hyperventilation, small dose epinephrine (<1mcg/kg), 20% lipid emulsion bolus +/- infusion, rapid 1L IV fluid administration, and calcium gluconate 1gm IV. The remaining two etiologies (cardiac tamponade and tension pneumothorax), which necessitated needle decompression, were deemed to be too risky for empiric use.
While focus should continue on practicing and preparing teams to treat AMCA with PD to improve maternal survival if ROSC is not achieved within 4 minutes [1-3], we believe teams should include a standard empiric approach aimed at optimizing maternal resuscitation prior to PD.
1. Jeejeebhoy FM, et al. Circulation 2015; 132(18): 1747-73.
2. Lipman S, et al. Anesth Analg 2014; 118(5): 1003-16.
3. Zelop CM, et al. Am J Obstet Gynecol 2018; 219(1): 52-61.