Resuscitation in late pregnancy

Functional Outcome of Lower Limb Long Bone Trauma Management in Pregnant Mothers: A Prospective Study of 30 Cases From a Tertiary Care Centre in North India

INTRODUCTION

The occurrence of orthopedic injuries during pregnancy carries considerable morbidity and mortality for both the mother and fetus. Successful care of lower limb fractures during pregnancy requires a multidisciplinary approach. Both operative and non-operative treatments must be taken into account by the treating orthopedic physician. There is limited literature available on the management of these lower limb fractures in pregnancy, and peri-operative management of this obstetric and orthopedic trauma is largely unclear. Trauma during pregnancy is a common cause of non-obstetrical maternal death, having a significant public health burden to both the mother and child. The aims and objectives of this study were to review the common causes of lower limb long bone trauma during pregnancy and their functional outcome in terms of morbidity and mortality. This study evaluates various operative and conservative methods of treatment to provide a comprehensive management approach to pregnant patients with lower limb trauma.

MATERIALS AND METHODS

A prospective study on functional outcomes of 30 pregnant females who were admitted with lower limb long bone fractures from 2017 to 2021 was done. The patients were randomly selected intra-operatively for various procedures based on the surgeon's preference. All patients were followed for two years or till union occurred, and the radiographic union score for tibial (RUST) and modified radiographic union score for tibial (mRUST) fracture criteria were used to assess bony union clinico-radiologically.  Results: During this study, the mean age of patients was 27 years (range 19-38), having right-side (53.33%) predominance with road traffic accidents (n=22) and falls (n=6) as the most common causes of injury. Two cases of domestic violence were also reported. In our study, the maximum number of cases was 17-25 weeks of their gestation; 12 (40%) patients had tibial fractures, and 18 (60%) had femoral fractures. Six tibial fractures were handled conservatively, while all femoral fractures required surgical intervention. Out of 18 femoral fractures, which were treated surgically, dynamic compression plating was done in 15 (83.33%) patients, while interlock nailing was done in three patients. Six tibial fractures have been operated upon, two (66.66%) with dynamic compression plating and four (33.33%) with an interlocking nail.

CONCLUSION

A multidisciplinary approach in terms of both operative and non-operative methods must be taken into account for treating pregnant mothers by the orthopedic physician while carefully weighing the benefits and risks of both procedures. Based on the pattern and displacement of the fracture, many prenatal fractures can be treated conservatively. Another alternative that is frequently safe is to postpone the surgical procedure until childbirth. The physiologic changes associated with pregnancy and any potential dangers to the fetus must be taken into account by the orthopedic surgeon when fractures necessitate surgical intervention. The surgeon is responsible for the patient's correct placement, the C-arm's use, the radiation dose, and the intra-operative fetal monitoring, as well as the danger brought on by anesthetics, antibiotics, analgesics, and anticoagulants.

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Effect of maternal positioning during cardiopulmonary resuscitation: a systematic review and meta-analyses

Background

Although rare, cardiac arrest during pregnancy is the leading cause of maternal death. Recently, its incidence has been increasing worldwide because more pregnant women have risk factors. The provision of early, high-quality cardiopulmonary resuscitation (CPR) plays a major role in the increased likelihood of survival; therefore, it is important for clinicians to know how to manage it. Due to the aortocaval compression caused by the gravid uterus, clinical guidelines often emphasise the importance of maternal positioning during CPR, but there has been little evidence regarding which position is most effective.

Methods

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and OpenGrey (updated on April 3, 2021). We included clinical trials and observational studies with reported outcomes related to successful resuscitations.

Results

We included eight studies from the 1,490 screened. The eight studies were simulation-based, crossover trials that examine the quality of chest compressions. No data were available about the survival rates of mothers or foetuses/neonates. The meta-analyses showed that resuscitation of pregnant women in the 27°–30° left-lateral tilt position resulted in lower quality chest compressions. The difference is an 19% and 9% reduction in correct compression depth rate and correct hand position rate, respectively, compared with resuscitations in the supine position. Inexperienced clinicians find it difficult to perform chest compressions in the left-lateral tilt position.

Conclusions

Given that manual left uterine displacement allows the patient to remain supine, the resuscitation of women in the supine position using manual left uterine displacement should continue to be supported. Further research is needed to fill knowledge gaps regarding the effects of maternal positioning on clinical outcomes, such as survival rates following maternal cardiac arrest.

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Effect of Different Positions During Surgical Preparation With Combined Spinal-Epidural Anesthesia for Elective Cesarean Delivery: A Randomized Controlled Trial

BACKGROUND

The intraoperative 15° left-tilt position during cesarean delivery has more recently been questioned regarding its effect on fetal acid-base balance and is a frequent source of complaints by surgeons. We hypothesized that a 30° left-tilt position during surgical preparation could improve the acid-base balance of the fetus compared with the 15° left-tilt or supine position during surgical preparation.

METHODS

Women undergoing elective cesarean delivery under combined spinal epidural anesthesia were randomized to a supine position, 15° left-lateral tilt position or 30° left-lateral tilt position; the position was changed to supine before the incision. Anesthetic management was standardized and included fluid loading with 10 mL/kg of normal saline followed by colloid loading. Hypotension (systolic blood pressure [SBP] reduction >20% baseline value or SBP <90 mm Hg) was treated with boluses of phenylephrine or ephedrine according to maternal heart rate. The primary outcome was umbilical arterial blood pH and the secondary outcomes included maternal SBP within 15 minutes after induction of anesthesia, the amount of vasoactive drug administered before end of the surgery, and the incidence of hypotension during cesarean delivery.

RESULTS

Seventy-five patients were included. After testing by analysis of variance, there was no significant difference in the umbilical arterial pH among the 3 groups (supine group: 7.31 ± 0.03 vs 15° group: 7.30 ± 0.04 vs 30° group: 7.31 ± 0.02, P = .28). The 30° group required significantly less phenylephrine (P = .007) and ephedrine (P = .005) before the end of surgery than the supine group; however, the only benefit observed in the 15° group was that the mean SBP at 3 minutes after spinal injection was significantly improved compared with the supine group.

CONCLUSIONS

Compared with the supine position, the 30° left-tilt position during surgical preparation did not significantly improve the fetal acid-base status, but it significantly reduced the use of phenylephrine and ephedrine and reduced the incidence of hypotension; however, these benefits were not observed in the 15° left-tilt group.

Maternal cardiac arrest

PURPOSE OF REVIEW

The review is intended to serve as a practical clinical aid for the clinician called to maternal cardiac arrest.

RECENT FINDINGS

Anesthesia complications comprise an important cause of maternal cardiac arrest in developed countries Also predominant are hemorrhage and infections. Recent in-depth reports highlight fractionated care for pregnant women with cardiac and also probably neurological comorbidities. Pathology reports reveal a prevalence of thromboembolic phenomena that is higher than previously assumed but still rare. These are accompanied by particularly high mortality rates. The presenting rhythms of cardiac arrest which differ from most cardiac arrest populations, suggest the need for further in-depth investigation of both the causes and management of these cases. Despite these, outcomes are far better than those of most arrests. Key differences in treatment include are consideration of early airway management and possible medication complications. Pulseless electrical activity and VF should always alert to the possibility of hemorrhage. Echocardiography can diagnose thromboembolism. Also different are the need for Left uterine displacement and early delivery within after 4-5 min of initiation of resuscitation effort in cases with suspected compromise of the venous return or a poor likelihood of a good maternal outcome.

SUMMARY

Maternal cardiac arrest should be managed similarly to other adult cardiac arrests. At the same time its unique reversible causes require a different form of thought regarding diagnosis and treatment during the code.

Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging

BACKGROUND

Despite the existing dogma that women undergoing cesarean delivery under spinal anesthesia should be positioned with a 15° left-lateral tilt, the patients were actually positioned in a right-lateral tilt position in several of the original studies. The superiority of right versus left positioning for optimal inferior vena cava volume is unknown. We used magnetic resonance imaging to compare the effects of right-lateral and left-lateral tilt positions on abdominal aortic and inferior vena cava volumes in pregnant women.

METHODS

Thirteen women with singleton pregnancies and gestational age 31-39 weeks underwent magnetic resonance imaging while in the supine position, and in the left-lateral (15° and 30°) and right-lateral tilt (15° and 30°) positions, which were maintained by placing a 1.5-m-long piece of polyethylene foam under either side of the body. Abdominal aorta and inferior vena cava volume were measured between the L1-L2 disk and L3-L4 disk levels using magnetic resonance images.

RESULTS

Aortic volume did not differ significantly among any of the positions examined. Mean inferior vena cava volume was significantly greater in the 30° left-lateral tilt position than in the 15° right-lateral tilt (10.7 ± 7.5 vs 5.9 ± 5.1 mL; mean difference, 4.8; 95% CI, 1.2-8.5; P = .002) and 30° right-lateral tilt (10.7 ± 7.5 vs 5.9 ± 2.5 mL; mean difference, 4.8; 95% CI, 1.2-8.4; P = .002) positions. Mean inferior vena cava volume in the 15° left-lateral tilt position did not differ significantly from that in the 15° right-lateral tilt (mean difference, 0.4; 95% CI, -3.2 to 4.0; P = 1.000) or 30° right-lateral tilt (mean difference, 0.4; 95% CI, -3.3 to 4.0; P = 1.000) positions. Mean inferior vena cava volume in the supine position only differed significantly from that in the 30° left-lateral tilt position (5.2 ± 3.8 vs 10.7 ± 7.5 mL; mean difference, 5.5; 95% CI, 1.8-9.1; P < .001). The greatest inferior vena cava volume was observed in the 30° left-lateral tilt position in 9 of 13 subjects (70%), and in the 30° right-lateral tilt in 3 subjects (23%).

CONCLUSIONS

The 30° left-lateral tilt position most consistently reduced inferior vena cava compression by the gravid uterus compared with the supine position. Mean inferior vena cava volume in pregnant women was not increased at either angle of the right-lateral tilt position compared with the 30° left-lateral tilt position. However, in a subset of patients, the 30° right-lateral tilt position achieved the optimal inferior vena cava volume. Further investigation to understand this variability is warranted.

Update: Focus in-hospital maternal cardiac arrest

The incidence of maternal cardiac arrest ranges from 1/55,000 to 1/12,000 births. It is due most frequently to cardiovascular, hemorrhagic, and anesthesia-related causes, as well as to amniotic fluid embolism. The basic principles of resuscitation remain applicable in this situation, but the physiological modifications of pregnancy must be taken into account, in particular, the aortocaval compression syndrome. After 24 weeks of gestation, a salvage cesarean delivery must be performed immediately, without transfer to the operating room, if resuscitation maneuvers have failed 4 min after arrest, because this interval conditions the mother's neurological prognosis and improves neonatal survival.

Cardiac arrest during pregnancy: ongoing clinical conundrum

While global maternal mortality has decreased in the last 25 years, the maternal mortality ratio in the United States has actually increased. Maternal mortality is a complex phenomenon involving multifaceted socioeconomic and clinical parameters including inequalities in access to health care, racial and ethnic disparities, maternal comorbidities, and epidemiologic ascertainment bias. Escalating maternal mortality underscores the importance of clinician preparedness to respond to maternal cardiac arrest that may occur in any maternal health care setting. Management of maternal cardiac arrest requires an interdisciplinary team familiar with the physiologic changes of pregnancy and the maternal resuscitation algorithm. Interventions intended to mitigate obstacles such as aortocaval compression, which may undermine the success of resuscitation interventions, must be performed concurrent to standard basic and advanced cardiac life support maneuvers. High-quality chest compressions and oxygenation must be performed along with manual left lateral uterine displacement when the uterine size is ≥20 weeks. While deciphering the etiology of maternal cardiac arrest, diagnoses unique to pregnancy and those of the nonpregnant state should be considered at the same time. If initial basic life support and advanced cardiac life support interventions fail to restore maternal circulation within 4 minutes of cardiac arrest, perimortem delivery is advised provided the uterus is ≥20 weeks' size. Preparations for perimortem delivery are best anticipated by the resuscitation team for the procedure to be executed opportunely. Following delivery, intraabdominal examination may reveal a vascular catastrophe, hematoma, or both. If return of spontaneous circulation has not been achieved, additional interventions may include cardiopulmonary bypass and/or extracorporeal membrane oxygenation. Simulation and team training enhance institution readiness for maternal cardiac arrest. Knowledge gaps are significant in the science of maternal resuscitation. Further research is required to fully optimize: relief of aortocaval compression during the resuscitation process, gestational age and timing of perimortem delivery, and other interventions that deviate from nonpregnant standard resuscitation protocol to achieve successful maternal resuscitation. A robust detailed national and international prospective database was recommended by the International Liaison Committee on Resuscitation in 2015 to facilitate further research unique to cardiac arrest during pregnancy that will produce optimal resuscitation techniques for maternal cardiac arrest.

Cardiac arrest in pregnancy

Cardiac arrest in pregnancy is a rare and frightening event. Although not every obstetrician will encounter cardiac arrest in pregnancy during their career, it is imperative to be prepared to manage this acute emergency. The management is particularly complex due to maternal physiologic changes from pregnancy and the simultaneous management of two patients, the mother and fetus. In 2010, the American Heart Association released their first scientific statement on guidelines for management of cardiac arrest in pregnancy that has since been updated in 2015. All providers who care for pregnant patients should be aware of these guidelines and ready to manage cardiac arrest in pregnancy because correct and timely interventions can affect real world outcomes.

Management of pregnancy and obstetric complications in prehospital trauma care: faculty of prehospital care consensus guidelines

This consensus statement seeks to provide clear guidance for the management of pregnant trauma patients in the prehospital setting. Pregnant patients sustaining trauma injuries have certain clinical management priorities beyond that of the non-pregnant trauma patients and that if overlooked may be detrimental to maternal and fetal outcomes.

Perimortem caesarean deliveries

Although cardiac arrest in pregnancy is rare, it is important that all individuals involved in the acute care of pregnant women are suitably trained, because the outcome for both mother and fetus can be affected by the management of the arrest. Perimortem caesarean delivery was first described in 715 BC. Initially the procedure was performed principally for religious or political reasons. Although the potential for fetal survival was proposed, it was rarely successful, probably because the delivery was delayed until maternal death was established. However, in recent decades, case reports have suggested improved maternal as well as fetal survival if perimortem caesarean section was performed rapidly once maternal arrest has occurred. While evidence for this is largely based on case reports, the physiological advantages including removing inferior caval obstruction, and hence improving venous return to the heart, reducing oxygen requirement and improving chest compliance appear compelling. Factors that reduce errors and minimise the delay in performance of caesarean delivery are discussed, in particular the importance of training, organizational factors within a hospital and the use of prompts during an arrest. While evidence is limited, it is probable that both maternal and fetal survival are improved with early delivery by perimortem caesarean delivery. More importantly, no evidence was found from case report reviews that either maternal or fetal survival was worsened. Perimortem caesarean delivery therefore remains a key consideration in the management of maternal arrest from the mid second trimester.

The role for surgery in pre-hospital care

Pre-hospital care requires a broad skillset. One of the most challenging aspects of pre-hospital care is performing surgical procedures. The indications and evidence for performing pre-hospital surgical airway, thoracostomy, thoracotomy, caesarean section and amputation are discussed. Where evidence for the procedure is lacking from pre-hospital care, evidence from in-hospital experience is sought.

Cardiac Arrest in Pregnancy

This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.

Management of critical asthma syndrome during pregnancy

One-third of pregnant asthmatics experience a worsening of their asthma that may progress to a critical asthma syndrome (CAS) that includes status asthmaticus (SA) and near-fatal asthma (NFA). Patients with severe asthma before pregnancy may experience more exacerbations, especially during late pregnancy. Prevention of the CAS includes excellent asthma control involving targeted early and regular medical care of the pregnant asthmatic, together with medication compliance. Spontaneous abortion risk is higher in pregnant women with uncontrolled asthma than in non-asthmatics. Should CAS occur during pregnancy, aggressive bronchodilator therapy, montelukast, and systemic corticosteroids can be used in the context of respiratory monitoring, preferably in an Intensive Care Unit (ICU). Systemic epinephrine should be avoided due to potential teratogenic side-effects and placental/uterine vasoconstriction. Non-invasive ventilation has been used in some cases. Intratracheal intubation can be hazardous and rapid-sequence intubation by an experienced physician is recommended. Mechanical ventilation parameters are adjusted based on changes to respiratory mechanics in the pregnant patient. An inhaled helium-oxygen gas admixture may promote laminar airflow and improve gas exchange. Permissive hypercapnea is controversial, but may be unavoidable. Sedation with propofol which itself has bronchodilating properties is preferred to benzodiazepines. Case reports delineating good outcomes for both mother and fetus despite intubation for SA suggest that multidisciplinary ICU care of the pregnant asthmatic with critical asthma are feasible especially if hypoxemia is avoided.

Effectiveness of chest compression feedback during cardiopulmonary resuscitation in lateral tilted and semirecumbent positions: a randomised controlled simulation study

Feedback devices have been shown to improve the quality of chest compression during cardiopulmonary resuscitation for patients in the supine position, but no studies have reported the effects of feedback devices on chest compression when the chest is tilted. Basic life support-trained providers were randomly assigned to administer chest compressions to a manikin in the supine, 30° left lateral tilt and 30° semirecumbent positions, with or without the aid of a feedback device incorporated into a smartphone. Thirty-six participants were studied. The feedback device did not affect the quality of chest compressions in the supine position, but improved aspects of performance in the tilted positions. In the lateral tilted position, the median (IQR [range]) chest compression rate was 99 (99-100 [96-117]) compressions.min(-1) with and 115 (95-128 [77-164]) compressions.min(-1) without feedback (p = 0.05), and the proportion of compressions of correct depth was 55 (0-96 [0-100])% with and 1 (0-30 [0-100])% without feedback (p = 0.03). In the semirecumbent position, the proportion of compressions of correct depth was 21 (0-87 [0-100])% with and 1 (0-26 [0-100])% without feedback (p = 0.05). Female participants applied chest compressions at a more accurate rate using the feedback device in the lateral tilted position but were unable to increase the chest compression depth, whereas male participants were able to increase the force of chest compression using the feedback device in the lateral tilted and semirecumbent positions. We conclude that a feedback device improves the application of chest compressions during simulated cardiopulmonary resuscitation when the chest is tilted.

MRI evaluation of maternal cardiac displacement in pregnancy: implications for cardiopulmonary resuscitation

OBJECTIVE

The purpose of this study was to determine, with the use of cardiac magnetic resonance imaging, whether there is vertical displacement of the heart during pregnancy. Cardiopulmonary resuscitation guidelines during pregnancy recommend placing the hands 2-3 cm higher on the sternum than in nonpregnant individuals. This recommendation is based on the presumption that the heart is displaced superiorly by the diaphragm during the third trimester. Whether there is true cardiac displacement because of the expanding uterus in pregnancy remains unknown.

STUDY DESIGN

A total of 34 healthy female volunteers 18-35 years old were enrolled prospectively from 2010-2012 at 2 tertiary care centers. The conditions of all participants were evaluated with cardiac magnetic resonance imaging in the one-half left lateral decubitus position during the third trimester of pregnancy and again at a minimum of 3 months after delivery (surrogate for the nonpregnant state). Superior displacement of the heart was determined by measurement of the distance between the inferior aspect of the clavicular heads and the coronary sinus at both time points.

RESULTS

The study population included 34 women (mean age, 29 ± 3 years; body mass index, 24 ± 4 kg/m(2)). The mean gestational age at third-trimester imaging was 237 ± 16 days (34 weeks ± 16 days); the mean number of days for postpartum imaging (baseline) was 107 ± 25 days (16 weeks ± 25 days). There was no statistical difference between the cardiac position at baseline (10.1 ± 1.2 cm) and during the third trimester (10.3 ± 1.1 cm; P = .22).

CONCLUSION

Contrary to popular assumption, there is no significant vertical displacement of the heart in the third trimester of pregnancy relative to the nonpregnant state. Accordingly, there is no need to alter hand placement for chest compressions during cardiopulmonary resuscitation in pregnancy.

Effect of Lateral Tilt Angle on the Volume of the Abdominal Aorta and Inferior Vena Cava in Pregnant and Nonpregnant Women Determined by Magnetic Resonance Imaging

Background:

Left-lateral tilt position is used to reduce assumed aortocaval compression by the pregnant uterus.

Methods:

Magnetic resonance images of 10 singleton parturients at full term and 10 healthy nonpregnant women were obtained for measurement of the abdominal aorta and inferior vena cava volume between the L1–L2 disk and L3–L4 disk levels in both the supine and left-lateral tilt positions (15°, 30°, and 45°) maintained by insertion of a 1.5-m-long polyethylene foam placed under the right side of the parturient’s body.

Results:

Aortic volume did not differ significantly between parturients and nonpregnant women in the supine position (12.7 ± 2.0 vs.12.6 ± 2.1 ml, mean ± SD; mean difference, –0.1; 95% confidence interval [CI], −2.0 to 1.9; P = 0.95). Inferior vena cava volume in the supine position was significantly lower in parturients than in nonpregnant women (3.2 ± 3.4 vs.17.5 ± 7.8 ml; mean difference, 14.3; 95% CI, 8.3–20.2; P &lt; 0.001). Aortic volume in parturients did not differ among left-lateral tilt positions. Inferior vena cava volume in the parturients was not increased at 15° (3.0 ± 2.1 ml; mean difference, −0.2; 95% CI, −1.5 to 1.2; P &gt; 0.99), but was significantly increased at 30° (11.5 ± 8.6 ml; mean difference, 8.3; 95% CI, 2.3–14.2; P = 0.009) and 45° (10.9 ± 6.8 ml; mean difference, 7.7; 95% CI, 2.2–13.1; P = 0.015).

Conclusions:

In parturients, the aorta was not compressed, and a 15° left-lateral tilt position did not effectively reduce inferior vena cava compression.

Cardiopulmonary resuscitation of pregnant women in the emergency department

AIM

Little is known about outcomes of cardiopulmonary resuscitation (CPR) in pregnancy. The purpose of this study was to determine the prognostic value of pregnancy in women receiving CPR in the emergency department (ED).

METHODS

We conducted a population-based, matched cohort study using the Nationwide Emergency Department Sample (NEDS) from 2006 to 2010. A cohort of pregnant women receiving CPR in the ED was compared to an age-matched cohort of non-pregnant women at a 1:10 ratio. Conditional logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence intervals (95% CIs) for variables of interest and survival.

RESULTS

Among 8162 women requiring CPR in the ED, we identified 157 pregnant women. Pregnancy was associated with better overall survival of 36.9% compared to 25.9% in non-pregnant women, OR 1.89 (1.32-2.70), p < 0.01. Traumatic injury was identified as a significant predictor of outcome in pregnancy. In non-trauma patients, pregnant women had significantly better odds of surviving CPR than non-pregnant women, OR 2.10 (1.41-3.13), p < 0.01. In cases of trauma, no significant difference was observed between groups.

CONCLUSION

Although further studies are needed, CPR in pregnancy is associated with a better prognosis compared to non-pregnant women, with trauma status being a key factor predicting outcome in the pregnant patient.

A new chest compression depth feedback algorithm for high-quality CPR based on smartphone

BACKGROUND

Although many smartphone application (app) programs provide education and guidance for basic life support, they do not commonly provide feedback on the chest compression depth (CCD) and rate. The validation of its accuracy has not been reported to date. This study was a feasibility assessment of use of the smartphone as a CCD feedback device. In this study, we proposed the concept of a new real-time CCD estimation algorithm using a smartphone and evaluated the accuracy of the algorithm.

MATERIALS AND METHODS

Using the double integration of the acceleration signal, which was obtained from the accelerometer in the smartphone, we estimated the CCD in real time. Based on its periodicity, we removed the bias error from the accelerometer. To evaluate this instrument's accuracy, we used a potentiometer as the reference depth measurement. The evaluation experiments included three levels of CCD (insufficient, adequate, and excessive) and four types of grasping orientations with various compression directions. We used the difference between the reference measurement and the estimated depth as the error. The error was calculated for each compression.

RESULTS

When chest compressions were performed with adequate depth for the patient who was lying on a flat floor, the mean (standard deviation) of the errors was 1.43 (1.00) mm. When the patient was lying on an oblique floor, the mean (standard deviation) of the errors was 3.13 (1.88) mm.

CONCLUSIONS

The error of the CCD estimation was tolerable for the algorithm to be used in the smartphone-based CCD feedback app to compress more than 51 mm, which is the 2010 American Heart Association guideline.

Efficacy of cardiopulmonary resuscitation in the supine position with manual displacement of the uterus vs lateral tilt using a firm wedge: a manikin study

Prevention of aortocaval compression is essential for effective cardiopulmonary resuscitation in late pregnancy. This can be achieved by either lateral maternal tilt or lateral uterine displacement. Results from a previous manikin study show that a firm foam-rubber wedge allowed successful chest compressions whilst providing stable and reliable lateral tilt. However, it did not investigate resuscitation in the supine position with manual uterine displacement. The aim of this study was to compare the effectiveness of chest compressions in a manikin in the supine position vs lateral tilt using a foam-rubber wedge, both on the floor and on a typical patient bed. Overall, we found that compressions were easier to perform in the supine position (p = 0.007 (bed) and 0.048 (floor)), and with greater stability in the supine position on the floor (p = 0.011). The effectiveness of chest compressions was similar in both the supine/uterine displacement and the lateral tilt positions, suggesting that either method may be suitable for CPR.

Maternal cardiac arrest: a practical and comprehensive review

Cardiac arrest during pregnancy is a dedicated chapter in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; however, a robust maternal cardiac arrest knowledge translation strategy and emergency response plan is not usually the focus of institutional emergency preparedness programs. Although maternal cardiac arrest is rare, the emergency department is a high-risk area for receiving pregnant women in either prearrest or full cardiac arrest. It is imperative that institutions review and update emergency response plans for a maternal arrest. This review highlights the most recent science, guidelines, and recommended implementation strategies related to a maternal arrest. The aim of this paper is to increase the understanding of the important physiological differences of, and management strategies for, a maternal cardiac arrest, as well as provide institutions with the most up-to-date literature on which they can build emergency preparedness programs for a maternal arrest.

Resuscitation of the pregnant patient: What is the effect of patient positioning on inferior vena cava diameter?

STUDY OBJECTIVE

Patients in the third trimester of pregnancy presenting to the emergency department (ED) with hypotension are routinely placed in the left lateral tilt (LLT) position to relieve inferior vena cava (IVC) compression from the gravid uterus thereby increasing venous return. However, the relationship between patient position and proximal intrahepatic IVC filling has never assessed directly. This study set out to determine the effect of LLT position on intrahepatic IVC diameter in third trimester patients under real-time visualization with ultrasound.

METHODS

This prospective observational study on the labor and delivery floor of a large urban academic teaching hospital enrolled patients between 30 and 42 weeks estimated gestational age from August 2011 to March 2012. Patients were placed in three different positions: supine, LLT, and right lateral tilt (RLT). After the patient was in each position for at least 3 min, IVC ultrasound using the intercostal window was performed by one of three study sonologists. Maternal and fetal hemodynamics were also monitored and recorded in each position.

RESULTS

A total of 26 patients were enrolled with one excluded from data analysis due to inability to obtain IVC measurements. The median IVC maximum diameter was 1.26 cm (95% confidence interval [CI] 1.13-1.55) in LLT compared to 1.13 cm (95% CI 0.89-1.41) in supine, p=0.01. When comparing each individual patient's LLT to supine measurement, LLT lead to an increase in maximum IVC diameter in 76% (19/25) of patients with the average LLT measurement 29% (95% confidence interval 10-48%) larger. Six patients had the largest maximum IVC measurement in the supine position. No patients experienced any hemodynamic instability or distress during the study.

CONCLUSION

IVC ultrasound is feasible in late pregnancy and demonstrates an increase in diameter with LLT positioning. However, a quarter of patients had a decrease in IVC diameter with tilting and, instead, had the largest IVC diameter in the supine position suggesting that uterine compression of the IVC may not occur universally. IVC assessment at the bedside may be a useful adjunct in determining optimal positioning for resuscitation of third trimester patients.

Effect of positioning from supine and left lateral positions to left lateral tilt on maternal blood flow velocities and waveforms in full-term parturients

Positioning the parturient from supine to the left lateral tilt position (supine-to-tilt) may not effectively displace the gravid uterus, but turning from the left lateral position to the left lateral tilt position (left lateral-to-tilt) may keep the gravid uterus displaced and prevent aortocaval compression. Fifty-one full-term parturients were randomly placed in the left lateral position, supine-to-tilt and left lateral-to-tilt positions using a Crawford wedge. Femoral vein area, femoral vein velocity, femoral artery area, pulsatility index, resistance index and right arm mean arterial blood pressure and heart rate were recorded. Our results showed a lower mean (SD) femoral vein area (82.2 (14.9) vs 96.2 (16.4) mm(2)), a lower pulsatility index (3.83 (1.3) vs 5.8 (2.2)), a lower resistance index (0.93 (0.06) vs 0.98 (0.57)), a higher femoral artery area (33.3 (3.8) vs 30.9 (4.4) mm(2)) and a higher femoral vein velocity (7.9 (1.2) vs 6.1 (1.6) cm.s(-1)) with left lateral-to-tilt when compared with supine-to-tilt (all p < 0.001). Our results suggest that moving a full-term parturient from the full left lateral to the lateral tilt position may prevent aortocaval compression in full-term parturients more efficiently than when positioning the parturient from a supine to left lateral tilt position.

When the Heart Stops

Cardiac arrest is a rare occurrence in pregnancy and may be related to obstetric or medical causes. Pregnancy is associated with profound physiologic changes that prepare the gravida for the challenges of labor and delivery, and resuscitation of the pregnant patient needs to take these changes into consideration. Cardiac output and plasma volume increase in pregnancy and distribute differently with the uterine circulation receiving approximately 17% of the total cardiac output. On the other hand, cardiac output is sensitive to positional changes in the second half of pregnancy but may improve with a lateral tilt of the gravida. Both oxygen reserve and upper airway size decrease in pregnancy, leading to difficulties surrounding airway management. Changes in the volume of distribution, renal and hepatic clearance may impact drug effects and need to be recognized. This review will discuss an overview of pregnancy physiology that is relevant to cardiac resuscitation, detail the challenges in the various resuscitative steps including a synopsis on perimortem delivery, and describe obstetric and nonobstetric causes of mortality and cardiac arrest in pregnancy.

Management principles of the critically ill obstetric patient

The goals in management of critically ill obstetric patients involve intensive monitoring and physiologic support for patients with life-threatening but potentially reversible conditions. Management principles of the mother should also take the fetus and gestational age into consideration. The most common reasons for intensive care admissions (ICU) in the United States and United Kingdom are hypertensive disorders, sepsis, and hemorrhage. The critically ill obstetric patient poses several challenges to the clinicians involved in her care, because of the anatomic and physiologic changes that take place during pregnancy.