Caroline Leech, an Emergency Medicine and Prehospital doctor, shares her expertise on maternal cardiac arrests, a rare but critical situation affecting mothers and their unborn babies. She discusses the physiological changes during pregnancy that complicate resuscitation efforts. Insights from her recent paper on Resuscitative Hysterotomy challenge the conventional survival expectations for both mother and child. Caroline emphasizes the need for effective teamwork, communication, and training to prepare for these high-stakes emergencies while navigating the emotional toll on responders.
Maternal cardiac arrest occurs in 1 in 12,000 to 30,000 pregnancies, with survival rates heavily influenced by cause and timely intervention.
Physiological changes during pregnancy require tailored resuscitation protocols to effectively manage cardiac arrest for both mother and fetus.
Resuscitative hysterotomy can improve survival outcomes, emphasizing the critical need for swift execution and prepared medical teams in emergencies.
Deep dives
Understanding Maternal Cardiac Arrest
Maternal cardiac arrest is a critical situation affecting approximately 1 in 12,000 to 30,000 pregnancies in developed countries, with high stakes for both the mother and the unborn child. The causes of such arrests can vary and include pre-existing cardiovascular conditions, complications from anesthesia, and conditions like amniotic fluid embolism and hemorrhage. While some sources suggest that maternal survival rates can exceed 50%, these rates largely depend on the cause of the collapse, gestational age, and the timeliness of receiving emergency care. Notably, 25% of maternal arrests in the UK relate to anesthesia complications, emphasizing the need for careful management and prompt response in these emergencies.
Anatomical and Physiological Changes in Pregnancy
Pregnancy introduces significant anatomical and physiological changes that impact resuscitation efforts during a cardiac arrest. These changes include increased abdominal pressure which can lead to airway complications, and diaphragm elevation that alters lung ventilation dynamics, resulting in reduced oxygen reserves. Additionally, the gravid uterus can compromise venous return when the woman is in a supine position, thus affecting cardiac output during CPR. These unique factors necessitate specific adaptations to standard resuscitation protocols to ensure the effectiveness of intervention for both mother and fetus during such emergencies.
Guidelines and Best Practices for Maternal Resuscitation
Current guidelines for handling maternal cardiac arrest recommend modifications to standard rescue protocols once a pregnancy reaches 20 weeks gestation, primarily due to the risk of aorta-caval compression. Essential adaptations include manual uterine displacement to enhance cardiac output during CPR and ensuring proper airway management given the increased likelihood of regurgitation due to physiological changes. It is crucial for all personnel involved in the resuscitation to address reversible causes of cardiac arrest, which can significantly influence outcomes. Comprehensive preparation and clear communication among the medical team are imperative for effective management in these high-stakes situations.
The Role of Resuscitative Hysterotomy
Resuscitative hysterotomy is a critical intervention performed on mothers who are 20 weeks pregnant or more, aimed at improving survival chances for both mother and child. Timing is of the essence; the procedure should ideally be performed within five minutes of maternal cardiac arrest to be effective. The procedure involves making an incision to access the uterus, which allows for potential delivery and resuscitation of the baby, enhancing outcomes. The procedure's success links closely to rapid execution and the presence of a well-coordinated medical team prepared for both maternal and neonatal support during the emergency.
Future Directions in Maternal Cardiac Arrest Management
Recent research has revealed discrepancies in expected outcomes for both mothers and neonates after resuscitative hysterotomy, with survival rates for babies often higher than for mothers. The ongoing discussion highlights the necessity of data collection regarding maternal cardiac arrests and the outcomes of respective interventions to refine guidelines and protocols. Addressing these knowledge gaps is integral for developing effective evidence-based practices in emergency medicine. Future studies aim to explore maternal and neonatal outcomes post-cardiac arrest, potentially leading to improved clinical guidelines and enhanced education for medical personnel.
Cardiac Arrest in pregnancy affects around 1: 12-30,000 women in the developed world.
As you’d expect the risk of death for mother and child is extremely high, but some causes of arrest are reversible and we can make a real impact with our care and treatment of these cases
Now it goes without saying that these are some of the most emotive, complex and technically challenging Resuscitations that you could think to be involved in; by definition young female arrest with unborn babies involved.
Thankfully this is not going to be a case that many of us see, but with the stakes so high and potential to impact on the outcome of two patients, it’s an area that’s worth real consideration, preparation and mental rehearsal in case we are one of the few that may need to deal with it!
In this episode we’re going to run through all the same stuff that you’d expect; pathophysiology of pregnancy, aetiology and the way in which we should approach these arrests. But then we’re lucky enough to be joined by Caroline Leech, an EM and Prehospital doctor who’s an expert in the area having just published a key paper that’s prompted loads of discussion in crew room and online on the topic of maternal arrest and Resuscitative Hysterotomy which will really challenges our perception on survival for both mum and the unborn baby if a RH is indicated.
So we’ll be running through that paper with some really valuable insights from Caroline and wrap up with some questions to her exploring experience from cases, along with potential strategies for how approach and manage these cases for those working both in prehospital and in-hospital settings.
Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!
Simon, Rob & James
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