Acutely unwell pregnant woman

Question 1

You are working in the ED when a nurse called you to see a patient Mrs Victoria Jenkins urgently. After a SBAR handover you found out that Mrs Jenkins is a 38-year-old woman who has been brought in by an ambulance having developed shortness of breath and chest pain over the last three hours. She is 34 weeks pregnant.

You carry out an ABCDE assessment and note the following:

A - Clear
B - Looks cyanosed, RR 40 min-1, SpO2 85% on 15 L min-1 of oxygen with reservoir
C - P 140 min-1, sinus tachycardia, BP 70/40 mmHg
D - Anxious and distressed. Blood sugar is normal. Apyrexial
E - Gravid uterus.

Differential diagnosis?

Answer 1

• Pulmonary embolism (the most likely cause in this case)
• Cardiac tamponade
• Pneumonia causing sepsis
• Amniotic fluid embolism (most cases occur during labour)

Other possible causes that need to be considered:

• haemorrhage e.g. placental abruption, placenta praevia
• cardiac disease of pregnancy e.g. peripartum cardiomyopathy.

Question 2

You are working in the ED when a nurse called you to see a patient Mrs Victoria Jenkins urgently. After a SBAR handover you found out that Mrs Jenkins is a 38-year-old woman who has been brought in by an ambulance having developed shortness of breath and chest pain over the last three hours. She is 34 weeks pregnant.

You carry out an ABCDE assessment and note the following:

A - Clear
B - Looks cyanosed, RR 40 min-1, SpO2 85% on 15 L min-1 of oxygen with reservoir
C - P 140 min-1, sinus tachycardia, BP 70/40 mmHg
D - Anxious and distressed. Blood sugar is normal. Apyrexial
E - Gravid uterus.

Mrs Jenkins continues to deteriorate and loses consciousness. She rapidly becomes apnoeic. The ECG monitor displays wide complexes at 20 min-1. You confirm cardiac arrest. What do you do next?

Answer 2

• call for help - including obstetrician, anaesthetist, paediatrician
• start CPR, with uterine displacement/left lateral tilt (if on tilting table) to prevent aortocaval compression
• give intravenous fluid
• early tracheal intubation/airway protection as there is a high risk for aspiration

Question 3

What key differences are there between ALS in normal patients and pregnant women?

Answer 3

• call for help - including obstetrician, anaesthetist, paediatrician
• start CPR, with uterine displacement/left lateral tilt (if on tilting table) to prevent aortocaval compression
• early tracheal intubation/airway protection as there is a high risk for aspiration
• use of ultrasound if available - may determine placental site, fetal viability, diagnosis of PE.

Question 4

You have started CPR on a pregnant woman. If there is no spontaneous return of circulation after 5 mins and the foetus is greater than 20 weeks gestation, what should be considered?

Answer 4

caesarean section/ hysterotomy and delivery of the fetus

Question 5

Thrombolysis for PE cannot be carried out in pregnant women.

True or False?

Answer 5

False.

Question 6

When performing CPR on a pregnant woman, should lateral displacement of the uterus be carried out in all patients?

Answer 6

ateral displacement of the uterus (> 20 weeks or if clinically obvious)

Question 7

A patient is in labour and decides to have an epidural for the pain. Shortly after the epidural infusion was started, she is unresponsive with no pulse. CPR is initiated. Whilst following the ALS guidelines, what reversible cause of the cardiac arrest can be treated?

Answer 7

IV lipid infusion is an antidote for local anaesthetic toxicity