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Y4 - GOSH > Cardiac Arrest in Pregnancy & Stillbirth > Flashcards

Cardiac Arrest in Pregnancy & Stillbirth Flashcards

1
Q

How can the reversible causes of adult cardiac arrest be remembered?

A

4Hs and 4Ts:

  • thrombosis (i.e. PE / MI)
  • tension pneumothorax
  • tamponade (cardiac)
  • toxins
  • hypovolaemia
  • hypoxia
  • hypothermia
  • hyperkalaemia / hypoglycaemia / other metabolic abnormalities
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2
Q

What are the additional reversible causes of cardiac arrest in pregnancy?

A
  • eclampsia
  • intracranial haemorrhage
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3
Q

What are the 3 major causes of cardiac arrest in pregnancy?

A
  • obstetric haemorrhage
    • resulting in severe hypovolaemia
  • pulmonary embolism
  • sepsis - leading to metabolic acidosis + septic shock
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4
Q

What are the major causes of massive obstetric haemorrhage?

A
  • ectopic pregnancy (early pregnancy)
  • placental abruption
    • including concealed haemorrhage
  • placenta praevia
  • placenta accreta
  • uterine rupture
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5
Q

What is aortocaval compression?

A
  • after 20 weeks, the uterus is a significant size
  • when a pregnant woman lies on their back, the uterus can compress the inferior vena cava + aorta
  • when the IVC is compressed, the venous return to the heart is reduced
  • this reduces cardiac output** and results in **hypotension
  • in some cases, this can result in cardiac arrest
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6
Q

How is aortocaval compression relieved?

A
  • the woman should lie in the left lateral position
  • the IVC is slightly to the right side of the body, so this positions the uterus away from it
  • this relieves the compression of the IVC and improves venous return + CO
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7
Q

What additional risk factors make resuscitation more complicated in pregnancy?

A
  • aortocaval compression
  • increased oxygen requirements
  • splinting of the diaphragm by the pregnant abdomen
  • difficulty with intubation
  • increased risk of aspiration
  • ongoing obstetric haemorrhage
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8
Q

How is resuscitation different in pregnancy?

A
  • 15 degree tilt to the left side for CPR
    • this relieves compression of the IVC + aorta
  • early intubation to protect the airway
  • early supplementary oxygen
  • aggressive fluid resuscitation
    • caution in pre-eclampsia
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9
Q

When should the baby be delivered following maternal resuscitation?

A
  • the baby should be delivered after 4 minutes

AND

  • within 5 minutes of starting CPR
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10
Q

When is immediate C-section performed?

A
  • if there is no response after 4 minutes of correctly performed CPR
  • CPR continues for > 4 minutes** in a woman **> 20 weeks gestation

!! the aim is to deliver the baby + placenta within 5 minutes of starting CPR !!

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11
Q

Why is an emergency C-section performed within 5 minutes of starting CPR?

A

to improve maternal survival:

  • delivery improves venous return to the heart
  • this increases cardiac output and reduces oxygen consumption
    • delivery also helps with ventilation + chest compressions
  • delivery increases chances of the baby surviving, but this is secondary to survival of the mother
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12
Q

What is the definition of a stillbirth?

A

the birth of a dead fetus after 24 weeks gestation

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13
Q

What are the causes of stillbirth?

How many cases are unexplained?

A

50% stillbirths are unexplained, but other possible causes are:

  • thyroid disease
  • pre-eclampsia
  • placental abruption
  • vasa praevia
  • cord prolapse / wrapped around fetal neck
  • obstetric cholestasis
  • diabetes
  • infections
    • listeria, rubella, parvovirus
  • genetic abnormalities / congenital malformations
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14
Q

What factors increase the risk of stillbirth?

A
  • fetal growth restriction
  • smoking / alcohol
  • increased maternal age
  • maternal obesity
  • twins
  • sleeping on the back (as opposed to either side)
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15
Q

What risk assessment is performed in the prevention of stillbirth?

A
  • assessment for a fetus that is small for gestational age** (SGA) or with **IUGR
  • risk factors for SGA increase the chance of stillbirth
  • anyone at risk of SGA is monitored with serial growth scans
  • planned early delivery is considered when growth is static
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16
Q

What lifestyle advice is given to reduce the risk of stillbirth?

A
  • smoking cessation
  • avoid drinking alcohol
  • effective control of diabetes
  • sleeping on the side (rather than the back)
17
Q

What is given to women at risk of pre-eclampsia?

A

prophylaxis with aspirin

18
Q

What are the 3 key symptoms to ask about during pregnancy?

A
  • reduced fetal movements
  • abdominal pain
  • vaginal bleeding
19
Q

How is intrauterine fetal death (IUFD) diagnosed?

A

ultrasound

  • this is used to visualise the fetal heartbeat to determine if it is still alive
  • passive fetal movements are possible after IUFD so a repeat scan is offered to confirm the diagnosis
20
Q

What treatment may be given to a select group of women following IUFD?

A

anti-D prophylaxis

  • given to Rhesus-D negative women
  • a Kleihauer test is performed to quantify the amount of fetal blood mixed in with maternal blood
  • this allows the dose of anti-D to be determined
21
Q

What is the standard dose of anti-D given?

A

500 units

  • if there has been massive blood loss, further doses may be required
  • this is determined through the Kleihauer test
22
Q

What is the first line delivery method following IUFD?

A

vaginal delivery

(unless there are other reasons for a LSCS)

23
Q

What are the 2 options given to women following diagnosis of IUFD?

A

expectant management:

  • this involves awaiting natural labour / delivery
  • women are monitored closely as the condition of the fetus deteriorates with time

induction of labour:

  • using oral mifepristone (anti-progesterone)

AND

  • vaginal or oral misoprostol (prostaglandin analogue)
24
Q

When is expectant management following IUFD not suitable?

A

when immediate delivery is required

  • e.g. sepsis, pre-eclampsia, haemorrhage
25
Q

What medication may be given to women after birth of a IUFD?

A

dopamine agonists

  • e.g. cabergoline
  • used to suppress lactation after stillbirth
26
Q

What testing is carried out after stillbirth to determine the cause?

(this requires parental consent)

A
  • genetic testing of fetus + placenta
  • postmortem examination of fetus
    • this includes XRs
  • testing for maternal / fetal infection
  • testing the mother for conditions associated with stillbirth
    • e.g. diabetes, thyroid disease & thrombophilia
27
Q

What future management is a woman offered following stillbirth?

A
  • identifying the cause can help to reduce the risk in future pregnancies
  • pregnancies are closely monitored in women with previous IUFD

Y4 - GOSH (62 decks)

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