Cardiac Arrest in Pregnancy & Stillbirth Flashcards
How can the reversible causes of adult cardiac arrest be remembered?
4Hs and 4Ts:
- thrombosis (i.e. PE / MI)
- tension pneumothorax
- tamponade (cardiac)
- toxins
- hypovolaemia
- hypoxia
- hypothermia
- hyperkalaemia / hypoglycaemia / other metabolic abnormalities
What are the additional reversible causes of cardiac arrest in pregnancy?
- eclampsia
- intracranial haemorrhage
What are the 3 major causes of cardiac arrest in pregnancy?
- obstetric haemorrhage
- resulting in severe hypovolaemia
- pulmonary embolism
- sepsis - leading to metabolic acidosis + septic shock
What are the major causes of massive obstetric haemorrhage?
- ectopic pregnancy (early pregnancy)
-
placental abruption
- including concealed haemorrhage
- placenta praevia
- placenta accreta
- uterine rupture
What is aortocaval compression?
- 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
How is aortocaval compression relieved?
- 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
What additional risk factors make resuscitation more complicated in pregnancy?
- aortocaval compression
- increased oxygen requirements
- splinting of the diaphragm by the pregnant abdomen
- difficulty with intubation
- increased risk of aspiration
- ongoing obstetric haemorrhage
How is resuscitation different in pregnancy?
-
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
When should the baby be delivered following maternal resuscitation?
- the baby should be delivered after 4 minutes
AND
- within 5 minutes of starting CPR
When is immediate C-section performed?
- 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 !!
Why is an emergency C-section performed within 5 minutes of starting CPR?
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
What is the definition of a stillbirth?
the birth of a dead fetus after 24 weeks gestation
What are the causes of stillbirth?
How many cases are unexplained?
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
What factors increase the risk of stillbirth?
- fetal growth restriction
- smoking / alcohol
- increased maternal age
- maternal obesity
- twins
- sleeping on the back (as opposed to either side)
What risk assessment is performed in the prevention of stillbirth?
- 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
What lifestyle advice is given to reduce the risk of stillbirth?
- smoking cessation
- avoid drinking alcohol
- effective control of diabetes
- sleeping on the side (rather than the back)
What is given to women at risk of pre-eclampsia?
prophylaxis with aspirin
What are the 3 key symptoms to ask about during pregnancy?
- reduced fetal movements
- abdominal pain
- vaginal bleeding
How is intrauterine fetal death (IUFD) diagnosed?
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
What treatment may be given to a select group of women following IUFD?
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
What is the standard dose of anti-D given?
500 units
- if there has been massive blood loss, further doses may be required
- this is determined through the Kleihauer test
What is the first line delivery method following IUFD?
vaginal delivery
(unless there are other reasons for a LSCS)
What are the 2 options given to women following diagnosis of IUFD?
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)
When is expectant management following IUFD not suitable?
when immediate delivery is required
- e.g. sepsis, pre-eclampsia, haemorrhage
What medication may be given to women after birth of a IUFD?
dopamine agonists
- e.g. cabergoline
- used to suppress lactation after stillbirth
What testing is carried out after stillbirth to determine the cause?
(this requires parental consent)
- 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
What future management is a woman offered following stillbirth?
- identifying the cause can help to reduce the risk in future pregnancies
- pregnancies are closely monitored in women with previous IUFD