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Chapter 25: Resuscitation in Pregnancy

Boyd Burns

INTRODUCTION AND EPIDEMIOLOGY

Cardiac arrest in pregnancy is rare, and resuscitation of a pregnant woman is typically an unexpected and chaotic event, which ideally involves multiple consultants from different specialties with different levels and types of skills. Emergency care and lifesaving procedures for resuscitation and cardiac arrest should not be delayed if specialists are not available. Contact the closest center providing neonatal and maternal services as soon as possible to facilitate rapid transport and continued care of the newly delivered infant and the mother.

The World Health Organization defines maternal deaths as deaths while pregnant or within 42 days of the end of pregnancy, related to or aggravated by pregnancy or pregnancy management, regardless of the duration or site of the pregnancy and irrespective of the cause of death.1 Factors associated with pregnancy-related deaths in the United States include advanced maternal age, African American race, increasing live birth order, and lack of prenatal care.2

Management of emergencies during labor and delivery and diagnosis and management of pulmonary embolism and eclampsia are discussed in the chapters 101, "Emergency Delivery" and 100, "Maternal Emergencies after 20 Weeks of Pregnancy and in the Postpartum Period."

PHYSIOLOGY OF PREGNANCY

Beginning early in pregnancy, virtually all major organ systems undergo changes (Table 25–1) that affect patient management.

Table 25–1

Physiologic Changes in Pregnancy Affecting Resuscitation

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Table 25–1

Physiologic Changes in Pregnancy Affecting Resuscitation
System Parameters Comment
Cardiovascular Cardiac output Increases 30%–50%
Peripheral resistance Decreases 20%
Blood pressure Decreases 10–15 mm Hg systolic in first half of pregnancy; then back to baseline
Blood volume 100 cc/kg or 6–7 L
Central venous pressure May be increased up to 10 mm Hg
Central venous oxygen saturation Increases as high as 80%3
Plasma volume Increases 30%–50%
Hematologic Fibrinogen, factors V, VII, VIII, X, von Willebrand factor Increase, with heightened risk for venous thromboembolism in second half of pregnancy
Respiratory and pulmonary Upper airway edema, hyperemia, and friability Estrogen and volume effects; can result in difficult airway
Diaphragm elevation Higher thoracostomy tube insertion site during pregnancy
Hemoglobin F has greater affinity for oxygen than maternal hemoglobin Fetal oxygen maintained at expense of maternal oxygenation; maintain maternal oxygen saturation >95%
Respiratory rate No change
Tidal volume, minute ventilation Increase
Renal and urinary Progesterone dilates renal collecting system; ureteral peristalsis decreases Renal US may show mild hydronephrosis; increased risk for ascending infection
GI Alkaline phosphatase rises from placental production; bile is more lithogenic Increased risk of cholecystitis/cholelithiasis
Decreased lower esophageal tone; decreased gastric emptying Increased likelihood of aspiration of gastric contents
Uteroplacental unit 25% of blood flow directed to uteroplacental unit; no autoregulation of blood flow; enlarging uterus can compress vena cava and vessels below the diaphragm; supine hypotension syndrome can occur after 30 min of supine position Place patient in left ...

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