Table 1 Comparison of key similarities and differences of AHA and OBLS maternal cardiac arrest resuscitation guidelines
Category | AHA 2020 Guideline | OBLS 2022 Guideline |
|---|---|---|
Airway management | Because pregnant patients are more prone to hypoxia, oxygenation and airway management should be prioritized during resuscitation from cardiac arrest in pregnancy | Unchanged |
Chest compressions | Priorities for the pregnant woman in cardiac arrest should include provision of high-quality CPR and relief of aortocaval compression through left lateral uterine displacement | High quality chest compressions may require hand positioning to rotate toward the patient’s shoulder (while still applying force to the sternum) to accommodate the larger/pendulous breasts of a pregnant patient |
Fetal monitoring during CPR | Because of potential interference with maternal resuscitation, fetal monitoring should not be undertaken during cardiac arrest in pregnancy | Fetal monitors should be removed during resuscitation |
Cesarean Delivery during CPR (Terminology, Timing, Personnel) | Perimortem cesarean delivery | The term “resuscitative cesarean delivery” should be used instead of “perimortem cesarean delivery” to more correctly describe the purpose/indication and increase the sense of urgency for performing this procedure |
At 4 min, a PMCD should be strongly considered for every mother in whom ROSC has not been achieved after ≈4 minutes of resuscitative efforts with no ROSC | Concur, with the addition that it is reasonable to consider RCD immediately in a term patient in maternal cardiac arrest | |
If maternal viability is not possible (through either fatal injury or prolonged pulselessness), the procedure should be started immediately; the team does not have to wait to begin the PMCD | Preform resuscitative caesarean delivery immediately in a pregnant patient with a fundus height at or above the umbilicus with a non-shockable rhythm | |
Decisions on the optimal timing of a PMCD for both the infant and mother are complex and require consideration of factors such as the cause of the arrest, maternal pathology and cardiac function, fetal gestational age, and resources (ie, may be delayed until qualified staff is available to perform this procedure). Shorter arrest-to-delivery time is associated with better outcome (Class I; Level of Evidence B). | Unchanged | |
Continuous manual LUD should be performed throughout the PMCD until the fetus is delivered (Class IIa; Level of Evidence C). Care should be taken to avoid injury to the rescuer performing the manual LUD during PMCD | Unchanged | |
If the uterus is difficult to assess (e.g., in the morbidly obese), then determining the size of the uterus may prove difficult. In this situation, PMCD should be considered at the discretion of the obstetrician by using his or her best assessment of the uterus. In these patients, bedside ultrasound may help guide decision making | See POC-US comments | |
POC-US | We suggest against the use of point-of-care ultrasound for prognostication during CPR (Class 3: No benefit, LOE C-LD). This recommendation does not preclude the use of ultrasound to identify potentially reversible causes of cardiac arrest or detect ROSC | Where available, POC-US should be used in the management of maternal cardiac arrest for identification of an intrauterine pregnancy and quick determination of gestational age to guide decision making on PMCD 1a. Note: POC-US should not interfere with CPR, thus should only be performed during brief pauses in CPR |
POC-US should be considered for use during maternal cardiac arrest in emergency protocols for identification of potentially reversible causes of cardiac arrest, identification of cardiac contractility activity without palpable pulse for clinical reclassification of pulseless electrical activity, and identification of the absence of cardiac contractility where further attempts at resuscitation may be unsuccessful 2a. Note: POC-US should not interfere with CPR, thus should only be performed during brief pauses in CPR | ||
ECPR | Not discussed | The use of ECPR may be considered for management of maternal cardiac arrest when there is no ROSC after resuscitative hysterotomy (if beyond 20 weeks) and the patient is in an ECMO center with the capacity to care for critically ill pregnant patients |
The use of ECPR should be considered for organ procurement in pregnant patients post-arrest with circulatory determination of death | ||
All pregnant women who receive ECPR in the setting of maternal cardiac arrest, regardless of outcome, should be reported in the Extracorporeal Life Support Organization (ELSO) registry (http://www.elso.org/Registry.aspx) | ||
Targeted temperature management | We recommend targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest | Unchanged |
During targeted temperature management of the pregnant patient, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication, and obstetric and neonatal consultation should be sought | Unchanged | |
Preparedness | Care teams that may be called upon to manage these situations should develop and practice standard institutional responses to allow for smooth delivery of resuscitative care | Providers staffing emergency departments should be trained in resuscitative cesarean delivery |
Protocols for management of OHCA in pregnancy should be developed to facilitate timely transport to a center with capacity to immediately perform PMCD while providing ongoing resuscitation | A minimum of 3 providers should be utilized during OH MCA resuscitation. It is reasonable to consider the use of automatic chest compression devices (ACCD) to assist with resuscitation with limited resources |