11Resuscitation in Pregnancy
Elizabeth M. Datner and Susan B. Promes
KEY POINTS
Displace the gravid uterus off the great vessels either
manually or with a left lateral tilt to avoid aortocaval
compression.
Gain intravenous access above the diaphragm.
Preoxygenate with 100% oxygen before intubation 4mm Hg.3
in anticipation of a more rapid onset of hypoxemia.
In a pregnant woman, hands for cardiopulmonary
resuscitation, chest tubes, and defibrillator paddles
should be placed higher on the chest wall.
Cardioversion and defibrillation will not harm the fetus.
When the uterus is palpable above the umbilicus and
the mother is in cardiac arrest, perform cesarean
section immediately.
Continue cardiopulmonary resuscitation during and
after perimortem cesarean section and consider
therapeutic hypothermia in a comatose patient with
return of spontaneous circulation.
For an Rh-negative woman who has vaginal bleeding
after trauma, administer Rh immunoglobulin (RhoGAM):
a 50-mcg dose in the first trimester and a 300-mcg
dose in the second or third trimester.
In any pregnant woman at more than 24 weeks
gestation who suffers trauma to the abdomen, fetal
monitoring should be initiated as soon as possible compresses the aorta and inferior vena cava and limits venous
and be maintained for 4 to 6 hours.
SCOPE
Resuscitation of a pregnant woman is an infrequent event.
Cardiac arrest statistics are difficult to quantify, but cardiac
arrest reportedly occurs in roughly 1 in 30,000 near-term
pregnancies.1 More recent data suggest an increase in mater-
nal mortality from cardiac arrest, with frequency rates of 1 in
20,000.2 In the event of cardiac arrest in a pregnant woman,
two lives must be resuscitated. Quick, decisive management
is paramount for the livelihood of the mother and her unborn
child. Knowing exactly what to do and acting quickly ensure
the best possible outcome for the mother and her unborn child.
ANATOMY AND PHYSIOLOGY
What are generally considered abnormal vital signs in non-
pregnant people may actually be within the normal range for
a pregnant woman. In gravid females, the heart rate and respi-
ratory rate are increased. In the second trimester, blood
92
pressure is decreased by 5 to 15mm Hg, but it returns to
normal near term. Hypoxemia occurs earlier in pregnant
patients because of diminished reserve and buffering capacity.
Pregnant patients have a slight respiratory alkalosisPCO2 of
30mm Hg and pH of 7.43that must be taken into account
when interpreting arterial blood gas values. Central venous
pressure decreases in pregnancy to a third-trimester value of
A pregnant woman has less respiratory reserve and greater
oxygen requirements. The gravid uterus pushes up on the
diaphragm, which results in reduced functional residual
capacity. Minute ventilation and tidal volume rise, as does
maternal oxygen consumption. The basal metabolic rate
increases during pregnancy. The greater oxygen demands of
the unborn child significantly alter the mothers respiratory
physiology, and the mother hyperventilates to meet the
demands of the fetus. A pregnant patient at baseline is in
a state of compensatory respiratory alkalosis because of
excessive secretion of bicarbonate. A pregnant womans
ability to compensate for acidosis is impaired. Other physio-
logic changes that may affect resuscitation are airway edema
and friability, reduced chest compliance, and higher risk for
regurgitation and aspiration.
As the uterus grows, it moves from the pelvis into the
abdominal cavity, which pushes the contents of the abdominal
cavity up toward the chest. In late pregnancy, the gravid uterus
return to the heart. Stroke volume is decreased when a near-
term pregnant woman is lying on her back and increased when
the uterus is moved away from the great vessels. A woman in
the second or third trimester of pregnancy should be placed
in the left lateral tilt position, or the uterus should be manually
displaced to the left to optimize cardiac output and venous
return. During late pregnancy, cardiac output is increased.
Pulmonary capillary wedge pressure remains unchanged, as
does the ejection fraction.
Electrocardiographic changes, including left axis deviation
secondary to the diaphragm moving cephalad and changing
the position of the heart, are also present during pregnancy.
Q waves are present in leads III and aVF, and flattened or
inverted T waves are seen in lead III.
During pregnancy blood volume increases, which causes a
dilution anemia. The average hematocrit value is 32% to 34%.
White blood cell counts are higher than normal and platelet
counts are lower in pregnancy. Blood urea nitrogen and serum
creatinine values are lower than normal, as are cortisol values.
The erythrocyte sedimentation rate is increased. Albumin and
total protein levels are decreased. Fibrinogen levels double in
pregnancy, so a patient with disseminated intravascular coagu-
lation could have a normal fibrinogen level.
Pregnancy-related changes can be seen on radiographic
studies. A chest radiograph of a pregnant woman shows an

increased anteroposterior diameter, mild cephalization of the
pulmonary vasculature, cardiomegaly, and a slightly widened
mediastinum. Widening of the sacroiliac joints and pubic
symphysis are apparent on imaging of the pelvis. Radiography
should not be avoided in a pregnant woman because of con-
cerns about radiation exposure of the fetus, which can simply
be shielded. Ultrasonography can be used at the bedside to
identify fluid in the abdomen, pelvis, and pericardium and
to evaluate fetal activity and heart rate. Fetal well-being is
closely linked to the well-being of the mother, so all studies
indicated for diagnosis and treatment of the mother should be
performed.
DIFFERENTIAL DIAGNOSIS
Pregnant women are generally young and healthy. The rare
cardiac arrest in a gravid female may be due to venous
thromboembolism, severe pregnancy-induced hypertension,
amniotic fluid embolism, or hemorrhage. In addition to such
pregnancy-related problems, pregnant women are not exempt
from common conditions that affect the general population.
Trauma and sepsis may lead to cardiopulmonary failure and
the need for maternal resuscitation. Box 11.1 lists key etio-
logic factors leading to cardiac arrest in pregnant patients.4
HEMORRHAGE
During routine vaginal delivery, the average blood loss is
500mL. Excessive blood loss or postpartum hemorrhage
complicates 4% of vaginal deliveries.5 Common causes of
hemorrhage around the time of delivery are uterine atony
(excessive bleeding with a large relaxed uterus after delivery),
vaginal or cervical tears, retained fragments of placenta, pla-
centa previa, placenta accreta, and uterine rupture. Hereditary
abnormalities in blood clotting may cause hemorrhage, so
inquiries about excessive bleeding, known disorders, and
family history are relevant in a patient with excessive
bleeding.
NONHEMORRHAGIC SHOCK
Causes of nonhemorrhagic obstetric shockpulmonary
embolism, amniotic fluid embolism, acute uterine inversion,
and sepsisare uncommon but are responsible for the major-
ity of maternal deaths in the developed world.6 These condi-
tions must be diagnosed and treated expeditiously. Patients in
whom pulmonary embolism is suspected should be adminis-
tered heparin and then undergo diagnostic imaging. Although
fibrinolytic agents are contraindicated in pregnancy, they
have been used successfully in patients with life-threatening
pulmonary embolism and ischemic stroke. Treatment of
amniotic fluid embolism is supportive, the goals being to
maintain maternal oxygenation and support blood pressure.
Some case reports describe success with the use of cardiopul-
monary bypass to treat women suffering from amniotic fluid
embolism.
Acute uterine inversion can also cause shock. Cardiovascu-
lar collapse complicates approximately half the cases of acute
uterine inversion. Classically, the extent of the shock is out of
proportion to the blood loss noted. One theory to explain this
observation is that a parasympathetic reflex causes neurogenic
shock from stretching of the broad ligament or compression
of the ovaries (or both) as they are drawn together. Uterine
CHAPTER 11 Resuscitation in Pregnancy
BOX 11.1 Major Causes of Cardiac Arrest
During Pregnancy*
Venous thromboembolism
Pregnancy-induced hypertension
Sepsis
Amniotic fluid embolism
Hemorrhage:
Placental abruption
Placenta previa
Uterine atony
Disseminated intravascular coagulation
Trauma
Iatrogenic:
Medication errors
Allergic reactions to medications
Anesthetic complications
Oxytocin administration
Hypermagnesemia
Preexisting heart disease:
Congenital
Acquired cardiomyopathy of pregnancy
*Listed in order of decreasing frequency.
From Mallampalli A, Powner DJ, Gardner MO. Cardiopulmonary resuscita-
tion and somatic support of the pregnant patient. Crit Care Clin
2004;20:748.
replacement combined with vigorous fluid resuscitation,
including blood transfusion as required, should reverse the
hypotension.7
TRAUMA
Traumatic injuries occur commonly in pregnancy and are
the leading cause of maternal death; they account for more
than 46% of cases. Motor vehicle crashes, assaults, and falls
are the most common causes of injuries. Pregnant women
are at increased risk for domestic violence, and this possi
bility should be considered and the police notified when
warranted.
Fetal outcome is affected when the mother becomes hypo-
tensive or acidotic as a result of major injury. Maternal vital
signs and physical symptoms do not predict fetal distress in
women with minor trauma. Only cardiotocographic monitor-
ing for a minimum of 4 to 6 hours is useful in predicting fetal
outcome. After even apparently minor falls women should
undergo fetal monitoring.
In pregnant women suffering blunt trauma, most fetal
deaths occur as a result of placental abruption. Classic symp-
toms are abdominal cramps, vaginal bleeding, uterine tender-
ness, and hypovolemia (several liters of blood can accumulate
in the uterus). None of these findings are sensitive and cannot
be relied on, so monitoring is required.
DIAGNOSTIC TESTING
INTERVENTIONS AND PROCEDURES
A fundamental principle in treating pregnant women is that
fetal well-being depends on maternal well-being. As with all
patients in the emergency department (ED), resuscitation
93
SECTION I RESUSCITATION SKILLS AND TECHNIQUES
starts with the ABCs (airway, breathing, and circulation). One
hundred percent oxygen should be administered to the mother
early. Hypoxia should be treated aggressively in this patient
population because when the mother is hypoxic, oxygen is
shunted away from the fetus. Additionally, preoxygenation is
important because apnea results in more rapid hypoxia in the
setting of pregnancy. Rapid-sequence induction with precau-
tions for aspiration is essential before intubation. Aggressive
volume resuscitation, administration of vasopressors if needed,
and close attention to the patients body position are all very
important in the treatment of hypotension in a pregnant
patient. Fetal heart monitoring and, ideally, cardiotocographic
monitoring should be initiated as soon as possible for patients
in the second or third trimester of pregnancy.8
A commercially produced wedge called a Cardiff wedge
is available to aid in the resuscitation of pregnant women.
It can be placed under the womans right side to support her
back while she lies in the preferred left lateral tilt position. In
the absence of a wedge, a human wedge can be used, with
the patient being tilted on the bent knees of a kneeling
rescuer. Pillows, towel rolls, and blanket rolls are readily
available in EDs and accomplish the same purpose of
angling the womans back 30 to 45 degrees from the floor
(Fig. 11.1). If for some reason the patient must lie on her back,
as in the case for adequate cardiopulmonary resuscitation
(CPR), a member of the health care team should manually
displace the uterus to the left so that it does not rest on the
great vessels.
The American Heart Association (AHA) basic life support
guidelines should be followed with two modifications:
Move the uterus off the great vessels.
Adjust the hand position for CPR cephalad to account for
displacement of the thoracic contents by the gravid uterus.
The AHA advanced cardiac life support (ACLS) guidelines
for medications, intubation, and defibrillation for patients in
cardiac arrest should be followed for gravid females with one
simple exceptiona change in placement of the defibrillation
paddles and pads:
Place one paddle below the right clavicle in the midclavicu-
lar line.
Position the second paddle outside the normal cardiac apex
so that it avoids breast tissue.7
Fig. 11.1 Blanket roll technique to tilt the patient.
94
Defibrillation energy requirements remain the same (Fig.
11.2).9 Defibrillation will not harm the fetus. ACLS medica-
tions should be used as needed. It is reasonable to remove
external or internal fetal monitoring devices during electrical
shock of the mother because of the possibility of creating
an electrical arc to the monitoring equipment, but this is
unlikely with the electrical current applied to the maternal
thorax. Box 11.2 lists the U.S. Food and Drug Administra
tion categories for the various ACLS drug options during
pregnancy.
In pregnant patients with trauma who are in need of a tho-
racostomy, the chest tube must be placed one or two intercos-
tal spaces higher than normal to avoid diaphragmatic injury.
An open supraumbilical approach should be used for diagnos-
tic peritoneal lavage in a pregnant patient, with the gravid
uterus palpable on abdominal examination.
If return of spontaneous circulation (ROSC) is achieved,
effort must be directed at further hemodynamic stabilization.
Postcardiac arrest therapeutic hypothermia has been success-
ful in the setting of early pregnancy and is recommended as
for nonpregnant patients.10 In a comatose postcardiac arrest
patient with ROSC, the patient should be cooled as soon as
possible and within 4 to 6 hours to 32 C to 34.8 C for a
12-to 24-hour duration to gain the best possible neurologic
outcome. If a perimortem cesarean section has not been per-
formed because of gestational age less than 24 weeks, fetal
monitoring should be performed during hypothermia in anti
cipation of bradycardia.11
IMAGING
Ultrasonography is an important method for assessment of
both the mother and fetus, but additional radiographic studies
are often required. Shielding can ensure that exposure even
with maternal head and chest computed tomography (CT) can
be kept below the 1-rad (1000-millirad) limit. Intrauterine
exposure to 10 rad (10,000 millirad) produces a small increase
in childhood cancer; exposure to 15 rad creates a risk for
mental retardation, childhood cancer, and a small head. A
head or chest radiograph delivers less than 1 millirad to the
shielded gravid uterus. A lumbar spine, hip, or kidneys-
ureters-bladder radiograph delivers more than 200 millirad. A
CT scan of the head delivers less than 50 millirad to the
shielded uterus, and a chest CT scan provides an exposure of
less than 1000 millirad. In sum, important radiographic studies
of the head, neck, and chest can safely proceed if the uterus
is shielded.
FETOMATERNAL TRANSFUSION
After the 12th week of pregnancy, when the uterus rises
above the pelvic rim and becomes susceptible to trauma, fetal
blood can theoretically cross into the maternal circulation
after significant trauma. A 50-mcg dose of Rh immuno
globulin (RhoGAM) is used when the mother is Rh negative.
During the second and third trimesters a 300-mcg dose is
administered, which protects against 30mL of fetomaternal
hemorrhage. A 16-week fetus has about a 30-mL volume
of blood, so the entire blood volume is covered by the 300-
mcg dose.
Pregnant patients in the second or third trimester who suffer
major traumatic injury could theoretically have fetomaternal
 CHAPTER 11 Resuscitation in Pregnancy

Airway

Open the airway.

Intubate if necessary using cricoid pressure
to decrease likelihood of aspiration.

Breathing

Begin bag-valve-mask ventilation.

Circulation

Maximize material circulation by moving

uterus off great vessels. Place patient in
left lateral tilt or manually displace uterus
to the left.
Adjust hand position for CPR superiorly.

Defibrillation/definitive care

Adjust paddle position for defibrillation.

Pulmonary embolism:
Treat underlying pathology.
thrombolytics/embolectomy
Perform cesarean section 4 minutes
after arrest if fetus believed to be
>20 weeks.
Consider cesarean section if the fetus
is not viable but the mother is believed Amniotic fluid embolism: consider
to be salvageable. Delivering the fetus cardiopulmonary bypass
may improve the mothers hemodynamic
status and allow return of
maternal circulation.
Septic shock: antibiotics and
institute vasopressors

Hemorrhagic shock: control

bleeding, treat uterine atony
if present, transfuse O-
negative blood

Administer RhoGAM for

Rh-negative mothers

Fig. 11.2 Algorithm for resuscitation of a pregnant patient. CPR, Cardiopulmonary resuscitation.

transfusion that exceeds the coverage provided by the 300-mcg
dose. This situation is rare and occurs in less than 1% of
pregnant patients after trauma. In patients with major trauma
and advanced pregnancy, the Kleihauer-Betke test should be
considered, especially when significant vaginal bleeding is
present. Rh immunoglobulin is effective when administered
within 72 hours, so the test does not have to be performed in
the ED.
PERIMORTEM CESAREAN SECTION
The two goals of perimortem cesarean section are to improve
the unstable hemodynamics of the mother and minimize
morbidity and mortality in the child. If resuscitative efforts,
including ACLS algorithms and alleviation of aortocaval com-
pression, fail to improve maternal hemodynamics, perimor-
tem cesarean section must be considered. The likelihood that
perimortem cesarean section will result in a living and neu-
rologically normal infant is related to the interval between
onset of maternal cardiac arrest and delivery of the infant.12,13
The gestational age of the neonate is also critical. If cesarean
section is performed in the ED, it should be done rapidly. Time
is of the essence. Fetal viability outside the uterus is best
beyond 24 weeks gestation, but it is not always possible to
know the exact gestational age in the ED. On the basis of case
reports, it is recommended that cesarean section be performed
in the ED if the gestational age is believed to be more than

95
SECTION I RESUSCITATION SKILLS AND TECHNIQUES
BOX 11.2 Classification of Drugs Used During
Pregnancy
The U.S. Food and Drug Administration categories for the
various advanced cardiac life support drug options during
pregnancy are as follows:
Category B
Definition
Animal studies have revealed no evidence of harm to the
fetus, although no adequate and well-controlled studies in
pregnant women have been conducted.
OR
Animal studies have shown an adverse effect, but adequate
and well-controlled studies in pregnant women have failed to
demonstrate a risk to the fetus in any trimester.
Agents
Atropine
Magnesium
Category C
Definition
Animal studies have shown an adverse effect, and no ade-
quate and well-controlled studies in pregnant women have
been conducted.
OR
No animal studies have been conducted, nor have ade
quate and well-controlled studies in pregnant women been
conducted.
Agents
Epinephrine
Lidocaine
Bretylium
Bicarbonate
Dopamine
Dobutamine
Adenosine
Category D
Definition
Adequate well-controlled or observational studies in preg-
nant women have demonstrated a risk to the fetus. The
benefits of therapy may outweigh the potential risk. For
example, the drug may be acceptable if needed in a life-
threatening situation or for serious disease for which safer
drugs cannot be used or are ineffective.
Agent
Amiodarone
20 weeks. At this stage of pregnancy, the fundus is likely to
be palpable at or above the level of the umbilicus.
The child should be delivered within 5 minutes of maternal
cardiac arrest, so the procedure should be initiated within 4
minutes of failed CPR of the mother. The procedure is sum-
marized in Box 11.3. Maternal CPR should be maintained
throughout the procedure to optimize blood flow to the uterus
and the mother and should be continued after cesarean
section. Once delivery is accomplished, ED personnel should
be prepared to resuscitate the neonate. It is important to note
96
BOX 11.3 Technique for Perimortem
Cesarean Section
NOTE: Have suction available for this procedure because
bleeding can be excessive.
1. Ideally, while the emergency physician is preparing for
the procedure, a catheter is placed in the bladder and
the abdominal wall is prepared with povidone-iodine.
However, do not delay the procedure for these
activities.
2. Using a No. 10 scalpel, make a midline vertical incision
from the umbilicus to the pubis along the linea nigra.
3. Once the peritoneal cavity is open, use bladder retrac-
tors and Richardson retractors to improve access to the
uterus.
4. Make a short vertical incision in the lower uterine segment
just cephalad to the bladder.
5. Extend the uterine incision cephalad with blunt scissors.
Place a hand in the uterus to keep the baby from
being cut.
6. Deliver the baby.
7. Suction the mouth and nose, cut and clamp the umbilical
cord, and resuscitate the baby.
8. Document Apgar scores at 1, 5, and 10 minutes.
9. If the mother regains vital signs, remove the placenta and
repair the uterus and abdominal wall.
10. Consider intramuscular injection of oxytocin into the
bleeding uterus.
that published and anecdotal reports describe return of mater-
nal blood pressure and maternal survival after perimortem
cesarean section.14 Successful resuscitation of a pregnant
woman and her unborn child requires a coordinated team
approach.
CONCLUSION
In the setting of resuscitation, a pregnant woman poses chal-
lenges given the physiologic and anatomic changes associated
with pregnancy. Remembering these normal adjustments that
occur in gravid women is critical. Aortocaval compression
must be avoided during resuscitation of a pregnant woman.
Appropriately diagnosing the cause of the patients medical
problem while being mindful of the ABCs of resuscitation is
a must. Thankfully, cardiac arrest is an uncommon event in
pregnant women. When it occurs later in pregnancy, perimor-
tem cesarean section may improve the outcome of the infant
and mother if performed in a timely manner. As with all
resuscitations, a team effort is mandatory, but possibly even
more so in this setting because the emergency practitioner is
caring for two patients whose lives are very tenuous and time
is of the essence.
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References can be found on Expert Consult @
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