Case report on effective cardiopulmonary resuscitation in a pregnant woman.

The management of cardiac arrest in pregnancy is an important task for the emergency physicians. Some reasons for cardiac arrest are reversible and should be recognized and managed promptly. Cardiopulmonary resuscitation follows general advanced cardiac life support guidelines with several modifications for pregnant women, taking into account the lives of both mother and fetus. Here, we present the case of 23-year-old pregnant patient who came to Guru Nanak Dev Hospital, Amritsar; in shock, had a cardiac arrest, successfully resuscitated in Intensive Care Unit (ICU), delivered by emergency cesarean section and was discharged from ICU on 9(th) day in healthy state.

INTRODUCTION

The cardiac arrest in pregnancy is very rare with an occurrence of one case in every 30,000 patients.[1] Various causes of cardiac arrest in pregnancy are amniotic fluid embolism, hemorrhagic shock, eclampsia, pulmonary thromboembolic events, sepsis, anaphylaxis, trauma, congenital, and acquired cardiac diseases.[23] It is estimated that the survival rate for in-hospital cardiac arrest varies from 0% to 42% and the most commonly seen in only 15–20% cases.[4] When a pregnant women's heart stops two lives are threatened. There are increased chances of cesarean section in them for the survival of mother/child or both. Favorable outcome is seen with effective and early cardiopulmonary resuscitation (CPR).[5]

CASE REPORT

A 23-year-old G2P1L1, at 28 weeks gestation with previous normal vaginal delivery was brought to emergency labor room in a state of shock. Blood pressure (BP) and pulse were unrecordable at the time of admission. The patient was unconscious and fetal heart sound was also unrecordable. History was derived from the relatives, and there was a history of amenorrhea since 7 months and bleeding per vaginam for the last more than 24 h. There was no any history of drug abuse or alcohol intake. We could not extract much obstetrical history as the attendants were illiterate and antenatal check-up was also missing. Before admission in our hospital, she remained admitted in three different private hospital for treatment, but was not treated for bleeding per vaginam anywhere. Immediately, a large bore intravenous (i.v) cannula was secured and i.v fluids in the forms of colloids and crystalloids were started. All the relevant samples were sent to investigate the case. Foley's catheter was put to measure hourly urine output, and urine was also sent for albumin, which came out to be negative after laboratory test. All electrolytes were within normal limits. Her blood sugar level was 84 mg%. Emergency ultrasound showed absent fetal heart. As the patient was in shock, so it was decided to shift the patient to Intensive Care Unit (ICU) as there was no immediate need for hysterotomy since fetus was already dead and our main consideration was to save the mother now. As the patient was being shifted from the stretcher to bed, the patient had a sudden cardiac arrest in labor room itself. Immediately, wedge was kept under the right hip, and chest compressions were started as per advanced cardiac life support (ACLS) guidelines that are, 100 compressions/min. The simultaneously patient was intubated with endotracheal tube number 7 fixed by another rescuer and tube was secured. Rescue breaths were given with AMBU at 12/min. Injection adrenaline 1 mg i.v was given twice and all others resuscitative measures were taken. The patient was revived within 4 min of CPR. Inotropes were started to maintain BP with dopamine at 10 µg/kg and noradrenaline at 1610 µg/kg. Then the patient was shifted to ICU and put on synchronized intermittent mandatory ventilation volume control (SIMV-VC) mode of ventilator with following settings FiO2: 100%, tidal volume (TV): 500 ml, positive end expiratory pressure (PEEP): Off, positive support ventilation (PSV): 15. Patient's vitals on ICU admission were as follows: BP 92/60 mmHg on the right side of the arm, pulse rate (PR): 120 bpm, SPO2: 95%. The patient was managed with 4 whole blood and both the vasopressors continued. As the patient's BP started rising, the patient had the second bout of bleeding per vaginam. P/A examination was done by the obstetrician and uterus was measured at 28 weeks, oblique lie. In the meantime, recent ultrasound scan was brought by attendants, which showed Grade 4 placenta previa (placenta completely covering internal os). After proper consent, the patient was shifted to operation theater with following vitals BP 100/64 on dopamine 1010 µg/kg and noradrenaline 1610 µg/kg, PR 128 bpm and an emergency lower segment cesarean section (LSCS) was performed under general anesthesia. The patient was given i.v 80 mg ketamine, 4 mg vecuronium and isoflurane and dead baby extracted out as breech. Placenta that was already lying separated was removed. Uterus was closed in layers. Intraoperatively, 3 whole blood transfusions, 1 L Ringer lactate and 4 fresh frozen plasma were transfused. Now blood samples were taken and sent for laboratory examination again. The patient stood the surgery well and was shifted back to ICU and put on ventilator SIMV-VC mode with following settings FiO2: 50%, TV: 500 ml, PEEP: 3, PSV: 15. The patient remained stable with vitals BP 120/72 mm Hg, PR 115 bpm, and SpO2 95%. The patient was intensively monitored in ICU. Inotropes were tapered off in next 4 days. The patient regained consciousness and responded to verbal commands and was weaned off from the ventilator on 7th day. She was shifted to the ward on 9th day and the subsequently discharged with intact neurological functions.

DISCUSSION

Resuscitation of pregnant women is a challenging process as there are various anatomical and physiological changes that are, decrease in respiratory reserve volume.[6] Furthermore, there is difficult airway resulting from pharyngeal edema, increased risk of aspiration due to relaxation of the esophageal sphincter, decreased effect of chest compressions as a result of decreased venous return leading to supine hypotension and obstruction of forward flow of blood by the gravid uterus, especially in cardiac arrest.

There are two lives at stake; mother and fetus. The correct and fast decision of the resuscitator leads to better survival rates of both mother and fetus. Early restoration of the maternal circulation should be there in order to increase the survival rate of the fetus.[7] In the present case, study fetus was already dead on admission. In India and other developing countries, most of the ignorant patients do not go for proper antenatal check-up despite government policies to give free treatment to patients to decrease infant mortality rate and mother mortality rate. Successful CPR implies that early recognition of cardiac arrest, aortocaval decompression, early hysterotomy, or cesarean section, and reversing the cause of cardiac arrest. According to ACLS guidelines mother's circulation should be restored within 5 min else emergency hysterotomy is to be done.[8] Since our patient was revived in <5 min and fetus had already expired so patient was first stabilized in ICU and cause of arrest was identified and treated, that is, hemorrhagic shock and then LSCS was performed.

Antepartum hemorrhage complicates about 2–5% of pregnancies, out of which one-third is due to placenta previa. It accounts for 25% of maternal deaths in pregnancy.[9] Rapid assessment and initiation of appropriate resuscitative measures can greatly improve prognosis.[10] Placenta previa is abnormal implantation of placenta in the lower uterine segment. Thus, an accurate and early diagnosis of placenta previa is important and useful in clinical obstetrical practice.[11] However, the technology advances in ultrasonography, the diagnosis of placenta previa is commonly made earlier in pregnancy. Transvaginal ultrasonography is most sensitive and specific for diagnosis.[12] If the bleeding is minimal, and fetal reassurance is noted, then expectant management may be considered. However, if bleeding or contractions occur, the patient must rapidly go to the hospital for evaluation and testing. If the bleeding persists and is heavy, preparation for immediate emergency LSCS is indicated. As in the present case, there was an oblique lie, preterm pregnancy with intra uterine device and bleeding per vaginam, so emergency LSCS was done.

CONCLUSION

Cardiac arrest is a rare, unexpected and devastating event for pregnant patients, as well as doctors who treat them. Early anticipation and treatment of various pathologies in pregnant women may prevent cardiac arrest. A multidisciplinary team should be familiar with ACLS guidelines and their modification in pregnant women. It should also be kept in mind that there is no change in doses of medication or defibrillator in the resuscitation of pregnant women.[13] However, as the pregnant patients have decreased functional residual capacity and increased oxygen demand, they develop hypoxemia very rapidly, so prompt and excellent CPR with some modifications should be started immediately. Proper co-ordination among the anesthesiologists, obstetrician, medical specialist and intensive care specialist is very important.

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Conflicts of interest

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