IV- 52 Circulation December 13. 2005 failure. If untreated it may result in maternal and fetal Decision Making for Emergency Hysterotomy morbidity and mortality. The resuscitation team should consider several maternal and Aortic dissection. Pregnant women are at increased risk fetal factors in determining the need for an emergency for spontaneous aortic dissection. Life-threatening pulmonary embolism and stroke. Suc cessful use of fibrinolytics for a massive, life-threatening Consider gestational age. Although the gravid uterus pulmonary embolism -l3 and ischemic stroke 4 have reaches a size that will begin to compromise aortocaval been reported in pregnant women. blood flow at approximately 20 weeks of gestation, fetal Amniotic fluid embolism. Clinicians have reported suc- viability begins at approximately 24 to 25 weeks. Portable cessful use of cardiopulmonary bypass for women with ultrasonography, available in some emergency depart life-threatening amniotic fluid embolism during labor ments, may aid in determination of gestational age(in and delivery. 5 experienced hands) and positioning. However, the use of Trauma and drug overdose. Pregnant women are not ultrasound should not delay the decision to perform emer exempt from the accidents and mental illnesses that gency hysterotomy. 30 afflict much of society. Domestic violence also increases Gestational age <20 weeks. Urgent cesarean delivery during pregnancy: in fact, homicide and suicide are need not be considered because a gravid uterus of this leading causes of mortality during pregnancy. 6. 7 size is unlikely to significantly compromis cardiac output Emergency Hysterotomy(Cesarean Delivery) for Gestational age approximately 20 to 23 weeks. Perform the pregnant woman in cardiac arrest an emergency hysterotomy to enable successful resusci- tation of the mother not the survival of the delivered Maternal Cardiac Arrest Not Immediately Reversed by bls and acls infant, which is unlikely at this gestational age. The resuscitation team leader should consider the need for an Gestational age approximately 224 to 25 weeks. Per emergency hysterotomy(cesarean delivery) protocol as soon form an emergency hysterotomy to save the life of both as a pregnant woman develops cardiac arrest. 4. l6-l8 The best the mother and the infant survival rate for infants >24 to 25 weeks in gestation occurs Consider features of the cardiac arrest. The hen the delivery of the infant occurs no more than 5 minutes features of the cardiac arrest can increase the infant's after the mother's heart stops beating. 6. 19-2 This typically chance for survival requires that the provider begin the hysterotomy about 4 Short interval between the mother's arrest and the minutes after cardiac arrest infants delivery Emergency hysterotomy is an aggressive procedure. It may No sustained prearrest hypoxia in the mother seem counterintuitive given that the key to salvage of a Minimal or no signs of fetal distress before the mothers potentially viable infant is resuscitation of the mother. 6, 10, cardiac arrest But the mother cannot be resuscitated until venous return and ggressive and effective resuscitative efforts for the aortic output are restored. Delivery of the baby empties the mother uterus, relieving both the venous obstruction and the aortic The hysterotomy is performed in a medical center with a compression. The hysterotomy also allows access to the neonatal intensive care unit infant so that newborn resu be Consider the professional setting The critical point to remember is that you will lose both Are appropriate equipment and supplies available? mother and infant if you cannot restore blood flow to the Is emergency hysterotomy within the rescuer's proce- mother ' s heart 4.18, 25,26 Note that 4 to 5 minutes is the dural range of experience and skills? maximum time rescuers will have to determine if the arrest Are skilled neonatal/pediatric support personnel avail- can be reversed by Bls and ACLS interventions. The rescue able to care for the infant, especially if the infant is not team is not required to wait for this time to elapse before full term? ng emergency hysterotomy. 27 Recent reports document Are obstetric personnel immediately available to support long intervals between an rgent decision for hysterotomy the mother after delivery and actual delivery of the infant, far exceeding the obstetrical Advance Preparation guideline of 30 minutes. 28,29 Experts and organizations have emphasized the importance of Establishment of iv access and an advanced airway typi- advance preparation. 4. 18 26 Medical centers must review cally requires several minutes. In most cases the actual whether performance of an emergency hysterotomy is feasi- cesarean delivery cannot proceed until after administration of ble at their center, and if so, they must identify the best means IV medications and endotracheal intubation. Resuscitation of rapidly accomplishing this procedure. The plans should be team leaders should activate the protocol for an emergency made in collaboration with the obstetric and pediatric cesarean delivery as soon as cardiac arrest is identified in the services. pregnant woman. By the time the team leader is poised to deliver the baby, IV access has been established, initial Summary medications have been administered, an advanced airway is Successful resuscitation of a pregnant woman and survival of in place, and the immediate reversibility of the cardiac arrest the fetus require prompt and excellent CPR with has been determined modifications in basic and advanced cardiovascularfailure. If untreated it may result in maternal and fetal morbidity and mortality. – Aortic dissection. Pregnant women are at increased risk for spontaneous aortic dissection. – Life-threatening pulmonary embolism and stroke. Suc￾cessful use of fibrinolytics for a massive, life-threatening pulmonary embolism11–13 and ischemic stroke14 have been reported in pregnant women. – Amniotic fluid embolism. Clinicians have reported suc￾cessful use of cardiopulmonary bypass for women with life-threatening amniotic fluid embolism during labor and delivery.15 – Trauma and drug overdose. Pregnant women are not exempt from the accidents and mental illnesses that afflict much of society. Domestic violence also increases during pregnancy; in fact, homicide and suicide are leading causes of mortality during pregnancy.6,7 Emergency Hysterotomy (Cesarean Delivery) for the Pregnant Woman in Cardiac Arrest Maternal Cardiac Arrest Not Immediately Reversed by BLS and ACLS The resuscitation team leader should consider the need for an emergency hysterotomy (cesarean delivery) protocol as soon as a pregnant woman develops cardiac arrest.4,16 –18 The best survival rate for infants
24 to 25 weeks in gestation occurs when the delivery of the infant occurs no more than 5 minutes after the mother’s heart stops beating.16,19 –21 This typically requires that the provider begin the hysterotomy about 4 minutes after cardiac arrest. Emergency hysterotomy is an aggressive procedure. It may seem counterintuitive given that the key to salvage of a potentially viable infant is resuscitation of the mother. 6,10,22–24 But the mother cannot be resuscitated until venous return and aortic output are restored. Delivery of the baby empties the uterus, relieving both the venous obstruction and the aortic compression. The hysterotomy also allows access to the infant so that newborn resuscitation can begin. The critical point to remember is that you will lose both mother and infant if you cannot restore blood flow to the mother’s heart.4,18,25,26 Note that 4 to 5 minutes is the maximum time rescuers will have to determine if the arrest can be reversed by BLS and ACLS interventions. The rescue team is not required to wait for this time to elapse before initiating emergency hysterotomy.27 Recent reports document long intervals between an urgent decision for hysterotomy and actual delivery of the infant, far exceeding the obstetrical guideline of 30 minutes.28,29 Establishment of IV access and an advanced airway typi￾cally requires several minutes. In most cases the actual cesarean delivery cannot proceed until after administration of IV medications and endotracheal intubation. Resuscitation team leaders should activate the protocol for an emergency cesarean delivery as soon as cardiac arrest is identified in the pregnant woman. By the time the team leader is poised to deliver the baby, IV access has been established, initial medications have been administered, an advanced airway is in place, and the immediate reversibility of the cardiac arrest has been determined. Decision Making for Emergency Hysterotomy The resuscitation team should consider several maternal and fetal factors in determining the need for an emergency hysterotomy. ● Consider gestational age. Although the gravid uterus reaches a size that will begin to compromise aortocaval blood flow at approximately 20 weeks of gestation, fetal viability begins at approximately 24 to 25 weeks. Portable ultrasonography, available in some emergency depart￾ments, may aid in determination of gestational age (in experienced hands) and positioning. However, the use of ultrasound should not delay the decision to perform emer￾gency hysterotomy.30 – Gestational age 20 weeks. Urgent cesarean delivery need not be considered because a gravid uterus of this size is unlikely to significantly compromise maternal cardiac output. – Gestational age approximately 20 to 23 weeks. Perform an emergency hysterotomy to enable successful resusci￾tation of the mother, not the survival of the delivered infant, which is unlikely at this gestational age. – Gestational age approximately
24 to 25 weeks. Per￾form an emergency hysterotomy to save the life of both the mother and the infant. ● Consider features of the cardiac arrest. The following features of the cardiac arrest can increase the infant’s chance for survival: – Short interval between the mother’s arrest and the infant’s delivery19 – No sustained prearrest hypoxia in the mother – Minimal or no signs of fetal distress before the mother’s cardiac arrest31 – Aggressive and effective resuscitative efforts for the mother – The hysterotomy is performed in a medical center with a neonatal intensive care unit ● Consider the professional setting. – Are appropriate equipment and supplies available? – Is emergency hysterotomy within the rescuer’s proce￾dural range of experience and skills? – Are skilled neonatal/pediatric support personnel avail￾able to care for the infant, especially if the infant is not full term? – Are obstetric personnel immediately available to support the mother after delivery? Advance Preparation Experts and organizations have emphasized the importance of advance preparation.4,18,26 Medical centers must review whether performance of an emergency hysterotomy is feasi￾ble at their center, and if so, they must identify the best means of rapidly accomplishing this procedure. The plans should be made in collaboration with the obstetric and pediatric services. Summary Successful resuscitation of a pregnant woman and survival of the fetus require prompt and excellent CPR with some modifications in basic and advanced cardiovascular life IV-152 Circulation December 13, 2005