Table 1.
Differential diagnosis of maternal cardiac arrest and suggested management. ECMO, extracorporeal membrane oxygenation; HELLP, haemolysis, elevated liver enzymes, low platelet count
| Diagnosis | Action item | ||
|---|---|---|---|
| Complications of anaesthesia | High neuraxial block | Treat hypotension aggressively (e.g. low dose adrenaline [epinephrine]) Support airway and breathing |
|
| Loss of airway, aspiration, respiratory depression | Support airway and breathing Difficult airway algorithm |
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| Hypotension | Treat with vasopressors Lower head of bed to improve cerebral perfusion Volume replacement Obtain more intravenous access |
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| Systemic toxicity from local anaesthetics | Give intralipid Consider cardiopulmonary bypass or ECMO |
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| Bleeding | Coagulopathy | Fibrinogen replacement Fresh frozen plasma Cryoprecipitate Platelets Consider tranexamic acid 1 g i.v. |
|
| Uterine atony | Give uterotonics Bakri balloon Compression suture Uterine artery embolisation Hysterectomy |
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| Placenta accreta | Consider uterine artery embolisation Consider hysterectomy |
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| Placental abruption | Delivery if indicated Monitor for coagulopathy |
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| Placenta praevia | Delivery if indicated Prepare for lower uterine segment atony |
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| Uterine rupture | Uterine repair or hysterectomy | ||
| Trauma | Call general surgeon Activate massive transfusion |
||
| Transfusion reaction | Stop transfusion Notify blood bank Adrenaline Steroids Send tryptase |
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| Cardiovascular | Cardiomyopathy | Inotrope infusion Call for ECMO |
|
| Myocardial infarction | Inotrope infusion Call for ECMO Call for cardiac surgeon Call cardiac catheterisation laboratory Send cardiac enzymes |
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| Aortic dissection | Call cardiac surgeon Activate massive transfusion |
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| Arrhythmias | Ventricular fibrillation Unstable ventricular tachycardia (VT) |
Defibrillate Amiodarone Lidocaine |
|
| Torsade de pointes | Defibrillate Magnesium |
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| Stable VT | Amiodarone Lidocaine |
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| Supraventricular tachycardia | Adenosine | ||
| Atrial fibrillation | Amiodarone Cardioversion |
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| Drugs | Anaphylaxis | Adrenaline Steroids Diphenhydramine Ranitidine |
|
| Illicit | Opioid overdose | Naloxone | |
| Benzodiazepine overdose | Flumazenil | ||
| Cocaine coronary vasospasm | Oxygen, aspirin, nitrates, thrombolytic therapy, or acute percutaneous coronary intervention | ||
| Drug error | Identify, discontinue agent and treat | ||
| Magnesium toxicity | Stop magnesium Give calcium chloride 10 ml in 10% solution or calcium gluconate 30 ml in 10% solution |
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| Insulin overdose | Give glucose/dextrose Glucagon |
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| Oxytocin overdose | Treat hypotension | ||
| Embolic | Pulmonary embolus | Call Interventional radiology Call cardiac surgeon Prepare catheterisation laboratory Echocardiography Start heparin i.v. Consider thrombolytics in cardiac arrest Nitric oxide |
|
| Coronary thrombus | Call cardiac surgeon Catheterisation laboratory Nitroglycerine Nitric oxide if right heart failure |
||
| Amniotic fluid embolism/Anaphylactoid syndrome of pregnancy | Adrenaline Initiate cardiopulmonary resuscitation Call for extracorporeal membrane oxygenator Call for transoesophageal echocardiography Prepare for coagulopathy and need for massive transfusion protocol Consider unproven ‘A-OK’ therapy: atropine, ondansetron, ketorolac Consider steroids Consider nitric oxide |
||
| Air | Flood field if uterine venous sinuses open Internalise uterus |
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| Fever | Infection, sepsis | Give broad spectrum antibiotics Fluids, volume replacement Vasopressors Place arterial line Perform echocardiogram Inotrope if low cardiac output |
|
| General non-obstetric causes of cardiac arrest | Hypotension | Treat with vasopressors Lower head of bed to improve cerebral perfusion Fluids, volume replacement Obtain more intravenous access Call for transthoracic echocardiography |
|
| Hypoxia | Airway control 100% oxygen |
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| Hypothermia | Warm patient Warm fluids Blankets Increase room temperature |
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| Hyperkalaemia | Calcium Insulin and glucose Furosemide Albuterol Sodium bicarbonate to correct acidosis Intubate and hyperventilate Polystyrene sulphonate (potassium binder) Consider haemodialysis |
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| Hypoglycaemia | Give glucose/dextrose Glucagon |
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| Hypercarbia/acidosis | Intubate trachea and optimise ventilation Determine cause of acidosis Sodium bicarbonate |
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| Thrombus | See pulmonary embolus above | ||
| Trauma | Call general or trauma surgeon | ||
| Toxin | Give antidote if agent known | ||
| Tension pneumothorax | Needle decompression Insert chest tube |
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| Tamponade | Call for ECMO Call cardiac surgeon |
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| Hypertension | Pre-eclampsia/eclampsia/HELLP | Antihypertensive agents: labetalol (avoid in asthmatics), hydralazine, nicardipine Magnesium |
|
| Intracranial haemorrhage with increased intracranial pressure | Call neurosurgeon BP goal: systolic <140 mmHg Elevate head of bed 30° Reverse coagulopathy if present Hypertonic saline/mannitol |
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