maternal code and maternal mortality - camls · 2018-02-13 · maternal code and maternal mortality...
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![Page 1: Maternal Code and Maternal Mortality - CAMLS · 2018-02-13 · Maternal Code and Maternal Mortality Mary Ashley Cain, MD, FACOG Assistant Professor Dept. of Obstetrics and Gynecology](https://reader030.vdocument.in/reader030/viewer/2022040122/5f0ffbe37e708231d446dce0/html5/thumbnails/1.jpg)
Maternal Code and
Maternal Mortality
Mary Ashley Cain, MD, FACOG
Assistant Professor Dept. of Obstetrics and Gynecology
Division of Maternal Fetal Medicine
University of South Florida Morsani College of Medicine
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• No disclosures to report
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Objectives
• Describe the incidence, etiologies, and racial
disparities in maternal mortality
• Understand basic resuscitation and the algorithm
modifications for a pregnant woman
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Maternal Mortality Ratio
Deaths/100,000 live births during pregnancy or within 1 year of
termination. A ratio not a rate: cannot count total # pregnancies
Pregnancy RelatedOB complications,
management, or
disease exacerbated
by pregnancy
Pregnancy AssociatedNot related to pregnancy
DirectOB diseases or
management
IndirectPreexisting disease
aggravated by pregnancy
Slide courtesy of Judette Louis
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Say lancet 2016
Maternal Mortality Worldwide-2015
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Slide courtesy of Judette Louis
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U.S.
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US Historical Perspective: Racial Disparities
Year MMR White MMR Black Risk Ratio
1915 601.0 1056.0 1.76
1930 601.0 1174.0 1.95
1945 172.0 445.0 2.59
1950 61.0 222.0 3.64
1990 6.5 26.7 4.11
1991-1999 8.1 30.0 3.70
Sources: MMWR 2003; JAMWA 57(3), 2002, slide courtesy of Judette Loius
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© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. Published by Lippincott Williams & Wilkins, Inc.
2
Population-level pregnancy-related mortality ratios by age, race-ethnicity, and overall for 2011-2013. Results are population-level and can be
compared as absolute values.
Pregnancy-Related Mortality in the United States, 2011-2013.Creanga, Andreea; MD, PhD; Syverson, Carla; CNM, MN; Seed, Kristi; Callaghan, William; MD, MPH
Obstetrics & Gynecology. 130(2):366-373, August 2017.DOI: 10.1097/AOG.0000000000002114
Population-level pregnancy-related mortality ratios by age, race-ethnicity, and overall for 2011-2013. Results are population-level and can be compared as absolute values. Figure 1. Creanga. Pregnancy-Related Mortality in the United States. Obstet Gynecol 2017.
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Timing of maternal mortality
Slide courtesy of Judette Louis
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• Regardless of the etiology or maternal age or race or BMI, all of these patients will have a cardiac event prior to mortality
• BLS/ACLS should be initiated
• Primary etiology should continue to be treated
• Must decide what to do about the fetus
• Ideally, could predict/prevent events by early aggressive therapy and risk assessment score
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Early Intervention—Rapid Response
Teams
• Instituted by many hospitals to treat critical patient and prevent a Code
• 80% of codes have abnormal vitals without 8h of event
• Call for:
• threatened airway
• RR < 6 or > 30, HR < 40 or >140, SBP <80/40
• sudden decrease in level of consciousness/agitation
• significant fall in urine output
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Initializing BLS/ACLS
• No RCTs for resuscitation in pregnancy
• Evidence based on non-pregnant codes and expert opinion
• Most teams lack experience
• Cardiac arrest occurs in ~1/12,000 OB admissions
• Standard AHA courses do not include pregnant women
• FIRST consensus statement in Circulation in 2015
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Most important thing in a Code
•COMMUNICATION!!
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Code Communication
• Team leader must delegate tasks
• Each team member needs to be clear about their role
and capable to fulfill their role, if not seek assistance
• Communication needs to be closed-loop
• “Nurse Smith give 1 mg of epinephrine IV now”
• Nurse Smith confirms the order , “ Epinephrine 1 mg IV
ordered,” and responds to the team leader when the task is
completed, “Epinephrine 1 mg IV is in.”
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Code Actions
• Call Code Blue (get help!)
• Include pediatric team if potentially viable fetus
• Assign time keeper
• Begin BLS (CAB-DE)
• Get code cart and backboard
• Prepare for cesarean delivery (E-extract fetus)
• Begin ACLS (D-Defibrillate)
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Code Treatment
• Circulation
• Airway
• Breathing
• Defibrillate
• Extract Fetus
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BLS in hospital steps
AHA Circulation 2015
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Circulation• 100 compression/min at depth of 5cm
• Middle of chest over lower half of sternum
• Interruptions <10sec
• Supine with LUD (left uterine displacement)
AHA Circulation 2015
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AHA Circulation 2015
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Airway and Breathing
• Chin lift/Jaw thrust to open airway
• Do bag-mask ventilation with 100% O2 at 10-15L/min
• Can attempt to intubate (if trained)
• Do not interrupt compressions
• May need smaller ET tube given airway edema
• 30 compressions : 2 breathes
• Breathe q 6 sec over 1 sec with artificial airway
AHA Circulation 2015
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m
AHA Circulation 2015
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Defibrillate
• Place AED pads
• Let AED analyze, defibrillate if needed
• Immediately resume CPR between shocks
• Same settings as the non-pregnant patient
• Start at 120-200 J and increase
• Safe for the fetus
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Extract Fetus• Can save fetus and improve maternal status
• Remove IVC compression, decrease O2 demand
• Perform for any uterus above the umbilicus (~20w)
• Ideally deliver within 5min of arrest
• Metabolic acidosis begins, causes injury within 4-6min
• Do CS in the location of the arrest
• No skin prep (or “splash)
• Continue LUD
• Only need a scalpel
• Can create “emergent PMCS kit”
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v
AHA Circulation 2015
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Potential causes
AHA Circulation 2015
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Neonatal survival improves with
• Short interval to delivery
• No sustained pre-arrest hypoxia in the mother
• Minimal or no signs of fetal distress before arrest
• Aggressive maternal resuscitation
• Presence of NICU
• In hospital arrest (up to 63% survival)
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After Resuscitation
• To the ICU
• Multidiciplinary care
• Continue to treat etiology for code
• Most deaths following arrest happen within 24h
• DIC, multiorgan system failure
• Arrhythmias
• Consider whole body cooling
• Survival as high as 54%
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Practice, practice, practice
• Simulation recommended by The Joint Commission
and the Enquiry into Maternal and Child Health
• Simulation
• Trains staff in protocols
• Identify and fix systems issues
• Has been shown to improve rates of perimortem CS
and team communication and efficiency
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Important Medications
• Epinephrine
• 1 mg 1:10,000 solution IV Q 3-5 min
• Support circulation for all events with no pulse
• Vasopressin:
• Vasopressor that may be used as alternative to epinephrine.
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Important Medications
• Adenosine:
• Supraventricular tachycardia (SVT Pulse 150-250 bpm)
• Lidocaine:
• VFib/VTach
• Magnesium sulfate:
• Torsades de Pointes
• Atropine
• 1 mg IV q 3-5 min up to 3 doses max
• Slow pulseless electrical activity with narrow QRS
• Type 1 and Mobitz II Type 1 blocks
• Asystole
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Important Medications
• Labetalol
• Afib
• A Flutter
• SVT
• Hypertensive crisis.
• Amiodarone
• Vfib
• Pulseless VTACH unresponsive to shock, CPR and vasopressor
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Pulseless Electrical Activity
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Tachyarrhythmia with a pulse
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Bradyarrhthymia
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Acute Coronary Syndrome
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• Questions??