MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Maternal Code and Maternal Mortality

Kelly S Gibson, MD, FACOGAssistant Professor Dept. of Reproductive Biology

Metrohealth Medical Center at Case Western Reserve Universitykgibson@metrohealth.org

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

• No disclosures to report

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Objectives

• Describe the incidence, etiologies, and racial disparities in maternal mortality

• Understand basic resuscitation and the algorithm modifications for a pregnant woman

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Maternal Mortality RatioDeaths/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

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

WHO Maternal Mortality Data

Maternal Mortality Worldwide

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Slide courtesy of Judette Louis

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

United States

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MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Global causes of Mortality

Say Lancet 2014

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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

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Mortality rate by age

Slide courtesy of Judette Louis

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Slide courtesy of Judette Louis

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

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 Invervention—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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AHA Circulation 2015

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MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

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 concensus 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)

- Get code cart and backboard

• Prepare for cesarean delivery• Begin ACLS (AED)

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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

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

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

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

m

AHA Circulation 2015

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

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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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 Code Pink• 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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MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Tachyarrhythmia with a pulse

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MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Bradyarrhthymia

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MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Acute Coronary Syndrome

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• Questions??