Cardiac arrest during pregnancy is a rare but critical event that requires immediate, specialized care. Pregnant patients have unique physiological changes and considerations that must be addressed during advanced cardiac life support (ACLS). The ACLS In-Hospital Cardiac Arrest in Pregnancy Algorithm provides healthcare providers with clear guidance to follow a structured approach for effectively and safely resuscitating pregnant women.

In this guide, you will learn about the key steps of the ACLS algorithm specifically for cardiac arrest in pregnancy, the modifications compared to non-pregnant adults, and important clinical points to improve survival for both mother and baby.

Note: ACLS In-Hospital Cardiac Arrest in Pregnancy Algorithm follows the guidelines of 2020-2025 (AHA)

Why is Cardiac Arrest in Pregnancy Different ?

Pregnancy changes the body in many ways that affect resuscitation:

  • The growing uterus compresses large blood vessels when the woman lies flat on her back. This reduces blood flow to the heart and brain.
  • Oxygen demand is higher in pregnancy.
  • There is increased blood volume but also risk of bleeding.
  • The presence of the fetus adds complexity and urgency.

Because of these factors, traditional ACLS needs adjustment to ensure the best chance of saving both lives.

  1. Early Recognition and Immediate Action: Rapid identification of cardiac arrest and swift initiation of resuscitation efforts are critical.

  2. Manual Left Uterine Displacement (LUD): To relieve pressure on the large veins (inferior vena cava and aorta) by the uterus, rescuers must push the uterus to the left side manually. This helps improve blood return to the heart.

  3. Standard ACLS Interventions: High-quality chest compressions, airway management, defibrillation, and medication administration follow standard ACLS protocols with special adjustments.

  4. Consider Emergency Cesarean Delivery (Perimortem Cesarean Section): If spontaneous circulation does not return within 4 minutes, and the uterus is large enough to affect circulation (generally after 20 weeks), an emergency cesarean delivery should be started by 5 minutes to improve chances for mother and fetus.
ACLS In-Hospital Cardiac Arrest in Pregnancy Algorithm

01.

Continue BLS/ACLS

ACLS starts with high-quality CPR to keep blood circulating to the heart and brain. If necessary, an external defibrillator (AED) is used to deliver a shock for dangerous heart rhythms such as ventricular fibrillation (V-fib) and pulseless ventricular tachycardia (pulseless V-tach). Medications like epinephrine are administered to help restart the heart and improve blood flow. Additional advanced steps, such as securing the airway and monitoring heart rhythms, are also part of ACLS care.

02.

Assemble the Maternal Cardiac Arrest Team

Promptly assemble a maternal cardiac arrest team that includes obstetrics (a field focused on childbirth, pregnancy, and the postpartum period), an anesthesiologist (a physician specializing in pain management and anesthesia), neonatal specialists, and critical care experts to deliver coordinated, specialized care during resuscitation.

03.

Consider the Etiology of the Arrest

Identify and address the potential causes of the cardiac arrest, such as bleeding, blood clots, heart problems, or other pregnancy-related complications.

04.

Perform Maternal Interventions

During maternal cardiac arrest, perform necessary interventions like airway management and securing an IV (intravenous) line above the diaphragm. Provide 100% oxygen while avoiding excessive ventilation. If the patient is receiving IV magnesium, stop the infusion and immediately give calcium chloride or calcium gluconate to counter its effects.

05.

Perform Obstetric Interventions

During maternal cardiac arrest, carry out obstetric interventions by maintaining continuous lateral uterine displacement to relieve pressure on major blood vessels. Remove or detach fetal monitors to concentrate on maternal resuscitation. If return of circulation is not achieved within 4 minutes, prepare for a perimortem cesarean delivery to enhance outcomes for both mother and fetus.

06.

Continue BLS/ACLS

Continue BLS/ACLS by delivering high-quality CPR to sustain circulation. Use defibrillation when indicated to restore a normal heart rhythm. Administer additional ACLS interventions, such as epinephrine, to enhance blood flow and support the heart.

07.

Perform Perimortem Cesarean Delivery

If spontaneous return of circulation (ROSC) is not achieved within 5 minutes, consider proceeding with an immediate perimortem cesarean delivery. This may improve survival chances for both the mother and the baby.

08.

The Neonatal Team to Receive the Neonate

Ensure the neonatal team (a group of healthcare professionals specialized in caring for newborns, especially premature infants) is prepared to receive the newborn immediately after delivery to provide resuscitation and stabilization as needed.

Timing of Cesarean Delivery

The “4-minute rule” is crucial. If resuscitation efforts fail to restore circulation within 4 minutes, start the cesarean immediately. This timing is based on the fact that the brain can only tolerate 4-6 minutes without oxygen before permanent damage.

Team Coordination

  • Procainamide IV dose: 20-50 mg/min until arrhythmia is suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg given. Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHF. 
  • Amiodarone IV dose: First dose: 150 mg over 10 minutes. Repeat as needed if VT recurs. Followed by maintenance infusion of 1 mg/min for the first 6 hours.
  • Sotalol IV dose: 100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.

Use of Ultrasound

If available, bedside ultrasound may help identify reversible causes such as cardiac tamponade or massive pulmonary embolism, but it should not delay CPR.

Airway Management

Pregnant women have increased risk of difficult airway due to swelling. Skilled providers should manage intubation to minimize interruptions.

Challenge

Solution

Uterine compression reducing blood return

Perform manual left uterine displacement (push uterus leftward manually during CPR).

Difficulty in airway management

Use skilled airway providers and consider early intubation to secure airway and oxygenation.

Delay in cesarean delivery

Prepare surgical instruments and team early if pregnancy >20 weeks and arrest occurs.

Identifying reversible causes

Rapid bedside assessment, point-of-care ultrasound, and blood tests when possible.

  • Begin high-quality CPR immediately.

  • Perform manual left uterine displacement to improve blood flow.

  • Follow standard ACLS medication and defibrillation protocols.

  • Identify and treat reversible causes promptly.

  • If no ROSC after 4 minutes, prepare and perform emergency cesarean delivery by 5 minutes.

  • Effective teamwork and communication are essential.

  • Time is critical to save both mother and child.

Cardiac arrest in pregnancy demands rapid, precise, and well-coordinated care. The ACLS In-Hospital Cardiac Arrest in Pregnancy Algorithm provides a clear pathway to save lives by adapting standard resuscitation principles to the unique needs of pregnancy. By following this protocol, healthcare providers can maximize survival chances for both mother and baby.

Understanding the importance of manual left uterine displacement, timely defibrillation, effective airway management, medication administration, and the critical timing of emergency cesarean delivery is essential for anyone involved in maternal care.

What is Manual Left Uterine Displacement?

It is the manual pushing of the pregnant uterus to the left side during CPR to relieve pressure on major blood vessels, allowing better blood flow to the heart.

Delivering the baby reduces the pressure the uterus places on blood vessels, improving maternal blood circulation and oxygen delivery. It also gives the fetus a chance to survive.

If spontaneous circulation is not restored within 4 minutes of cardiac arrest and the pregnancy is far enough along (uterus at or above umbilicus), start the cesarean immediately to deliver by 5 minutes.

No. The medication dosages for ACLS drugs like epinephrine remain the same for pregnant and non-pregnant patients.

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