2020 AHA Updates on Maternal Resuscitation from Cardiac Arrest

Sudden Cardiac Arrest in pregnant women is a dangerous and complex condition owing to the presence of two patients (mother and fetus) as well as the need for immediate treatment. The newly released 2020 AHA CPR & EGG guidelines provide a framework to optimize resuscitation for in-hospital maternal cardiac arrest victims. The guidelines, created by leading physicians and scientists, leverage existing research to generate an algorithm for maternal resuscitation that highlights the importance of concurrent intervention. Broadly speaking, concurrent intervention means that advanced life support professionals responding to maternal cardiac arrest must simultaneously perform maternal and obstetric treatments as seen in the algorithm below. For example, chest compressions (a maternal intervention) will not be effective without left lateral uterine displacement (an obstetric intervention) because the pressure of the uterus limits the ability of compressions to circulate blood. Similarly, while healthcare providers are performing chest compressions, defibrillation, and other essential resuscitative interventions, appropriate personnel should also be preparing for and, if indicated, ultimately performing perimortem cesarean delivery. As maternal-fetal medicine specialist Dr. Carolyn Zelop describes, “The multidisciplinary team responding to maternal cardiac arrest executes concurrent interventions that accommodate the unique physiologic changes of pregnancy.” 

The 2020 AHA Algorithm for Responding to Maternal Cardiac Arrest

Highlights of the 2020 AHA CPR & ECC Guidelines

Alongside the emphasis on simultaneous treatment, the 2020 AHA CPR & ECC Guidelines indicate that the following interventions are important in managing maternal cardiac arrest. All the following should be performed by highly collaborative obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services. 

1. Oxygenation & Ventilation — During pregnancy, the fetus requires significant amounts of oxygen, causing mothers to have an 20% increase in oxygen consumption. Altered levels of hormones like progesterone and estrogen during pregnancy can also restrict air passages and exacerbate the dangers associated with maternal cardiac arrest. Under the new guidelines, the responding healthcare team is urged to place the most experienced provider in charge of advanced airway management. A difficult airway is common in pregnancy and therefore endotracheal intubation or supraglottic advanced airway are advised. After an advanced airway is successfully in place, 1 breath every 6 seconds is recommended alongside continuous chest compressions.  

2. Left Lateral Uterine Displacement — As described above, left lateral uterine displacement removes aortocaval compression which then improves the success of other resuscitative treatments. Aortocaval compression is clinically significant when the uterine size is greater than or equal to 20 weeks or when the uterus is at the umbilicus or higher. 

3. Stabilization of the Mother — Simply put, what is best for mom is also best for the baby. Evidence indicates that responding healthcare providers should seek to stabilize mothers in cardiac arrest to achieve better outcomes for both the mother and baby. As such, the 2020 CPR Guidelines recommend removing fetal monitors which distract from maternal resuscitation (and also pose a hypothetical risk of electric arching during defibrillation). 

4. Targeted Temperature Management — The 2020 Guidelines also recommend targeted temperature management for pregnant women recovering from cardiac arrest. At the same time, the fetal heart rhythm should be monitored continuously for bradycardia and other complications.