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

mcain@health.usf.edu

• No disclosures to report

Objectives

• Describe the incidence, etiologies, and racial

disparities in maternal mortality

• Understand basic resuscitation and the algorithm

modifications for a pregnant woman

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

Say lancet 2016

Maternal Mortality Worldwide-2015

Slide courtesy of Judette Louis

U.S.

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

© 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.

Timing of maternal mortality

Slide courtesy of Judette Louis

• 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

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

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

Most important thing in a Code

•COMMUNICATION!!

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.”

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)

Code Treatment

• Circulation

• Airway

• Breathing

• Defibrillate

• Extract Fetus

BLS in hospital steps

AHA Circulation 2015

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

AHA Circulation 2015

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

m

AHA Circulation 2015

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

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”

v

AHA Circulation 2015

Potential causes

AHA Circulation 2015

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)

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%

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

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.

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

Important Medications

• Labetalol

• Afib

• A Flutter

• SVT

• Hypertensive crisis.

• Amiodarone

• Vfib

• Pulseless VTACH unresponsive to shock, CPR and vasopressor

Pulseless Electrical Activity

Tachyarrhythmia with a pulse

Bradyarrhthymia

Acute Coronary Syndrome

• Questions??