Resuscitation 82 (2011) 801–809

Contents lists available at ScienceDirect

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Review article

Management of cardiac arrest in pregnancy: A systematic review夽

Farida M. Jeejeebhoy a , Carolyn M. Zelop b , Rory Windrim c , Jose C.A. Carvalho d ,
Paul Dorian e , Laurie J. Morrison f,∗
a
Department of Medicine, University of Toronto, Division of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada
b
Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
c
Mount Sinai Hospital, Division of Maternal Fetal Medicine, University of Toronto, Toronto, ON, Canada
d
University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada
e
Division of Cardiology, St. Michael’s Hospital, Toronto, ON, Canada
f
Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Department of Medicine, Division of Emergency Medicine, University of Toronto, 193 Yonge St., 5th
Floor, Toronto, ON M5B 1M8, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To describe the consensus on science pertaining to resuscitation of the pregnant patient.
Received 28 June 2010 Design: Systematic review.
Received in revised form 17 January 2011 Data sources: EMBASE, Ovid MEDLINE, Evidence Based Reviews, American Heart Association library and
Accepted 26 January 2011
bibliographies of selected articles.
Review methods: The following inclusion criteria were used: pregnancy and cardiac arrest out of hospital,
pregnancy and cardiac arrest in hospital, cardiovascular, respiratory, fetal survival, and pharmacology
Keywords:
as they relate to cardiac arrest and resuscitation. Non-English papers, case reports and reviews were
Cardiac arrest
Maternal resuscitation
excluded. Studies were selected through an independent review of titles, abstracts and full article. Two
Systematic review reviewers independently graded the methodological quality of selected articles.
Results: 1305 articles were identified and 5 were selected for further review. There were no randomized
trials and overall the quality of the selected studies was good. Two studies examined chest compressions
on a manikin in left lateral tilt from the horizontal and concluded that although feasible with increasing
degrees of tilt forcefulness of the chest compressions decreases. The third study observed the transtho-
racic impedance was not altered during pregnancy. One case series and one retrospective cohort study
reviewed perimortem cesarean section. Both reports concluded that perimortem cesarean section is
rarely done within the recommended time frame of 5 min after the onset of maternal cardiac arrest.
Conclusions: Usual defibrillation dosages are likely appropriate in pregnancy. Perimortem cesarean sec-
tion is an intervention which is rarely done within 5 min to optimize maternal salvage from cardiac arrest.
Chest compressions in left lateral tilt are less forceful compared to the supine position.
© 2011 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
2.1. Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
2.2. Study selection and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
3.1. Consensus on science by category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
3.1.1. Perimortem cesarean section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
3.1.2. Resuscitation technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804

Abbreviations: PMCS, perimortem cesarean section; MOET, Managing Obstetric Emergencies and Trauma; AHA, American Heart Association; ACLS, advance cardiovascular
life support; ROSC, return of spontaneous circulation; ILCOR, The International Liaison Committee on Resuscitation.
夽 A Spanish translated version of the abstract of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2011.01.028.
∗ Corresponding author.
E-mail addresses: farida.j@sympatico.ca (F.M. Jeejeebhoy), czelop@bidmc.harvard.edu (C.M. Zelop), rwindrim@mtsinai.on.ca (R. Windrim),
jose.carvalho@uhn.on.ca (J.C.A. Carvalho), dorianp@smh.toronto.on.ca (P. Dorian), morrisonl@smh.ca, singhs@smh.toronto.on.ca (L.J. Morrison).

0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2011.01.028
802 F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809

4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Conflict of interest statement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808

1. Introduction to cardiac arrest and resuscitation. Review articles, case reports

and articles not available in English were excluded. Articles which
Cardiac disease in the United Kingdom is the most common were purely obstetrical in nature with no link to resuscitation were
cause of maternal deaths overall based on the 2003–2005 Confi- excluded. Two authors (FJ, CZ) completed the literature search and
dential Enquiries into Maternal and Child Health1 data set which selected by consensus the studies based on inclusion criteria as
constitutes the largest population based data set on this target pop- judged by title, abstract and complete manuscript. Two authors
ulation. The number of cardiac deaths during pregnancy has been (FJ, RW) independently evaluated the methodological quality of
increasing since 1991.1 Likely contributors to this increase include the selected articles using the quality list described by Hayden8
a rise in the number of women with risk factors for ischemic heart as adapted by Moulaert et al.9 This particular scoring method was
disease1 and an increase in the number of babies born with con- chosen to allow a standardized comparison of quality across the
genital heart disease that survive to adulthood.2 heterogeneity of study designs employed in the selected studies.
The incidence of cardiac arrest in pregnancy is reported to be Based on this quality assessment tool, each article was evaluated for
1:20,000,1 which is an increase from the 1:30,000 reported in the their risk of bias in 5 domains: study participation, study attrition,
previous enquiry.3 Although these numbers are small, they are outcome measurement, confounding measurement and statistical
higher than the incidence of sudden cardiac death in young athletes, analysis. For each article, each domain was rated for the risk of bias
estimated to be 1:200,000.4 Death of an athlete and death during with low receiving 2 points, medium receiving 1 point and high
pregnancy are similar in that they both involve young people, how- receiving 0 points. This would give a potential score for each study
ever, death during pregnancy involves two lives and attention to between 0 (indicating poor quality) to 10 (indicating excellent qual-
this topic has been lacking. ity) (Appendix A).
Our objective was to systematically review the literature that The weighted kappa score was used to assess the degree of con-
may contribute to defining the modifications to advance care life cordance between the two reviewers of methodological quality.10
support resuscitation for the pregnant woman based on a con- The weighted kappa score measures the strength of agreement
sensus of science. To our knowledge the evidence behind the between the two reviewers. Scores up to 0.2 reflect poor agreement
appropriate management of cardiac arrest associated in pregnancy while values over 0.8 demonstrate substantial agreement.
has not been previously systematically reviewed.7
3. Results
2. Methods
The search strategy initially identified 1305 citations. Assess-
2.1. Sources ment of the articles for the stated inclusion and exclusion
criteria based on title, abstract or full text resulted in 5 articles
The literature search was performed using EMBASE (1980–2010 being selected for final review (see Fig. 1). The search strategy
week 10), Ovid MEDLINE (1950–March week 1 2010), all evidence included pregnancy related topics and although the search strat-
based medicine (EMB) reviews (which include: ACP Journal Club egy attempted to narrow the field to resuscitation related articles
<1991–March 2010>, Cochrane Central Register of Controlled Tri- only, many citations retrieved had no relevance to resuscitation
als <1st Quarter 2010>, Cochrane Database of Systematic Reviews science or practice. For example, many articles dealt with purely
<1st Quarter 2010>, Cochrane Methodology Register <1st Quarter obstetrical and obstetrical anesthesia related topics.
2010>, Database of Abstracts of Reviews of Effects <1st Quarter There was substantial agreement between the reviewer’s qual-
2010>, Health Technology Assessment <1st Quarter 2010>, NHS ity scores, with a weighted kappa score of 0.82. The quality
Economic Evaluation Database <1st Quarter 2010>) and the Amer- assessment score and a summary for each of the selected articles
ican Heart Association Emergency Cardiac Care Endnote Master are presented in Table 2.
library. In addition, we hand searched the bibliographies of all
selected articles. The details of the search strategies are presented 3.1. Consensus on science by category
in Table 1 .
3.1.1. Perimortem cesarean section
2.2. Study selection and evaluation There was one case series on perimortem cesarean section
and one study evaluating the rate of perimortem cesarean sec-
After the initial search, no randomized trials evaluating the tion before and after an education intervention aimed at improving
effect of specialized interventions for cardiac arrest associated with the use of this procedure.11,12 In the case series of 38 cases in this
pregnancy versus standard care were identified. Therefore, we category,11 the perimortem cesarean section was performed within
chose to expand the search to include studies addressing impor- the recommended 4–5 min time frame after the onset of maternal
tant aspects of maternal physiology which would have a potential cardiac arrest in only 8 of 38 cases. Seventeen infants were born
impact on the resuscitation of cardiac arrest in pregnancy in an without sequelae, and 4 of these infants who were 30–38 weeks
attempt to capture any studies related to resuscitation during preg- gestational age were born >15 min after the onset of maternal
nancy. The inclusion criteria were pregnancy and cardiac arrest cardiac arrest. Of the 22 cases which provided enough informa-
out of hospital, pregnancy and cardiac arrest in hospital, cardiovas- tion regarding the effects of the cesarean delivery on maternal
cular, respiratory, fetal survival, and pharmacology as they relate hemodynamic status, twelve women had sudden and often dra-
 F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809 803

Table 1
Search strategy.

Topic Keywords Database

Out of hospital arrest Pregnancy, pregnant woman EMBASE 1980–2010 week 10

In hospital arrest
Pregnancy and cardiovascular physiology
Pregnancy and respiratory physiology
Heart arrest
Out-of-hospital, pre-hospital
Pregnancy/or pregnancy complications, cardiovascular Ovid MEDLINE(R) 1996–2010 March week 1
Pregnant women
Heart arrest
Emergencies, emergency medical services
Emergency treatment
Out-of-hospital, pre-hospital
Pregnant All EBM Reviews – Cochrane DSR, ACP Journal Club, DARE,
CCTR, CMR, HTA, and NHSEED
Cardiac arrest, heart arrest
Out-of-hospital, pre-hospital
Pregnancy, pregnant woman EMBASE 1980–2010 week 10
Heart arrest
In-hospital, hospital
Pregnancy, pregnant women Ovid MEDLINE(R) 1996 2010 March week 1
Pregnancy complications
Radiotherapy, diet therapy, drug therapy, prevention and
control, surgery, mortality, rehabilitation, therapy
Outcome assessment (health care)
Cardiovascular
Heart arrest
Survival
Return of spontaneous circulation
In-hospital, hospitals
Pregnant All EBM Reviews – Cochrane DSR, ACP Journal Club, DARE,
CCTR, CMR, HTA, and NHSEED
Cardiac arrest
Heart arrest
In-hospital
Pregnancy, pregnant woman EMBASE 1980–2010 week 10
Heart output
Heart arrest
Cardiovascular system
Hemodynamics
Pregnancy, pregnant women Ovid MEDLINE(R) 1996–2010 March week 1
Blood pressure
Cardiovascular system
Heart arrest
Hemodynamics, hemodynamic change
Maternal cardiac output
Posture/or left lateral position
Pregnancy complications, cardiovascular
Pregnancy All EBM Reviews – Cochrane DSR, ACP Journal Club, DARE,
CCTR, CMR, HTA, and NHSEED
Cardiovascular
Cardiac output
Hemodynamic
Left lateral position
Posture
Cardiac arrest, heart arrest
Pregnancy, pregnant woman EMBASE 1980–2010 week 10
Heart arrest
Airway
Respiratory system
Respiratory function
Breathing mechanics
Airway Ovid MEDLINE(R) 1996–2010 March week 1
Respiratory system/or respiratory physiologic
phenomena/or respiratory physiology/or respiratory
mechanics
Pregnancy, pregnant women
Pregnancy complications
Lung physiopathology
Respiratory function tests
Respiration disorders/or respiration
Respiratory function tests
Pregnancy All EBM Reviews – Cochrane DSR, ACP Journal Club, DARE,
CCTR, CMR, HTA, and NHSEED
Airway
Pulmonary function
Pulmonary physiology
804 F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809
Table 1 (Continued)
Topic Keywords
Fetal survival Pregnancy
Pregnant woman
Fetus outcome/or exp pregnancy outcome
Fetal survival, fetus
Heart arrest
Heart arrest
Pregnancy/or exp pregnancy complications, cardiovascular
Pregnancy outcome
Fetal outcome, fetal survival, fetus
Maternal cardiac arrest
Pregnancy
Heart arrest
Fetal outcome, fetal survival, fetus, infant
Pharmcokinetics in pregnancy Pharmacokinetics
Pregnancy
Resuscitation
Resuscitation drugs
Drug/pk [pharmacokinetics]
Pregnancy
Resuscitation
Resuscitation drug
Pharmacokinetic changes pharmacokinetics
Pregnancy
Pharmacokinetic
Resuscitation
Drug
All topics Pregnancy
matic improvement in their clinical status immediately after the
uterus was emptied including a return of the pulse and blood pres-
sure. The second study, a recent retrospective cohort study done
in the Netherlands, reviewed all cases of perimortem cesarean sec-
tion (PMCS) from 1993 to 2008.12 They examined the incidence of
PMCS before and after emergency skills training with the Manag-
ing Obstetric Emergencies and Trauma (MOET) course. This study
found that out of 55 cases of resuscitation, 12 PMCS were per-
formed. However, the number of PMCS increased significantly after
the MOET course training. There were 4 PMCS performed (all PMCS
were performed after the year 2000) over an 11 year period before
the MOET course (0.36/year), versus 8 PMCS which were performed
the 5 years after the MOET course (1.6/year) (p = 0.01). The number
of women that gained cardiac output after PMCS was 67% (8/12).
However, the maternal case fatality rate was lower in the group
without PMCS at 67% versus 83% in the PMCS group. It should
be noted there were factors that would likely affect outcome for
all of the twelve women in the PMCS group, i.e., (1) no cases of
PMCS were performed within the recommended 5 min after the
onset of maternal cardiac arrest, (2) four women were transported
to the operating theatre, and (3) time-consuming activities were
performed to assess fetal viability in six women. Also, the lack
of maternal or neonatal survivors of the 4 cases of out-of hospi-
tal arrest who had a PMCS was likely attributed to the delay from
onset of cardiac arrest and the delivery. Maternal survival overall
was only 15% (8/55). Only 2 of the 12 women (17%) that had PMCS
survived. The maternal survivors that had a PMCS were delivered
within 15 min after the onset of maternal cardiac arrest. Of the two
women that survived post PMCS, one showed neurological dam-
age in the radial region of the right hand 8 years after resuscitation.
The second women showed signs of vascular dementia at the 2
month follow-up. There were 6/43 maternal survivors (14%) in the
group that did not have a PMCS. Neonatal survival was only 5 of
12 patients with PMCS and the surviving neonates were delivered
within 30 min after the onset of maternal cardiac arrest. Of these 5
neonatal survivors, 1 neonate had impaired neurological function
at 3 months of age, and one had age appropriate development at
Database
EMBASE 1980–2010 week 10
Ovid MEDLINE(R) 1996–2010 March week 1
All EBM Reviews – Cochrane DSR, ACP Journal Club, DARE,
CCTR, CMR, HTA, and NHSEED
EMBASE 1980–2010 week 10
Ovid MEDLINE(R) 1996–2010 March week 1
All EBM Reviews – Cochrane DSR, ACP Journal Club, DARE,
CCTR, CMR, HTA, and NHSEED
ECC endnote library
2.5 years of age. One was lost to follow-up. The other two neonates
seemed healthy at the time of discharge. There is no follow-up clin-
ical information given in this study about survivors (maternal or
fetal) in those who did not have a PMCS.
3.1.2. Resuscitation technique
There were 3 trials in this category.13–15
One study demonstrated that the transthoracic impedance was
not altered significantly during pregnancy.13 Therefore, the rec-
ommendations regarding energy settings for defibrillation seem
reasonable to apply when delivering defibrillation shocks during
pregnancy.
There were 2 small studies that examined if effective chest
compressions can be performed in a left lateral tilt from the
horizontal.14,15 The first study by Goodwin et al. instructed the
rescuers to kneel on the floor, and sit on their heels. The manikin
is then positioned so that the back is positioned on the thighs of
the human wedge/rescuer.14 This study found that when using the
human wedge technique to provide a left lateral tilt from the hori-
zontal, the rescuer could also provide effective chest compressions
on a manikin (non-physiologic study).14 However, the degree of tilt
was not measured in this study. The second study by Rees and Willis
assessed the efficacy of chest compressions with the manikin at var-
ious angles of inclination of left lateral tilt from the horizontal.15
They set up the study by fitting a calibrated force transducer onto a
plane that was able to be at inclinations from 0◦ (supine) to 90◦ (full
left lateral tilt from the horizontal). The maximum possible resusci-
tative force of the 8 physicians studied was expressed as a function
of the angle of inclination. The measured resuscitative force for each
angle of inclination was expressed as a percentage of the rescuers
body weight. This study found that the maximum possible resus-
citative force in terms of percent body weight decreased as the
angle of inclination of the plane increased.15 In the supine position
the maximal resuscitative force was 67% of the body weight com-
pared to 36% in the 90◦ left lateral tilt from the horizontal. At angles
of >30◦ left lateral tilt from the horizontal the surrogate patient
(manikin/human volunteer) tended to slide or roll off the incline
Table 2
Summary of selected studies based on category of interest.

Category of question Author, year of Population Exposure/intervention Assessment/ Design Outcome Quality
publication In: inclusion criteria measurement instrument score
Ex: exclusion criteria
N: number of participants
GA: gestational age

Perimortem cesarean Katz, 200511 In: Ovid MEDLINE search on
section (PMCS) perimortem cesarean section
Time frame: 1985–2004
N: 38 case reports
Dijkman, All cases of PMCS in the
201012 Netherlands
• Search words: perimortem or Case series • 28/38 infants lived, GA Mean = 5
postmortem or cardiac arrest or heart 25–42
arrest or cardiopulmonary arrest or 17/24 had no sequelae:
cardiopulmonary resuscitation and - 8/17 infants born 0–5 min
cesarean section after cardiac arrest
• Case reports from bibliographies of - 4/17 infants born >15 min
articles included after cardiac arrest
(30–38 weeks GA)
• 12/20 woman that
survived improved only
after delivery
Data collected through all Dutch OB, Incidence and case fatality rate of Retrospective • 12/55 maternal cardiac Mean = 8.5
MOET instructors, Nation wide data PMCS before and after MOET cohort arrest had PMCS

F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809

collection sources • Significant more PMCS
were performed after
MOET
• No cases of PMCS were
performed within 5 min
• 67% of woman regained
CO after PMCS
• Matrenla case fatality
rate: 83%
• Infant case fatality rate:
58%
Resuscitation technique Nanson, 200113 In: uncomplicated pregnancy • Measurements were taken at term • Transthoracic impedance (TTI) as an • Observa- • There was no difference Mean = 9
within 2 weeks of EDC and then 6–8 weeks Postpartum assessment of transthoracic current tional in the TTI between term
N: 45 during defibrillation • Cohort and postpartum
GA: term study
Goodwin, In: qualified midwives who • Basic life support training • Asked to perform basic life support • Observa- • External compressions Mean = 10
199214 attended resuscitation update on the Laerdal Resusci Anne Skillmeter tional were performed
N: 18 in the supine and wedged positions • Cross- significantly better in the
GA: n/a employing the human wedge sectional wedged than in the supine
maneuver position (p = 0.0005)
• The percentage of correct chest • The human wedge
compressions and ventilations were maneuver was found to be
recorded in both positions easy to perform although
some complained of
painful knees.
Rees, 198915 In: anaesthetists • Efficacy of resuscitation at various • Maximum possible resuscitative • Observa- • Maximum resuscitative Mean = 5.5
N: 7 angles of inclination using a calibrated forced measured by the force tional force decreased with
GA: n/a force transducer transducer expressed as a function of • Cross- increasing angle of
the angle of inclination sectional inclination: 67% of body
weight in the supine
position to 36% in full left
lateral tilt
• Tendency to roll off
incline plane angle >30◦
• At 27% tilt achieved 80%
resuscitative force of the
supine position

GA, gestational age; MOET, Managing Obstetric Emergencies and Trauma; PMCS, perimortem cesarean section; EDC, estimated date of confinement; TTI, transthoracic impedance.

805
806 F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809
Fig. 1. Flow chart of the selection process.
plane.15 The study concluded that at a maximum left lateral tilt
of 27◦ from the horizontal, as provided by the Cardiff wedge, the
patient would not slid or roll off the wedge, and this resulted in a
maximum resuscitative force of 55% of the body weight, which is
80% of the force applied in the supine position.
4. Discussion
This systematic review revealed that the management of car-
diac arrest associated with pregnancy is an under-developed area
of medicine with very little science to guide treatment recommen-
dations. Based on this systematic review, there are no randomized
control trials that evaluated different resuscitation techniques
versus standard care during cardiac arrest associated with preg-
nancy.
There are previously published recommendations on optimal
resuscitation techniques and important factors to consider for the
management of cardiac arrest associated with pregnancy.16,17 The
gravid uterus may cause aortocaval compression and, aortocaval
compression can have a negative impact on both the maternal
and fetal status and hemodynamics18–24 and subsequently infe-
rior vena cava compression may negatively affect resuscitation
efforts. In the International Liaison Committee on Resuscitation
(ILCOR) Consensus on Science and Treatment recommendations of
200517 and the 2005 European Resuscitation Council Guidelines16
advised rescuers to place pregnant patients in cardiac arrest into
a 15◦ left lateral tilt from the horizontal in order to effectively
relieve aortocaval compression.16 The 2005 American Heart Associ-
ation (AHA) advance cardiovascular life support (ACLS) guidelines7
suggest either tilting the women to 15–30◦ prior to chest compres-
sions, placing a wedge under the woman’s right side or manual
displacement of the uterus to the left. There are several impor-
tant questions that are not addressed in these guidelines. First, at
what degree of tilt does aortic and inferior vena caval decompres-
sion occur?25 Non-arrest studies have found that a left lateral tilt of
10◦ or less from the horizontal did not result in any hemodynami-
cally detectable relief of aortocaval compression.26 In addition, a
study position with a left lateral tilt of 12◦ from the horizontal
resulted in more hypotension prior to cesarean delivery than when
 F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809 807

patients were placed in a full left lateral tilt prior to surgery.23 Even
though 15◦ of left lateral tilt from the horizontal is standard during
a cesarean delivery, aortic compression can still occur at this degree
tilt,27 with the leg blood pressure being lower when compared to
a full left lateral tilt of 90◦ from the horizontal.22
The second important question relates to combining resusci-
tation science with maternal physiology. Is it possible to perform
effective chest compressions when the patient is in a left lateral
tilt from the horizontal? We know from advances in resuscitation
science that high quality chest compressions are essential for max-
imizing the chances of a successful resuscitation effort.28 There are
several components to high quality chest compressions.
First, the physiologic basis for chest compressions maintain-
ing adequate coronary and cerebral perfusion pressure have only
been confirmed in the supine position.29 Therefore, there is no evi-
dence on whether or not chest compressions done in the left lateral
tilt from the horizontal will result in the maintenance of coronary
and cerebral perfusion similar to that which occurs in the supine
position.
Chest compression depth is another factor involved in maintain-
Fig. 2. Manual leftward uterine displacement.
ing high quality chest compression. However, the study presented
in the paper by Rees and Willis,15 demonstrated that the forceful-
ness of chest compressions will decrease as the degree of left tilt
from the horizontal increases. Therefore, chest compressions per- cesarean section (PMCS). Unfortunately there is no information
formed in left lateral tilt from the horizontal may result in reduced provided in these studies as to whether inferior vena caval com-
force of chest compressions. pression was relieved by any modality, such as a left lateral tilt
Thirdly, current resuscitation science emphasizes the impor- from the horizontal or with leftward manual displacement of the
tance of minimizing interruptions in chest compression as a key uterus, prior to the observation that only PMCS resulted in ROSC. In
component of high quality CPR. Interruptions in chest compres- addition there are many case reports of unsuccessful resuscitation
sions have a negative impact on coronary perfusion pressure.30 attempts with usual life support measures, but which noted ROSC
Consequently interruptions result in reduced survival. In order to only after the uterus is emptied.36–39 Consequently, perimortem
minimize interruptions during chest compressions the 2005 AHA cesarean section may be regarded as one treatment option when all
guidelines recommended a reduction in the number of ventila- other resuscitation methods fail. Ideally perimortem cesarean sec-
tions during cardiopulmonary resuscitation compared to previous tion should be performed within 5 min after the onset of maternal
recommendations and this change in protocol has been shown to cardiac arrest. However, based on the case series and retrospec-
result in increased survival rates.31 Tilting a pregnant patient in car- tive cohort studies reviewed in this paper, successful maternal and
diac arrest will take time which may result in a lengthy interruption neonatal outcomes can occur beyond this recommendation espe-
in chest compressions. cially at older gestational ages of 30–38 weeks. In theory, if there is
We believe that the recommendation to tilt a pregnant patient no ROSC within 4 min, PMCS should result in a lower case fatality
from the supine position during chest compressions, although rate when performed within 5 min after the onset of maternal car-
feasible as outlined in the studies presented in this systematic diac arrest when compared to patients who do not have a PMCS.
review14,15 does not take into account the important aspects of However, this theory cannot be assessed in the study by the Dijk-
resuscitation science which emphasize high quality chest compres- man et al. study as all of the PMCS were performed beyond 5 min
sions. Supine manual leftward displacement of the uterus may be after the onset of cardiac arrest.
the preferred method of relieving aortocaval compression because
this technique would allow for rescuers to perform concurrent high
quality supine chest compressions. Manual leftward displacement
of the uterus has been shown to be at least as effective if not
more effective than left lateral tilt from the horizontal in reliev-
ing aortocaval compression in a cesarean delivery (non-cardiac
arrest) population.32 Manual leftward displacement of the gravid
uterus is illustrated in Fig. 2. An example of the organization of
the resuscitation team during manual leftward displacement of the
uterus is illustrated in Fig. 3. With the lack of any science to guide
us, it seems reasonable to consider the manual leftward displace-
ment of the gravid uterus as an alternative to left lateral tilt from
the horizontal to optimize the quality and effectiveness of chest
compressions during cardiac arrest resuscitation of the pregnant
patient. The above findings and recommendations have been pub-
lished in the most recent 2010 American Heart Association, and
European Resuscitation Council guidelines and the ILCOR Consen-
sus on science publication.33–35
The studies by Katz et al.11 and Dijkman et al.12 demonstrated
that there are cases in which return of spontaneous circulation
(ROSC) does not occur until the uterus is emptied by a perimortem
Fig. 3. Manual leftward uterine displacement-with resuscitation team.
808 F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809
Current recommendations state that the drugs and dosages used
for resuscitation during cardiac arrest in pregnancy should be the
same as with the non-pregnant patient.18 This systematic review
did not find any new information in this area.
It is important to consider the pregnant woman for appropriate
post-arrest care. There are no studies on the use of hypothermia
during pregnancy, however, there is one successful case report
which used hypothermia after ventricular fibrillation cardiac arrest
during pregnancy, where both the mother and baby survived.40
5. Conclusions
Usual defibrillation dosages are likely appropriate in pregnancy.
Perimortem cesarean section is rarely done within 5 min from car-
diac arrest. Maternal and neonatal survival has been documented
with the use of perimortem cesarean section; however, there is not
enough information about it optimal use. Chest compressions in
a left lateral tilt from the horizontal are feasible but less forceful
compared to the supine position, and there are good theoretical
arguments to use left lateral uterine displacement rather than lat-
eral tilt from the horizontal during maternal resuscitation.
Research on optimal resuscitation techniques during pregnancy
is lacking. We suggest an international registry would be one
approach to assess the world’s experience in this area and could
help with future recommendations.
Funding
None.
Conflict of interest statement
None.
Acknowledgements
Author contributions: Dr Jeejeebhoy had full access to all of the
data in the study and takes responsibility for the integrity of the data
and the accuracy of the data analysis. Study concept and design:
Jeejeebhoy, Zelop, Morrison, Windrim.
Acquisition of data: Jeejeebhoy, Zelop, Windrim.
Analysis and interpretation of data: Jeejeebhoy, Zelop, Morrison,
Windrim, Dorian and Carvalho.
Drafting of the manuscript: Jeejeebhoy.
Critical revision of the manuscript for important intellectual
content: Jeejeebhoy, Zelop, Morrison, Windrim, Dorian and Car-
valho.
Statistical analysis: Jeejeebhoy, Zelop.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at doi:10.1016/j.resuscitation.2011.01.028.
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