Resuscitation interventions for cardiac arrest during pregnancy: ALS ScR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. All authors submitted conflict of interest disclosures prior to initiation of the scoping review and had no relevant conflicts to report.

Task Force Synthesis Citation

Zelop CM, Shamshirsaz A, Drennan I, Berg K, on behalf of the ALS Task Force. Resuscitation interventions for cardiac arrest during pregnancy: Task Force Synthesis of a Scoping Review [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2023 November 24. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

As part of the continuous evidence evaluation process, we performed a scoping review of interventions in addition to usual basic life support (BLS) and advanced life support (ALS) treatment for resuscitation of cardiac arrest during pregnancy. A scoping/systematic review was last performed in 2014 (unpublished) and used to advise the current CoSTR, with the treatment recommendations last updated in 2015. An evidence update was completed in 2020.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Pregnant or up to 1 year postpartum patients in cardiac arrest in any setting (in-hospital or out-of-hospital)

Intervention: Any specific intervention (s)

Comparators: Standard care or usual resuscitation practice

Outcomes: Maternal: ROSC, Survival to hospital discharge, 30 days, 60 days, 180 days AND/OR 1 year; survival with favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year

Neonatal: ROSC, Survival to hospital discharge, 30 days, 60 days, 180 days AND/OR 1 year; survival with favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, simulation/mannequin and animal studies), case series with >/= to 20 patients, and descriptive studies without a comparator group are eligible for inclusion. Grey literature and social media and non-peer reviewed studies, unpublished studies, conference abstracts and trial protocols are eligible for inclusion based upon standard scoping review methodology.

Timeframe: From August, 2014 to September, 2023. August, 2014 was the date for the search for the last completed unpublished systematic review forming the basis for the current CoSTR

Literature search last searched Sept 26^th, 2023

Search Strategies

The databases searched included Medline, PubMed, Embase, and Cochrane library. Search terms are included below:

"Heart Arrest"[Mesh] OR cardiac arrest [tw] OR cardiac arrests [tw] OR cardiovascular arrest [tw] OR heart arrest [tw] OR heart arrests [tw] OR asystole [tw] OR pulseless electrical activity [tw] cardiopulmonary arrest [tw] OR cardiopulmonary arrests [tw] Sort by: First Author

AND

CPR [tw] OR resuscitation [mesh] OR resuscitat* [tw] OR chest compression [tw] OR chest compressions [tw] OR heart massage [tw] OR cardiac massage [tw] OR cardiac compression [tw] OR cardiac compressions [tw] OR thoracic compression [tw] OR thoracic compressions [tw] OR maternal resuscitation [tw] OR defibrillation [tw] OR electric countershock [mesh] OR airway management [tw] OR Extracorporeal Membrane Oxygenation [mesh] OR extracorporeal life support [tw] OR manual uterine displacement [tw] OR supraglottic airway devices [tw] OR combitube [tw] OR intubation [tw] OR ventilation [tw] OR perimortem cesarean section [tw] OR perimortem delivery [tw] OR left lateral [tiab] OR lateral tilt [tiab] OR uterine displacement [tw] OR aortocaval compression [tw] OR supine position [tw] OR patient positioning [mesh] OR lipid resuscitation [tw] OR thrombolytic therapy [mesh] OR fibrinolytic therapy [tw] OR fat emulsions, intravenous [mesh] OR intravenous fat emulsion* [tw] OR lipid emulsion* [tw] OR hypothermia induced [Mesh:NoExp] OR induces hypothermia [tw] OR emergency medical services [mesh] OR combined modality therapy [mesh:noexp] OR pad placement [tw] OR pad size [tw] Sort by: First Author

AND

"Pregnancy"[Mesh:NoExp] OR "Pregnant Women"[Mesh] OR "Pregnancy Complications"[Mesh:NoExp] OR "Anesthesia, Obstetrical"[Mesh] OR "Perinatology"[Mesh] OR "Maternal Mortality"[Mesh] OR pregnant [tw] OR pregnancy [tw] OR paturient [tw] OR postpartum [tw] OR postpartum [tw] OR parturition [tw] OR postpartum period [mesh] OR puerperium [tw] OR peripartum [tw] Sort by: First Author

Inclusion and Exclusion criteria

Inclusion Criteria:

• Eligible study design
• Study describes treatment interventions and outcomes in cardiac arrest during pregnancy and or the postpartum period.

Exclusion Criteria:

• Non-systematic reviews and small case series were not included.

Our search revealed 2169 studies and 993 were screened after removing duplicates. After screening, 13 studies were assessed for eligibility. Manuscript review revealed a total of eight studies detailed in data tables below.

Data Tables: Pregnancy Data tables

Task Force Insights

1. Why this topic was reviewed.

Earlier this year, a report detailing mortality during pregnancy in UN regions estimated that there were 287, 000 deaths globally in 2020 (Zarocostos, J, 2023, 632). Mortality during pregnancy, particularly in the US and especially during the pandemic, has continued to increase (Thoma, ME, 2023, 911). The prevalence of cardiac arrest during hospitalizations for delivery in the US during the 2017-2019 time period rose to 1/9000, previously reported as 1/12000 in 2014 using the US National Inpatient database (Ford, N, 2023, 472). Cardiac arrest is the final common pathway of a number of pathophysiologic conditions leading to death during pregnancy including: hemorrhage, cardiomyopathy, hypertensive complications, embolic events and sepsis. Management of cardiac arrest is a complex clinical scenario involving at least two patients that requires accommodation for the physiological changes of pregnancy. Since randomized trials are challenging to perform for the advancement of resuscitation science during pregnancy, it is imperative to summarize emerging research concepts and identity specific knowledge gaps.

The ALS TF last posted a full CoSTR in 2015 and an evidence update was performed in 2020.

2. Summary of evidence identified

This comprehensive scoping review of the literature revealed eight heterogeneous studies describing several interventions for cardiac arrest during pregnancy. The studies are substantially limited by lack of granularity, small sample sizes, indirect measures of interventional effects and high degrees of bias and confounding. The inconsistencies and limitations within the retrospective descriptive data do not support a more specific or rigorous systematic review.

The published literature identified by this scoping review concentrated on three interventions: left lateral uterine displacement with supine positioning for resuscitation, perimortem or resuscitative delivery, and extracorporeal life support. Indirect data from a pig model (Dohi, S, 2017, 98) demonstrating statistically significant higher coronary perfusion pressures during resuscitation favor supine positioning of the pregnant victim with left lateral uterine displacement. Five studies (Kobori, S, 2019, 325; Beckett, VA, 2017, 1374; Maurin, O, 2019, 205; Schaap, TP, 2019, 145; Benson, MD, 2016, 253) recommend performing perimortem cesarean or resuscitative delivery when return of spontaneous circulation does not occur early during resuscitation of cardiac arrest in a pregnant person with a uterine size greater than or equal to 20 weeks gestation. Shorter times from arrest to delivery are associated with improved maternal and neonatal outcomes. Two studies (Van den Bosch, OFC, 2022, 1172; Naoum EE, 2020, 1) suggested that extracorporeal life support (ECLS) may improve pregnancy and peripartum outcomes for both mother and fetus in the setting of cardiac arrest despite the potential of bleeding and clotting complications.

3. Reporting of the task force discussions

No randomized intervention control trials were identified for in-hospital or out-of-hospital management of cardiac arrest during pregnancy or the post-partum period. Although the task force agreed that the limitations of the data did not support a full systematic review to create a new CoSTR, it was thought that generation of two good practice statements was warranted.

4. Treatment recommendations

As this was a scoping review, no changes were made to the existing treatment recommendations (Berg 2020 S92), which are:

We suggest delivery of the fetus by perimortem cesarean delivery for women in cardiac arrest in the second half of pregnancy (weak recommendation, very-low-quality evidence).

There is insufficient evidence to define a specific time interval by which delivery should begin.

High-quality usual resuscitation care and therapeutic interventions that target the most likely cause(s) of cardiac arrest remain important in this population.

There is insufficient evidence to make a recommendation about the use of left-lateral tilt and/or uterine displacement during CPR in the pregnant patient.

After consideration of evidence identified in this scoping review, the task force agreed on the addition of the following statements:

ECPR may be considered as a rescue therapy for selected patients with cardiac arrest during pregnancy or in the post-partum period when conventional CPR is failing, in settings in which it can be implemented (good practice statement).

Institution readiness and resuscitation education is required to accommodate the unique physiologic challenges of cardiac arrest during pregnancy. (good practice statement)

This good practice statement does not replace the ALS treatment recommendation for use of ECPR in general.

Knowledge Gaps

1. Optimal management of cardiac arrest during pregnancy is an ongoing clinical conundrum.
2. There are no studies specific for airway management in cardiac arrest in pregnancy including: placement of advanced airway, intubation and use of video laryngoscopy.
3. Management of out-of-hospital pregnancy cardiac arrest poses multiple challenges especially when transport delays perimortem or resuscitative delivery.
4. Further research is necessary to select best candidates for ECLS to balance bleeding and clotting complications.
5. Research for post arrest care during pregnancy requires further study to optimize clinical resuscitation outcomes.

References

1. Beckett VA, Knight M, Sharpe P. The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study. BJOG. 2017;124(9):1374-81.
2. Benson MD, Padovano A, Bourjeily G, Zhou Y. Maternal collapse: Challenging the four-minute rule. EBioMedicine. 2016;6:253-57.
3. Berg KM, Soar J, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D'Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CWE, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O'Neil BJ, Otto Q, de Paiva EF, Parr MJA, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP; Adult Advanced Life Support Collaborators. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020 Oct 20;142(16_suppl_1):S92-S139. doi: 10.1161/CIR.0000000000000893. Epub 2020 Oct 21. PMID: 33084390.
4. Dohi S, Ichizuka K, Matsuoka R, Seo K, Nagatsuka M, Sekizawa A. Coronary perfusion pressure and compression quality in maternal cardiopulmonary resuscitation in supine and left-lateral tilt positions: A prospective, crossover study using mannequins and swine models. Eur J Obstet Gynecol Reprod Biol. 2017;216:98-103.
5. Ford ND, DeSisto CL, Galang RR, Kuklina EV, Sperling LS, Ko JY. Cardiac Arrest during Delivery Hospitalization: A Cohort Study. Ann Intern Med. 2023;176(4):472-79.
6. Kobori S, Toshimitsu M, Nagaoka S, Yaegashi N, Murotsuki J. Utility and limitations of perimortem cesarean section: A nationwide survey in Japan. J Obstet Gynaecol Res. 2019;45(2):325-30.
7. Maurin O, Lemoine S, Jost D, et al. Maternal out-of-hospital cardiac arrest: A retrospective observational study. Resuscitation. 2019;135:205-11.
8. Naoum EE, Chalupka A, Haft J, et al. Extracorporeal Life Support in Pregnancy: A Systematic Review. J Am Heart Assoc. 2020;9(13):e016072.
9. Schaap TP, Overtoom E, van den Akker T, Zwart JJ, van Roosmalen J, Bloemenkamp KWM. Maternal cardiac arrest in the Netherlands: A nationwide surveillance study. Eur J Obstet Gynecol Reprod Biol. 2019;237:145-50.
10. Thoma ME, Declercq ER. Changes in pregnancy-related mortality associated with the coronavirus disease 2019 (COVID-19) pandemic in the United States. Obstet Gynecol. 2022:10.1097.
11. Van Den Bosch OFC, Chaudhry R, Wicker J, et al. Predictors and Hospital Outcomes in Pregnant Patients Undergoing Extracorporeal Membrane Oxygenation: A Nationwide Study. Anesth Analg. 2022;135(6):1172-79.
12. Zarocostas J. Global maternal mortality rates stagnating. The Lancet. 2023;401(10377):632.
13. Zelop CM, Einav S, Mhyre JM, Martin S. Cardiac arrest during pregnancy: ongoing clinical conundrum. Am J Obstet Gynecol. 2018;219(1):52-61.