Resuscitation in Pregnancy
Epidemiology
Leading causes of death: PE (19%), haemorrhage (17%), HTN (15%), infection (12%), idiopathic
peripartum cardiomyopathy (8%), CVA (5%), local anaesthetic OD (1%), other (19%), amniotic fluid
embolism
Management
Before 22/40: concentrate on mother only with no change in resus for normal
After 22/40: put stuff under right buttock (roll to left); intubate early as  lower oesophageal sphincter
tone and  intraabdominal pressure; use ETT 0.5-1mm smaller due to airway oedema; prepare for
potential Caesarian section (within 5mins of cardiac arrest in ED); adrenaline is preferred vasopressor;
consider open chest CPR if >15mins arrest; oxytocin and prostaglandin for uterine atony; may be need
uterine embolisation, hysterectomy, aortic cross clamping; fibrinolytics relatively contraindicated
Complications
of CPR
Liver lacerations, uterine rupture, haemothorax, haemopericardium
Pregnancy is relative contraindication for fibrinolysis (only use if in extremis)
TVUS:
Empty gestational sac +
Empty gestational sac +
USS
Investigation
In Fetal
Demise
No cardiac activity
+
No yolk sac
No fetal pole
+
+
diameter <20mm = inconclusive  do follow up
gestational sac diameter >15mm (7/40)
OR >21mm (8/40)
(90% specificity)
gestational sac diameter >9-16mm
OR CRL >5-6mm (non-viable)
gestational sac diameter >10-13mm
gestational sac diameter >18-20mm (non-viable)
If beta-hCG above discriminatory zone (>2000) and no IUP, or mass in ovary / tube = likely ectopic (90%
PPV)
If beta-hCG >6500 and no fetal heart seen on USS = 80% chance of miscarriage
If beta-hCG below discriminatory zone (<2000) and inconclusive scan = pregnancy unknown location 
48hr follow up (serial beta-hCG’s or repeat USS)
Management
If unstable: ?cervical shock  resus, IV fluids, atropine 600mcg IV if bradycardic (to max 3mg), speculum
ASAP; can consider uterine compression, vaginal packs, compression of abdominal aorta, urinary
catheter, ergometrine / oxytocin
Empathy; pan when toileting
Rh prophylaxis – early pregnancy bleeding, singleton, <13/40  250iu IM
early pregnancy bleeding, multipleton, >13/40  625iu IM
Chance of Rh- mother developing antibodies to Rh+ child is <20% regardless (ie. 15%) of whether antiD is
given; Kleihaur done to quantify fetomaternal haemorrhage and thus work out amount to give; of
mother’s serum has detectable anti-D antibodies at 24-48hrs then correct dose has been given; if given
after 3-10/7, still has some effect; 1ml protects against 6mls of fetal blood; 85% Caucasians are Rh +ive;
antiD decreases risk from 1% to 0.3%
Complete: conservative management
Incomplete / inevitable: women’s preference
1) ERPOC –  infection risk, cervical trauma, uterine perforation, intrauterine adhesions
2) Medical – misoprostol 600mcg PO (PGE1 analogue  uterotonic; used in MTOP, miscarriage,
induction of labour; stable, low cost, easy to give, patient acceptance; contraindications:
previous uterine surgery ( risk of uterine rupture)
3) Watch and wait – longer duration of PV bleeding and pain,  need for blood transfusion
Discharge with Early Pregnancy Clinic referral if: bleeding not severe, easy hospital access, good
discharge advice (come back if deterioration, avoid sex and tampax if threatened), cervical os closed,
>6/40 with IUP on scan
USS before discharge if: can’t get to EPAC <72hrs, high maternal anxiety and in-hours, >6/40 with no IUP
on USS
Refer gynaecology if: ?ectopic (unilateral pain, severe, pain, PMH ectopic / tubal surgery / PID), ?actively
miscarrying (heavy bleeding / products / USS evidence of miscarriage), unwell, non-viable fetus on USS