Successful Use of Therapeutic Hypothermia in a Pregnant Patient

Environmental Exposures and Risks During Pregnancy

The Women in Wilderness Medicine Research Committee of the Wilderness Medical Society conducted a narrative review to address considerations for pregnant individuals in wilderness environments. There is limited evidence behind many opinion-based recommendations on the safety of various environmental exposures in pregnancy. The authors reviewed the literature for the best available evidence, including observational studies, case series, limited controlled trials, and extrapolation from physiological data, as well as evaluating expert consensus statements. The benefits of exposure to natural environments include better pregnancy outcomes and improved maternal mental and physical health. Risks are similar to nonpregnant individuals with the added risks associated with maternal-fetal physiology in wilderness environments and difficulties of evacuation. This narrative review discusses pregnancy-specific concerns in extreme environments, including high altitude, hypothermia, hyperthermia, lightning strikes, envenomations, and common outdoor exposures.

Recommendations for the Management of High-Risk Cardiac Delivery: ACC Cardiovascular Disease in Women Committee Panel

Maternal mortality is a major public health crisis in the United States. Cardiovascular disease (CVD) is a leading cause of maternal mortality and morbidity. Labor and delivery is a vulnerable time for pregnant individuals with CVD but there is significant heterogeneity in the management of labor and delivery in high-risk patients due in part to paucity of high-quality randomized data. The authors have convened a multidisciplinary panel of cardio-obstetrics experts including cardiologists, obstetricians and maternal fetal medicine physicians, critical care physicians, and anesthesiologists to provide a practical approach to the management of labor and delivery in high-risk individuals with CVD. This expert panel will review key elements of management from mode, timing, and location of delivery to use of invasive monitoring, cardiac devices, and mechanical circulatory support.

Post-Cardiac arrest targeted temperature management in a parturient with severe COVID-19 disease

Background and Objective

Targeted temperature management (TTM) may improve neurological outcomes and mortality after cardiac arrest. We present a targeted mild hypothermia treatment in a postpartum patient with COVID-19 after successful cardiopulmonary resuscitation (CPR).

Case presentation

A 23 year old, 26-week pregnant patient with the diagnosis of COVID-19. The patient developed respiratory arrest followed by cardiac arrest and underwent CPR for six minutes. The patient underwent an emergency cesarean section after CPR in intensive care unit. After the resuscitation, 72-hours hypothermia protocol was initiated. We extubated the patient 13 days after the hypothermia procedure. The patient was conscious and cooperative. Respiratory distress worsened in the following days; the patient was re-intubated 18 days after the TTM. The benefit of targeted hypothermia was improved neurologic outcome in our patient. However, severe infectious complications led to multi-organ failure and the patient died on the 45th ICU admission day.

A modified Delphi approach to determine current treatment advances for the development of a resuscitation program for maternal cardiac arrest

OBJECTIVE

Maternal cardiac arrest is a rare and complex process requiring pregnancy-specific responses and techniques. The goals of this study were to (1) identify, evaluate, and determine the most current best practices to treat this patient population and (2) establish a standardized set of guidelines to serve as a foundation for a future educational simulation-based curriculum.

STUDY DESIGN

We used a three-step modified Delphi process to achieve consensus. Twenty-two healthcare experts from across North America agreed to participate in the expert panel. In round 1, 12 pregnancy-specific best practice statements were distributed to the expert panel. Panelists anonymously ranked these using a 7-point Likert scale and provided feedback. Round 2 consisted of a face-to-face consensus meeting where statements that had not already achieved consensus were discussed and then subsequently voted upon by the panelists.

RESULTS

Through two rounds, we achieved consensus on nine evidence-based pregnancy-specific techniques to optimize response to maternal cardiac arrest. Round one resulted in one of the 12 best practice statements achieving consensus. Round two resulted in six of the remaining 12 gaining consensus. Best practice techniques involved use of point-of care ultrasound, resuscitative cesarean delivery, cardiopulmonary resuscitation techniques, and the use of extracorporeal cardiopulmonary resuscitation.

CONCLUSION

The results of this study provide the foundation to develop an optimal, long-term strategy to treat cardiac arrest in pregnancy. We propose these nine priorities for standard practice, curricula, and guidelines to treat maternal cardiac arrest and hope they serve as a foundation for a future educational curriculum.

Acute Intracranial Hypertension During Pregnancy: Special Considerations and Management Adjustments

Pregnancy is associated with a number of pathophysiological changes (including modification of vascular resistance, increased vascular permeability, and coagulative disorders) that can lead to specific (eclampsia, preeclampsia) or not specific (intracranial hemorrhage) neurological complications. In addition to these disorders, pregnancy can affect numerous preexisting neurologic conditions, including epilepsy, brain tumors, and intracerebral bleeding from cerebral aneurysm or arteriovenous malformations. Intracranial complications related to pregnancy can expose patients to a high risk of intracranial hypertension (IHT). Unfortunately, at present, the therapeutic measures that are generally adopted for the control of elevated intracranial pressure (ICP) in the general population have not been examined in pregnant patients, and their efficacy and safety for the mother and the fetus is still unknown. In addition, no specific guidelines for the application of the staircase approach, including escalating treatments with increasing intensity of level, for the management of IHT exist for this population. Although some of basic measures can be considered safe even in pregnant patients (management of stable hemodynamic and respiratory function, optimization of systemic physiology), some other interventions, such as hyperventilation, osmotic therapy, hypothermia, barbiturates, and decompressive craniectomy, can lead to specific concerns for the safety of both mother and fetus. The aim of this review is to summarize the neurological pathophysiological changes occurring during pregnancy and explore the effects of the possible therapeutic interventions applied to the general population for the management of IHT during pregnancy, taking into consideration ethical and clinical concerns as well as the decision for the timing of treatment and delivery.

Case Report of Cardiopulmonary Arrest During Pregnancy due to Opioid Overdose

In the United States, the number of deaths related to overdose of heroin and other opioids, specifically among women of reproductive age, has been rising. This case report adds new knowledge to the limited scientific literature currently available. We describe the care of a 30-year-old pregnant (31.4 weeks gestation) woman who was found unresponsive from a suspected opioid overdose in a friend's home. In response to an unwitnessed cardiopulmonary arrest, the team initiated therapeutic hypothermia 12 hours after the event. Multiple interdisciplinary teams came together to care for this woman and fetus. Information sharing among care providers from multiple disciplines is needed to build expertise in managing the care of pregnant women who experience opioid overdose.

Maternal hypothermia from environmental exposure in the third trimester

A primigravida at 32 weeks gestation developed hypothermia after prolonged exposure to the elements at -30.0°C. Her core temperature dropped to 29.8°C with associated foetal bradycardia. Passive rewarming was undertaken with forced warm air blankets and warmed IV fluids. The foetal heart rate normalised once normothermia was achieved. Serial foetal assessments showed appropriate growth and normal Doppler studies. She went to on deliver a healthy term infant. This case highlights conservative management and prioritising of maternal well-being with a good maternal and foetal outcome.

Therapeutic hypothermia and cardiac intervention after cardiac arrest in pregnancy with underlying maternal arrhythmia: A case report

There are few case reports of utilization of therapeutic hypothermia during pregnancy, and most report successful maternal and fetal outcomes. There is no available evidence that supports withholding therapeutic hypothermia in these patients. There are no long-term data on neonatal outcomes. We report the case of a 28-year-old pregnant patient with long QT syndrome who experienced multiple cardiac arrests during the second trimester and underwent therapeutic hypothermia, cardiac ablation, transvenous pacemaker placement, and placement of an implantable cardioverter defibrillator (ICD). She subsequently delivered a viable infant at term. The evidence seems to support the use of hypothermia during pregnancy, but patients should be counseled about the unknown maternal and fetal risks and long-term neonatal outcomes. Decisions to utilize therapeutic hypothermia should be made on an individual basis.

Resuscitation of the Pregnant Patient

Many health care providers lack familiarity with maternal physiologic changes and the distinctive underlying etiology of cardiac arrest in pregnancy. Knowledge of what changes are expected in pregnancy and an understanding of how to adapt clinical practice is essential for the care of the pregnant woman in the emergency department. Amniotic fluid embolism should be recognized as a rare cause of cardiac arrest in pregnancy, characterized by the triad of cardiovascular collapse, hypoxic respiratory failure, and coagulopathy. Cardiopulmonary resuscitation should follow standard AHA ACLS guidelines. Resuscitative hysterotomy may be attempted to restore perfusion to both mother and fetus.

Successful treatment of pulmonary embolism-induced cardiac arrest by thrombolysis and targeted temperature management during pregnancy

Background

Thrombolysis for pulmonary embolism and targeted temperature management for cardiac arrest are controversial treatments in pregnancy.

Case

A 37‐year‐old woman at 23 weeks gestation presented with persistent dyspnea. She experienced cardiac arrest soon after arrival at the emergency room. Massive right ventricular dilatation on echocardiography during the transient return of spontaneous circulation suggested pulmonary embolism. We administered recombinant tissue plasminogen activator for suspected pulmonary embolism to successfully resuscitate the patient experiencing refractory cardiac arrest despite heparin infusion. After an additional dose of monteplase for persistent shock with remaining right ventricular dilatation on echocardiography, maternal hemodynamics dramatically improved, but fetal heart rate transiently decreased. Targeted temperature management was initiated for delayed recovery of consciousness. She fully recovered consciousness without neurological deficit. However, the fetus was aborted because of fetal hydrops.

Conclusion

Thrombolysis and targeted temperature management should be considered as treatment options for pulmonary embolism‐induced cardiac arrest during pregnancy.