| Begin basic and advanced cardiac life support maneuvers | - Manual chest percussions, emergency airway management with 100% oxygen and intubation, and the establishment of intravenous (IV) access. Pregnancy-specific issues include manual uterine displacement to avoid aortocaval compression, intravenous access above the diaphragm, avoidance of alkalosis, lower than usual ventilation volumes, high fractions of inspired oxygen. ECMO may be considered for refractory hypoxemia during CPR.
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| Provide hemodynamic support | - Rapid administration of crystalloid (eg, normal saline or lactated Ringer’s solution) for non-hemorrhagic shock or blood for hemorrhagic shock. The response should be acutely followed by the assessment of vital signs, and bedside ultrasound monitoring of the inferior cava, if available. Discontinue fluids when intravascular volume has been replenished or pulmonary edema becomes apparent.
- Administer vasopressor therapy for refractory shock. Norepinephrine is typically first choice. Consider addition of dobutamine or other inotrope for cardiogenic shock. Alternatives are epinephrine (preferred in anaphylaxis), ephedrine (post anesthesia hypotension), or phenylephrine (if tacharrythmia is an issue). Many experts avoid vasopressin (increased uterine contractions ) and dopamine (possible increase risk in death in sepsis patients).
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| Management of hemorrhage and coagulopathy* | - Prolonged PT, aPTT, fibrinogen <100 mg/dL → FFP and croprecipitate → Goal is normalization of INR and fibrinogen >100 mg/dL.
- Platelet count <50,000/microL-one to two units of random donor platelets per 10 kg of body weight.
- Consider other agents for cases refractory to standard DIC treatment measures.¶
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| Delivery of fetus | - Determine uterine size and estimate gestational age. Delivery is considered in most cases for pregnancies ≥20 weeks of gestation/uterine size at or above the umbilicus to relieve aortocaval compression and facilitate return of spontaneous circulation, regardless of fetal status (alive or demised).
- Consider cesarean delivery if spontaneous circulation has not returned within 4 minutes of maternal cardiorespiratory collapse and delivery of the fetus should be completed within 5 minutes (known as the "4-minute rule" or "the 5-minute rule").Δ
- Perimortem operative vaginal delivery with forceps or vacuum is appropriate if it can be achieved within this timeframe.
- Delivery is preferably at the location of the arrest (often not an operating room).
- Manage postdelivery uterine bleeding with standard methods (eg, uterotonic drugs, balloon tamponade or packing, hemostatic sutures)
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| Preliminary testing | - Complete blood count, chemistries including metabolic profile, PT, aPTT, INR, troponin, brain natriuretic peptide, type and screen, complement 3 and 4, serum tryptase and histamine. Arterial blood gas, chest radiograph, electrocardiography, bedside ultrasonography (if available; this may include thoracic, cardiac, abdominal, and/or lower extremity ultrasonography).
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