Contributor: Aaron Lessen MD

Educational Pearls:

Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care
A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD
T: Tilt the patient to the left lateral decubitus position

This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload
If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side

Lines below the diaphragm are ineffective due to uterine compression of the IVC
May consider humeral interosseous line vs. internal jugular or subclavian central line

> 20 weeks, can consider a resuscitative hysterotomy (previously known as perimortem c-section) to improve chances of survival
The uterus is palpable at the umbilicus at 20 weeks and 1 cm superior to the umbilicus for every week thereafter

References

ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5)
Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MAHM, Ozaki M. Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg. 2019;128(6):1217-1222. doi:10.1213/ANE.0000000000004166
Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300
Singh, Ajay; Dhir, Ankita; Jain, Kajal; Trikha, Anjan1. Role of High Flow Nasal Cannula (HFNC) for Pre-Oxygenation Among Pregnant Patients: Current Evidence and Review of Literature. Journal of Obstetric Anaesthesia and Critical Care 12(2):p 99-104, Jul–Dec 2022. | DOI: 10.4103/JOACC.JOACC_18_22

Summarized & Edited by Jorge Chalit, OMS3

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Episode 935: Pregnancy Extremis - TOLDD

Emergency Medical Minute