Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Review article
a r t i c l e i n f o a b s t r a c t
Article history: Objective: To describe the consensus on science pertaining to resuscitation of the pregnant patient.
Received 28 June 2010 Design: Systematic review.
Received in revised form 17 January 2011 Data sources: EMBASE, Ovid MEDLINE, Evidence Based Reviews, American Heart Association library and
Accepted 26 January 2011
bibliographies of selected articles.
Review methods: The following inclusion criteria were used: pregnancy and cardiac arrest out of hospital,
pregnancy and cardiac arrest in hospital, cardiovascular, respiratory, fetal survival, and pharmacology
Keywords:
as they relate to cardiac arrest and resuscitation. Non-English papers, case reports and reviews were
Cardiac arrest
Maternal resuscitation
excluded. Studies were selected through an independent review of titles, abstracts and full article. Two
Systematic review reviewers independently graded the methodological quality of selected articles.
Results: 1305 articles were identified and 5 were selected for further review. There were no randomized
trials and overall the quality of the selected studies was good. Two studies examined chest compressions
on a manikin in left lateral tilt from the horizontal and concluded that although feasible with increasing
degrees of tilt forcefulness of the chest compressions decreases. The third study observed the transtho-
racic impedance was not altered during pregnancy. One case series and one retrospective cohort study
reviewed perimortem cesarean section. Both reports concluded that perimortem cesarean section is
rarely done within the recommended time frame of 5 min after the onset of maternal cardiac arrest.
Conclusions: Usual defibrillation dosages are likely appropriate in pregnancy. Perimortem cesarean sec-
tion is an intervention which is rarely done within 5 min to optimize maternal salvage from cardiac arrest.
Chest compressions in left lateral tilt are less forceful compared to the supine position.
© 2011 Elsevier Ireland Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
2.1. Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
2.2. Study selection and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
3.1. Consensus on science by category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
3.1.1. Perimortem cesarean section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
3.1.2. Resuscitation technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804
Abbreviations: PMCS, perimortem cesarean section; MOET, Managing Obstetric Emergencies and Trauma; AHA, American Heart Association; ACLS, advance cardiovascular
life support; ROSC, return of spontaneous circulation; ILCOR, The International Liaison Committee on Resuscitation.
夽 A Spanish translated version of the abstract of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2011.01.028.
∗ Corresponding author.
E-mail addresses: farida.j@sympatico.ca (F.M. Jeejeebhoy), czelop@bidmc.harvard.edu (C.M. Zelop), rwindrim@mtsinai.on.ca (R. Windrim),
jose.carvalho@uhn.on.ca (J.C.A. Carvalho), dorianp@smh.toronto.on.ca (P. Dorian), morrisonl@smh.ca, singhs@smh.toronto.on.ca (L.J. Morrison).
0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2011.01.028
802 F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 806
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Conflict of interest statement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Table 1
Search strategy.
Table 1 (Continued)
matic improvement in their clinical status immediately after the 2.5 years of age. One was lost to follow-up. The other two neonates
uterus was emptied including a return of the pulse and blood pres- seemed healthy at the time of discharge. There is no follow-up clin-
sure. The second study, a recent retrospective cohort study done ical information given in this study about survivors (maternal or
in the Netherlands, reviewed all cases of perimortem cesarean sec- fetal) in those who did not have a PMCS.
tion (PMCS) from 1993 to 2008.12 They examined the incidence of
PMCS before and after emergency skills training with the Manag- 3.1.2. Resuscitation technique
ing Obstetric Emergencies and Trauma (MOET) course. This study There were 3 trials in this category.13–15
found that out of 55 cases of resuscitation, 12 PMCS were per- One study demonstrated that the transthoracic impedance was
formed. However, the number of PMCS increased significantly after not altered significantly during pregnancy.13 Therefore, the rec-
the MOET course training. There were 4 PMCS performed (all PMCS ommendations regarding energy settings for defibrillation seem
were performed after the year 2000) over an 11 year period before reasonable to apply when delivering defibrillation shocks during
the MOET course (0.36/year), versus 8 PMCS which were performed pregnancy.
the 5 years after the MOET course (1.6/year) (p = 0.01). The number There were 2 small studies that examined if effective chest
of women that gained cardiac output after PMCS was 67% (8/12). compressions can be performed in a left lateral tilt from the
However, the maternal case fatality rate was lower in the group horizontal.14,15 The first study by Goodwin et al. instructed the
without PMCS at 67% versus 83% in the PMCS group. It should rescuers to kneel on the floor, and sit on their heels. The manikin
be noted there were factors that would likely affect outcome for is then positioned so that the back is positioned on the thighs of
all of the twelve women in the PMCS group, i.e., (1) no cases of the human wedge/rescuer.14 This study found that when using the
PMCS were performed within the recommended 5 min after the human wedge technique to provide a left lateral tilt from the hori-
onset of maternal cardiac arrest, (2) four women were transported zontal, the rescuer could also provide effective chest compressions
to the operating theatre, and (3) time-consuming activities were on a manikin (non-physiologic study).14 However, the degree of tilt
performed to assess fetal viability in six women. Also, the lack was not measured in this study. The second study by Rees and Willis
of maternal or neonatal survivors of the 4 cases of out-of hospi- assessed the efficacy of chest compressions with the manikin at var-
tal arrest who had a PMCS was likely attributed to the delay from ious angles of inclination of left lateral tilt from the horizontal.15
onset of cardiac arrest and the delivery. Maternal survival overall They set up the study by fitting a calibrated force transducer onto a
was only 15% (8/55). Only 2 of the 12 women (17%) that had PMCS plane that was able to be at inclinations from 0◦ (supine) to 90◦ (full
survived. The maternal survivors that had a PMCS were delivered left lateral tilt from the horizontal). The maximum possible resusci-
within 15 min after the onset of maternal cardiac arrest. Of the two tative force of the 8 physicians studied was expressed as a function
women that survived post PMCS, one showed neurological dam- of the angle of inclination. The measured resuscitative force for each
age in the radial region of the right hand 8 years after resuscitation. angle of inclination was expressed as a percentage of the rescuers
The second women showed signs of vascular dementia at the 2 body weight. This study found that the maximum possible resus-
month follow-up. There were 6/43 maternal survivors (14%) in the citative force in terms of percent body weight decreased as the
group that did not have a PMCS. Neonatal survival was only 5 of angle of inclination of the plane increased.15 In the supine position
12 patients with PMCS and the surviving neonates were delivered the maximal resuscitative force was 67% of the body weight com-
within 30 min after the onset of maternal cardiac arrest. Of these 5 pared to 36% in the 90◦ left lateral tilt from the horizontal. At angles
neonatal survivors, 1 neonate had impaired neurological function of >30◦ left lateral tilt from the horizontal the surrogate patient
at 3 months of age, and one had age appropriate development at (manikin/human volunteer) tended to slide or roll off the incline
Table 2
Summary of selected studies based on category of interest.
Category of question Author, year of Population Exposure/intervention Assessment/ Design Outcome Quality
publication In: inclusion criteria measurement instrument score
Ex: exclusion criteria
N: number of participants
GA: gestational age
Perimortem cesarean Katz, 200511 In: Ovid MEDLINE search on • Search words: perimortem or Case series • 28/38 infants lived, GA Mean = 5
section (PMCS) perimortem cesarean section postmortem or cardiac arrest or heart 25–42
Time frame: 1985–2004 arrest or cardiopulmonary arrest or 17/24 had no sequelae:
N: 38 case reports cardiopulmonary resuscitation and - 8/17 infants born 0–5 min
cesarean section after cardiac arrest
• Case reports from bibliographies of - 4/17 infants born >15 min
articles included after cardiac arrest
(30–38 weeks GA)
• 12/20 woman that
survived improved only
after delivery
Dijkman, All cases of PMCS in the Data collected through all Dutch OB, Incidence and case fatality rate of Retrospective • 12/55 maternal cardiac Mean = 8.5
201012 Netherlands MOET instructors, Nation wide data PMCS before and after MOET cohort arrest had PMCS
GA, gestational age; MOET, Managing Obstetric Emergencies and Trauma; PMCS, perimortem cesarean section; EDC, estimated date of confinement; TTI, transthoracic impedance.
805
806 F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809
plane.15 The study concluded that at a maximum left lateral tilt compression can have a negative impact on both the maternal
of 27◦ from the horizontal, as provided by the Cardiff wedge, the and fetal status and hemodynamics18–24 and subsequently infe-
patient would not slid or roll off the wedge, and this resulted in a rior vena cava compression may negatively affect resuscitation
maximum resuscitative force of 55% of the body weight, which is efforts. In the International Liaison Committee on Resuscitation
80% of the force applied in the supine position. (ILCOR) Consensus on Science and Treatment recommendations of
200517 and the 2005 European Resuscitation Council Guidelines16
advised rescuers to place pregnant patients in cardiac arrest into
4. Discussion a 15◦ left lateral tilt from the horizontal in order to effectively
relieve aortocaval compression.16 The 2005 American Heart Associ-
This systematic review revealed that the management of car- ation (AHA) advance cardiovascular life support (ACLS) guidelines7
diac arrest associated with pregnancy is an under-developed area suggest either tilting the women to 15–30◦ prior to chest compres-
of medicine with very little science to guide treatment recommen- sions, placing a wedge under the woman’s right side or manual
dations. Based on this systematic review, there are no randomized displacement of the uterus to the left. There are several impor-
control trials that evaluated different resuscitation techniques tant questions that are not addressed in these guidelines. First, at
versus standard care during cardiac arrest associated with preg- what degree of tilt does aortic and inferior vena caval decompres-
nancy. sion occur?25 Non-arrest studies have found that a left lateral tilt of
There are previously published recommendations on optimal 10◦ or less from the horizontal did not result in any hemodynami-
resuscitation techniques and important factors to consider for the cally detectable relief of aortocaval compression.26 In addition, a
management of cardiac arrest associated with pregnancy.16,17 The study position with a left lateral tilt of 12◦ from the horizontal
gravid uterus may cause aortocaval compression and, aortocaval resulted in more hypotension prior to cesarean delivery than when
F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809 807
patients were placed in a full left lateral tilt prior to surgery.23 Even
though 15◦ of left lateral tilt from the horizontal is standard during
a cesarean delivery, aortic compression can still occur at this degree
tilt,27 with the leg blood pressure being lower when compared to
a full left lateral tilt of 90◦ from the horizontal.22
The second important question relates to combining resusci-
tation science with maternal physiology. Is it possible to perform
effective chest compressions when the patient is in a left lateral
tilt from the horizontal? We know from advances in resuscitation
science that high quality chest compressions are essential for max-
imizing the chances of a successful resuscitation effort.28 There are
several components to high quality chest compressions.
First, the physiologic basis for chest compressions maintain-
ing adequate coronary and cerebral perfusion pressure have only
been confirmed in the supine position.29 Therefore, there is no evi-
dence on whether or not chest compressions done in the left lateral
tilt from the horizontal will result in the maintenance of coronary
and cerebral perfusion similar to that which occurs in the supine
position.
Chest compression depth is another factor involved in maintain-
Fig. 2. Manual leftward uterine displacement.
ing high quality chest compression. However, the study presented
in the paper by Rees and Willis,15 demonstrated that the forceful-
ness of chest compressions will decrease as the degree of left tilt
from the horizontal increases. Therefore, chest compressions per- cesarean section (PMCS). Unfortunately there is no information
formed in left lateral tilt from the horizontal may result in reduced provided in these studies as to whether inferior vena caval com-
force of chest compressions. pression was relieved by any modality, such as a left lateral tilt
Thirdly, current resuscitation science emphasizes the impor- from the horizontal or with leftward manual displacement of the
tance of minimizing interruptions in chest compression as a key uterus, prior to the observation that only PMCS resulted in ROSC. In
component of high quality CPR. Interruptions in chest compres- addition there are many case reports of unsuccessful resuscitation
sions have a negative impact on coronary perfusion pressure.30 attempts with usual life support measures, but which noted ROSC
Consequently interruptions result in reduced survival. In order to only after the uterus is emptied.36–39 Consequently, perimortem
minimize interruptions during chest compressions the 2005 AHA cesarean section may be regarded as one treatment option when all
guidelines recommended a reduction in the number of ventila- other resuscitation methods fail. Ideally perimortem cesarean sec-
tions during cardiopulmonary resuscitation compared to previous tion should be performed within 5 min after the onset of maternal
recommendations and this change in protocol has been shown to cardiac arrest. However, based on the case series and retrospec-
result in increased survival rates.31 Tilting a pregnant patient in car- tive cohort studies reviewed in this paper, successful maternal and
diac arrest will take time which may result in a lengthy interruption neonatal outcomes can occur beyond this recommendation espe-
in chest compressions. cially at older gestational ages of 30–38 weeks. In theory, if there is
We believe that the recommendation to tilt a pregnant patient no ROSC within 4 min, PMCS should result in a lower case fatality
from the supine position during chest compressions, although rate when performed within 5 min after the onset of maternal car-
feasible as outlined in the studies presented in this systematic diac arrest when compared to patients who do not have a PMCS.
review14,15 does not take into account the important aspects of However, this theory cannot be assessed in the study by the Dijk-
resuscitation science which emphasize high quality chest compres- man et al. study as all of the PMCS were performed beyond 5 min
sions. Supine manual leftward displacement of the uterus may be after the onset of cardiac arrest.
the preferred method of relieving aortocaval compression because
this technique would allow for rescuers to perform concurrent high
quality supine chest compressions. Manual leftward displacement
of the uterus has been shown to be at least as effective if not
more effective than left lateral tilt from the horizontal in reliev-
ing aortocaval compression in a cesarean delivery (non-cardiac
arrest) population.32 Manual leftward displacement of the gravid
uterus is illustrated in Fig. 2. An example of the organization of
the resuscitation team during manual leftward displacement of the
uterus is illustrated in Fig. 3. With the lack of any science to guide
us, it seems reasonable to consider the manual leftward displace-
ment of the gravid uterus as an alternative to left lateral tilt from
the horizontal to optimize the quality and effectiveness of chest
compressions during cardiac arrest resuscitation of the pregnant
patient. The above findings and recommendations have been pub-
lished in the most recent 2010 American Heart Association, and
European Resuscitation Council guidelines and the ILCOR Consen-
sus on science publication.33–35
The studies by Katz et al.11 and Dijkman et al.12 demonstrated
that there are cases in which return of spontaneous circulation
(ROSC) does not occur until the uterus is emptied by a perimortem
Fig. 3. Manual leftward uterine displacement-with resuscitation team.
808 F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809
Current recommendations state that the drugs and dosages used in competitive athletes: 2007 update: a scientific statement from the Ameri-
for resuscitation during cardiac arrest in pregnancy should be the can Heart Association Council on Nutrition, Physical Activity, and Metabolism:
endorsed by the American College of Cardiology Foundation. Circulation
same as with the non-pregnant patient.18 This systematic review 2007;115:1643–55.
did not find any new information in this area. 7. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation
It is important to consider the pregnant woman for appropriate and Emergency Cardiovascular Care. Circulation 2005;112(24 Suppl.):IV1–203.
8. Hayden JA, Cote P, Bombardier C. Evaluation of the quality of prognosis studies
post-arrest care. There are no studies on the use of hypothermia in systematic reviews. Ann Intern Med 2006;144:427–37.
during pregnancy, however, there is one successful case report 9. Moulaert VR, Verbunt JA, van Heugten CM, Wade DT. Cognitive impairments in
which used hypothermia after ventricular fibrillation cardiac arrest survivors of out-of-hospital cardiac arrest: a systematic review. Resuscitation
2009;80:297–305.
during pregnancy, where both the mother and baby survived.40 10. Fleiss JL. Statistical methods for rates and proportions. 2d ed. New York: Wiley;
1981.
11. Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: were our
5. Conclusions
assumptions correct? Am J Obstet Gynecol 2005;192:1916–20 [discussion
1920–1911].
Usual defibrillation dosages are likely appropriate in pregnancy. 12. Dijkman A, Huisman CM, Smit M, et al. Cardiac arrest in pregnancy: increasing
use of perimortem caesarean section due to emergency skills training? BJOG
Perimortem cesarean section is rarely done within 5 min from car-
2010;117:282–7.
diac arrest. Maternal and neonatal survival has been documented 13. Nanson J, Elcock D, Williams M, Deakin CD. Do physiological changes in preg-
with the use of perimortem cesarean section; however, there is not nancy change defibrillation energy requirements? Br J Anaesth 2001;87:237–9.
enough information about it optimal use. Chest compressions in 14. Goodwin AP, Pearce AJ. The human wedge. A manoeuvre to relieve aor-
tocaval compression during resuscitation in late pregnancy. Anaesthesia
a left lateral tilt from the horizontal are feasible but less forceful 1992;47:433–4.
compared to the supine position, and there are good theoretical 15. Rees GA, Willis BA. Resuscitation in late pregnancy. Anaesthesia 1988;43:347–9.
arguments to use left lateral uterine displacement rather than lat- 16. Soar J, Deakin CD, Nolan JP, et al. European Resuscitation Council guidelines for
resuscitation 2005. Section 7. Cardiac arrest in special circumstances. Resusci-
eral tilt from the horizontal during maternal resuscitation. tation 2005;67(Suppl. 1):S135–70.
Research on optimal resuscitation techniques during pregnancy 17. 2005 International Consensus on Cardiopulmonary Resuscitation and Emer-
is lacking. We suggest an international registry would be one gency Cardiovascular Care Science with Treatment Recommendations. Part 2:
adult basic life support. Resuscitation 2005;67:187–201.
approach to assess the world’s experience in this area and could 18. Carbonne B, Benachi A, Leveque ML, Cabrol D, Papiernik E. Maternal position
help with future recommendations. during labor: effects on fetal oxygen saturation measured by pulse oximetry.
Obstet Gynecol 1996;88:797–800.
19. Tamas P, Szilagyi A, Jeges S, et al. Effects of maternal central hemodynamics on
Funding fetal heart rate patterns. Acta Obstet Gynecol Scand 2007;86:711–4.
20. Bamber JH, Dresner M. Aortocaval compression in pregnancy: the effect of
changing the degree and direction of lateral tilt on maternal cardiac output.
None.
Anesth Analg 2003;97:256–8 [table of contents].
21. Abitbol MM. Supine position in labor and associated fetal heart rate changes.
Obstet Gynecol 1985;65:481–6.
Conflict of interest statement
22. Rees SG, Thurlow JA, Gardner IC, Scrutton MJ, Kinsella SM. Maternal cardiovascu-
lar consequences of positioning after spinal anaesthesia for Caesarean section:
None. left 15 degree table tilt vs. left lateral. Anaesthesia 2002;57:15–20.
23. Mendonca C, Griffiths J, Ateleanu B, Collis RE. Hypotension following combined
spinal-epidural anaesthesia for Caesarean section. Left lateral position vs. tilted
Acknowledgements supine position. Anaesthesia 2003;58:428–31.
24. Ueland K, Novy MJ, Peterson EN, Metcalfe J. Maternal cardiovascular dynamics.
IV. The influence of gestational age on the maternal cardiovascular response to
Author contributions: Dr Jeejeebhoy had full access to all of the posture and exercise. Am J Obstet Gynecol 1969;104:856–64.
data in the study and takes responsibility for the integrity of the data 25. Kinsella SM. Lateral tilt for pregnant women: why 15 degrees? Anaesthesia
and the accuracy of the data analysis. Study concept and design: 2003;58:835–6.
26. Ellington C, Katz VL, Watson WJ, Spielman FJ. The effect of lateral tilt on maternal
Jeejeebhoy, Zelop, Morrison, Windrim. and fetal hemodynamic variables. Obstet Gynecol 1991;77:201–3.
Acquisition of data: Jeejeebhoy, Zelop, Windrim. 27. Gupta B, Hartsilver E. Cardiac arrest during caesarean section for twins. Int J
Analysis and interpretation of data: Jeejeebhoy, Zelop, Morrison, Obstet Anesth 2008;17:196–7.
28. Steen PA, Kramer-Johansen J. Improving cardiopulmonary resuscitation quality
Windrim, Dorian and Carvalho. to ensure survival. Curr Opin Crit Care 2008;14:299–304.
Drafting of the manuscript: Jeejeebhoy. 29. Rudikoff MT, Maughan WL, Effron M, Freund P, Weisfeldt ML. Mechanisms
Critical revision of the manuscript for important intellectual of blood flow during cardiopulmonary resuscitation. Circulation 1980;61:
345–52.
content: Jeejeebhoy, Zelop, Morrison, Windrim, Dorian and Car-
30. Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting
valho. chest compressions for rescue breathing during cardiopulmonary resuscitation
Statistical analysis: Jeejeebhoy, Zelop. for ventricular fibrillation cardiac arrest. Circulation 2001;104:2465–70.
31. Garza AG, Gratton MC, Salomone JA, Lindholm D, McElroy J, Archer R. Improved
patient survival using a modified resuscitation protocol for out-of-hospital car-
Appendix A. Supplementary data diac arrest. Circulation 2009;119:2597–605.
32. Kundra P, Khanna S, Habeebullah S, Ravishankar M. Manual displacement of the
uterus during Caesarean section. Anaesthesia 2007;62:460–5.
Supplementary data associated with this article can be found, in 33. Morrison LJ, Deakin CD, Morley PT, et al. Part 8: advanced life support: 2010
the online version, at doi:10.1016/j.resuscitation.2011.01.028. International Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science with Treatment Recommendations. Circulation
2010;122(16 Suppl. 2):S345–421.
References 34. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special
situations: 2010 American Heart Association Guidelines for Cardiopulmonary
1. Lewis Ge. The Confidential Enquiry into Maternal and Child Health (CEMACH). Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18
Saving mothers’ lives: reviewing maternal deaths to make motherhood safer Suppl. 3):S829–861.
2003–2005. The seventh confidential enquiry into maternal deaths in the United 35. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guide-
Kingdom. RCOG Press; 2007. lines for Resuscitation 2010: section 8. Cardiac arrest in special circumstances:
2. Marelli AJ, Therrien J, Mackie AS, Ionescu-Ittu R, Pilote L. Planning the specialized electrolyte abnormalities, poisoning, drowning, accidental hypothermia,
care of adult congenital heart disease patients: from numbers to guidelines; an hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, elec-
epidemiologic approach. Am Heart J 2009;157:1–8. trocution. Resuscitation 2010.
3. Lewis. Why mothers die 2000–2002: confidential enquiry into maternal and 36. Stehr SN, Liebich I, Kamin G, Koch T, Litz RJ. Closing the gap between deci-
child health. London, UK: Centre for Maternal and Child Enquiries; 2004. sion and delivery – amniotic fluid embolism with severe cardiopulmonary
4. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and consid- and haemostatic complications with a good outcome. Resuscitation 2007;
erations related to preparticipation screening for cardiovascular abnormalities 74:377–81.
F.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809 809
37. Parker J, Balis N, Chester S, Adey D. Cardiopulmonary arrest in pregnancy: 39. McDonnell NJ. Cardiopulmonary arrest in pregnancy: two case reports of suc-
successful resuscitation of mother and infant following immediate caesarean cessful outcomes in association with perimortem Caesarean delivery. Br J
section in labour ward. Aust N Z J Obstet Gynaecol 1996;36:207–10. Anaesth 2009;103:406–9.
38. Page-Rodriguez A, Gonzalez-Sanchez JA. Perimortem cesarean section of 40. Rittenberger JC, Kelly E, Jang D, Greer K, Heffner A. Successful outcome utiliz-
twin pregnancy: case report and review of the literature. Acad Emerg Med ing hypothermia after cardiac arrest in pregnancy: a case report. Crit Care Med
1999;6:1072–4. 2008;36:1354–6.