1 Supplemental Table 1. Patient bloodwork results
Test type
Time of test
15:10 15:32 16:15 18:10 19:05 21:49 22:43 Glucose,
mmol/L
3.0 4.4
Na+, mmol/L
136 139
K+, mmol/L
4.1 3.6
Cl–, mmol/L
108 110
Lactate, mmol/L
2.4 6.42
Clauss fibrinogen, g/L
2.1 0.9 0.7 1.3 1.0 1.7
INR-PT 1.1 1.3 1.5 1.4 25 25 1.3
aPTT, s 21 91 58 >150 >150
TCT 2 U, s >150
aPTT, activated partial thromboplastin time; INR-PT, international normalized ratio-prothrombin time;
TCT, thrombin clotting time
2
Supplemental Table 2. Causes of maternal cardiac arrest.
1-5A to H Checklists Cause
Anesthesia Failed airway
High spinal
Local anesthetic toxicity
Bleeding Intra-/post-partum hemorrhage
Cardiovascular Peripartum cardiomyopathy
Ischemic heart disease Valvular lesions Aortic dissection
Drugs Magnesium overdose
Narcotic overdose
Anaphylaxis; consider drugs or latex
Embolic Thromboembolism
Amniotic fluid embolism
Febrile causes Sepsis
Malignant hyperthermia
General H’s and T’s*
Hypertensive disorders of pregnancy
*Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hyper-/hypokalemia, and Hypothermia; and Toxins, Tamponade (cardiac),Tension pneumothorax, and Thrombosis (coronary and pulmonary)
3
Supplemental Table 3. Cardiac arrest management specific to pregnancy.
1-5Management of instability pre-arrest
• Full left lateral decubitus position
• 100 % oxygen by mask
• Place IV access above the diaphragm
• Plan for perimortem Cesarean delivery
• Plan for neonatal resuscitation
• If indicated, use chest thrusts instead of Heimlich maneuver
• If amniotic fluid embolism suspected, consider activating Massive Transfusion Protocol
Management of cardiac arrest (Basic cardiac life support and ACLS to be performed as for the non-pregnant patient, with the following considerations):
• Record accurate time of arrest
• Chest compressions:
o Maintain supine position
o Left lateral uterine displacement by hand, pulled or pushed upward and laterally 1.5” (3.81 cm)5 o Hand position as for non-pregnant patient: Lower half of sternum1
o Compression depth 2”, (5 cm), 100 times/minute
• Defibrillation:
o Dosage as for non-pregnant patient: 120-200 J (biphasic)
o Anterior-posterior4 or anterolateral pad placement,1 with lateral pad under left breast. Pads with adhesive preferred.
o Remove fetal electrodes only if time allows
• Airway management:
o Anticipate airway edema and tissue friability, making intubation more difficult1
o Failed intubation attempts may cause further airway swelling.5 Two attempts recommended before change in technique.
o Consider two-handed mask placement, with oral airway
o Early intubation with smaller endotracheal tube: 6-7 mm internal diameter, or smaller if airway swollen4 o Avoid hyperventilation
o Supraglottic airway if intubation fails
o Cricothyrotomy in “can’t intubate, can’t ventilate” scenario o Cricoid pressure is not recommended1
o Monitor end-tidal CO2: Target > 10 mm Hg
• Pharmacology (use ACLS drugs at usual doses1):
o Epinephrine 1 mg IV or IO injection, every 3-5 minutes until return of spontaneous circulation1,4
4
o Amiodarone 300 mg IV or IO, with repeat dose of 150 mg4for refractory ventricular tachycardia or ventricular fibrillation1,4
o CaCl2 1 g or calcium gluconate 3 g if magnesium toxicity or hyperkalemia suspected2,4,5
o Intralipid 20% emulsion 1.5 ml/kg bolus, then 0.25-0.5 mL/kg/min by infusion, if intravenous local anesthetic toxicity suspected5
o Naloxone if narcotic overdose suspected4
• Perimortem Cesarean delivery:1-5
o Indicated if return of spontaneous circulation not achieved by 4 minutes and uterus is at or above umbilicus.
o Later attempts have been successful
o Consider an immediate start if patient has sustained non-survivable trauma or an unwitnessed arrest o Perform at site of arrest
ACLS, advanced cardiac life support; IO, intraosseous; IV, intravenous