Episode 935: Pregnancy Extremis - TOLDD

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

• O: Administer high-flow adjunctive oxygen 

• L: Lines should be placed above the diaphragm

• 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

• D: Dates should be estimated

• > 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

• D: Call the labor and delivery unit for additional help

References

1. ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5)

2. 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

3. Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300

4. 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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