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Pregnancy and Postpartum Considerations 733

FHR
FHR

UA
UA
FIGURE 26.4 Normal CTG trace. FHR = fetal heart rate; UA = uterine activity.

MODIFICATIONS TO BASIC AND ADVANCED disease is moderate or severe the fetus can have a more
LIFE SUPPORT marked anaemia and erythroblastosis. When the disease
Generally speaking, all standard basic and advanced life is very severe it can cause morbus haemolyticus neonato-
rum, hydrops fetalis or stillbirth. Management of Rhesus
support algorithms can be used with only minor adapta- disease is outlined in Table 26.6.
tions for the pregnant and postpartum woman (Box
26.10). 187 First, for women over 20 weeks’ gestation, the Most Rhesus disease can be prevented by treating the Rh-
sheer bulk of the uterus and contents impair any ability negative mother during pregnancy or promptly (within
to obtain adequate circulation using cardiac compres- 72 hrs) post childbirth. 188 The mother is given an intra-
sions. Left lateral displacement of the uterus is necessary muscular injection of 500 IU of anti-D immunoglobulin
to enable optimal venous return and cardiac output. which destroys any Rh D positive fetal red blood cells in
Regardless, it is very difficult to obtain adequate perfusion her circulation before the maternal immune system can
during CPR of an obviously pregnant woman and discover them and produce antibodies. This is passive
arrangements should be made for an emergency caesar- immunity and the effect of the immunity will diminish
ean section. Delivery of the fetus within five minutes of post injection at around 4 to 6 weeks. Anti-D immuno-
a witnessed arrest is generally desired. Second, expect a globulin is used to prevent the development of anti-D
difficult intubation and try to have an experienced person antibodies and is of no use once the antibodies
intubate the trachea. Third, consider the list of obstetric are present. Administration of 500 IU of anti-D immu-
conditions that may have precipitated the arrest and noglobulin to all Rhesus D-negative pregnant women at
provide any specific appropriate treatment. Cardiac arrest 28–34 weeks is now routine care, even in the absence of
in pregnancy is a rare event and the chance of a successful any vaginal bleeding.
resuscitation is about the same as a non-pregnant arrest.

PREVENTION OF RHESUS DISEASE Practice tip
During pregnancy, a small amount of the fetal blood can The dose of anti-D immunoglobulin depends on the amount of
enter the maternal circulation. If the mother is Rh-negative fetal blood cells detected in the maternal blood using the
and the fetus is Rh-positive, the mother produces anti- Kleihauer-Betke test. The more fetal cells present, the higher the
bodies against the Rhesus D antigen on her baby’s red dose of anti-D required.
blood cells. During this, and subsequent pregnancies, the
anti-D antibodies are able to pass across the placenta to
the fetus and if the level is sufficient, cause destruction of MEDICATION ADMINISTRATION IN
Rhesus D-positive fetal red blood cells, leading to the PREGNANCY
development of Rhesus disease. The disease ranges from Many drugs used in the critical care environment have
mild to severe; when the disease is mild the fetus may not been researched for safe use in pregnant or lactating
develop mild anaemia with reticulocytosis. When the mothers. There are two key periods when consideration