# A 35-year-old woman at 37 weeks gestation is in active labor when she suddenly develops severe dyspnea, cyanosis, and hypotension. The fetal heart rate shows bradycardia. The nurse suspects anaphylactoid syndrome of pregnancy (ASP). What is the priority nursing action?

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> subject: Maternal Newborn Health

## 문제

A 35-year-old woman at 37 weeks gestation is in active labor when she suddenly develops severe dyspnea, cyanosis, and hypotension. The fetal heart rate shows bradycardia. The nurse suspects anaphylactoid syndrome of pregnancy (ASP). What is the priority nursing action?

The patient becomes unresponsive with signs of cardiovascular collapse and respiratory distress during labor.

## 보기

1. Administer high-flow oxygen via a non-rebreather mask immediately
2. Position the patient flat with a left lateral tilt to relieve aortocaval compression
3. Call for immediate emergency assistance and prepare for cardiopulmonary resuscitation **✔ 정답**
4. Initiate rapid intravenous fluid bolus with crystalloid solution

**정답: 3**

## 해설

ASP requires immediate emergency assistance and CPR preparation due to rapid cardiovascular collapse. Other options delay critical resuscitation.

## 심화 해설

Understanding the Clinical Scenario

This question presents a classic, high-acuity obstetric emergency: anaphylactoid syndrome of pregnancy (ASP), more commonly referred to as amniotic fluid embolism (AFE). The sudden onset of severe dyspnea, cyanosis, hypotension, and fetal bradycardia in a laboring patient is the hallmark presentation. AFE is a rare but catastrophic condition with high morbidity and mortality, as highlighted in the provided literature [1][2]. The underlying pathophysiology is believed to be a biphasic reaction where amniotic fluid and fetal material enter the maternal circulation, triggering an immune-mediated response. This initially causes severe pulmonary vasoconstriction, leading to right heart failure, respiratory collapse, and hypoxemia, followed by left ventricular failure and cardiovascular collapse. The fetal bradycardia is a direct consequence of maternal hypoxemia and hypoperfusion.

Analyzing the Priority Nursing Action

The question asks for the priority nursing action when the patient becomes unresponsive with signs of cardiovascular collapse. This wording signals a shift from initial management to a life-threatening deterioration. In the NCLEX-RN framework, the priority is determined by the ABCs (Airway, Breathing, Circulation) and the nursing process, but when a patient is unresponsive and collapsing, the very first step is to activate the emergency response system to bring the necessary skilled personnel and equipment to the bedside. You cannot manage a maternal cardiac arrest alone.

- Option 1 (Administer high-flow oxygen) is a critical early intervention for the hypoxemia seen in AFE, but it addresses only the "Breathing" component. When the patient becomes unresponsive and is progressing to cardiac arrest, oxygenation without concurrent chest compressions and a coordinated team is insufficient.

- Option 2 (Position with a left lateral tilt) is a key intervention for relieving aortocaval compression to improve maternal circulation, but it is a preventative and supportive measure, not the immediate response to a full cardiovascular collapse.

- Option 4 (Initiate rapid IV fluid bolus) is part of the resuscitation algorithm to support circulation, but it is not the first independent nursing action when a patient loses consciousness and pulses may be absent.

Why Calling for Help and Preparing for CPR is the Priority

Option 3 (Call for immediate emergency assistance and prepare for cardiopulmonary resuscitation) is the correct answer because it reflects the most time-sensitive, life-saving intervention. When a patient becomes unresponsive with cardiovascular collapse, the immediate priority is to confirm the arrest, call a code, and initiate high-quality CPR. The systematic review by Hongo et al.  specifically examines advanced resuscitation strategies for cardiac arrest in pregnancy, underscoring that maternal cardiac arrest management is the central concern. The review highlights the critical role of immediate resuscitation, including the potential need for resuscitative delivery (perimortem cesarean section) to aid maternal circulation by relieving aortocaval compression. This complex, multidisciplinary response can only happen if the emergency team is activated without delay. The case reports [1] further illustrate that survival from AFE often requires advanced interventions like extracorporeal cardiopulmonary resuscitation (ECPR) and massive transfusion protocols, which are impossible to mobilize without first calling for help. The nurse’s primary role at this critical juncture is to recognize the arrest, summon the team, and begin BLS (Basic Life Support) until the code team arrives. All other interventions, including oxygen, positioning, and IV fluids, are performed simultaneously by the team after the code is activated.References (research sources)

- [1]Extracorporeal cardiopulmonary resuscitation for maternal cardiac arrest secondary to amniotic fluid embolism during external cephalic version: a case report.Case reportThiele CM, Seelhammer TG, Kuly HM, Torbenson VE, Peclat TR, Duda SL, Sharpe EE. (2026) · DOI: 10.1016/j.ijoa.2026.104917

- [2]Amniotic Fluid Embolism in Donor Egg Twin Pregnancy: A Clinical Challenge in Critical Care.Research articleOwies A, Attia A, John HT, Gajjar R, Abbas M. (2025) · DOI: 10.7759/cureus.84557

## 임상 시나리오

Clinical Practice Guideline for Anaphylactoid Syndrome of Pregnancy (Amniotic Fluid Embolism)

Anaphylactoid syndrome of pregnancy (ASP) is a catastrophic obstetric emergency requiring immediate, coordinated intervention. The cornerstone of survival is early recognition and high-quality, multidisciplinary resuscitation.

Immediate Response to Maternal Collapse

- **Activate the emergency response system.** Call a maternal code blue or adult code team immediately. State clearly that this is a maternal cardiac arrest.

- **Initiate high-quality CPR.** Begin chest compressions immediately. Perform continuous compressions with manual left uterine displacement (LUD) to relieve aortocaval compression and optimize venous return. If a second rescuer is available, the primary rescuer should focus solely on compressions while the other manages the airway and displacement.

- **Prepare for perimortem cesarean delivery.** If there is no return of spontaneous circulation (ROSC) within 4 minutes of the arrest, prepare to assist with an emergency cesarean delivery at the bedside. The goal is to deliver the fetus within 5 minutes of the arrest to improve both maternal and neonatal outcomes.

Key Resuscitation Modifications in Pregnancy

- **Left Uterine Displacement:** Continuously push the uterus to the left and upward. This is non-negotiable during CPR in a woman past 20 weeks gestation.

- **Airway Management:** Anticipate a difficult airway due to edema and decreased gastric emptying. Apply cricoid pressure during intubation and have suction immediately available.

- **Intravenous Access:** Establish two large-bore IV lines above the diaphragm to ensure medications and fluids reach the central circulation without being impeded by uterine compression of the inferior vena cava.

Nursing Priorities During the Event

- Assign a dedicated recorder to document all events, medications, and times.

- Delegate a team member to provide clear, ongoing communication with the patient's family.

- Prepare for massive transfusion protocol activation, as disseminated intravascular coagulation (DIC) and hemorrhage frequently follow the initial cardiopulmonary collapse.

- Ensure the neonatal resuscitation team is present and prepared for a compromised infant.

## 핵심 개념

- **Anaphylactoid Syndrome of Pregnancy (ASP)** — A rare, life-threatening obstetric emergency, also known as amniotic fluid embolism (AFE), characterized by sudden cardiovascular collapse, respiratory distress, and coagulopathy during labor or shortly after delivery.
- **Cardiopulmonary Resuscitation (CPR)** — An emergency procedure combining chest compressions and ventilation to manually preserve brain function and circulation in a person in cardiac arrest.
- **Aortocaval Compression** — Compression of the aorta and inferior vena cava by the gravid uterus when a pregnant woman lies supine, reducing venous return and cardiac output.
- **High-Flow Oxygen via Non-Rebreather Mask** — A device delivering high concentrations of oxygen (up to 90-95%) to a spontaneously breathing patient, used in respiratory emergencies to correct hypoxemia.

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