Acute uterine torsion complicated by severe placental abruption resulting in maternal cardiopulmonary arrest.

Motor Vehicle Accidents in Pregnancy: Implications and Management

Cardiac arrest in pregnancy is a rare, catastrophic condition that can lead to major morbidity and mortality for both mother and baby. Prompt high-quality resuscitative measures need to be employed keeping in mind the altered maternal anatomy and physiology, presence of a compromised fetus, and an urgent need to deliver the baby for optimizing maternal and fetal outcomes. Therefore, it is important that health care facilities make appropriate systems in consonance with the latest recommendations of cardiopulmonary resuscitation (CPR) for this special group of parturients. Despite protocols and training, the clinical scenario often is emotionally overwhelming and brings forth an enormous cognitive load of resuscitating two lives along with the performance of perimortem cesarean delivery (PMCD) or resuscitative hysterotomy. We report five cases of maternal cardiac arrest referred to our tertiary care hospital, wherein PMCD was performed as part of ongoing high-quality CPR with manual left uterine displacement. Two mothers had a return of spontaneous circulation (ROSC), whereas ROSC could not be achieved in three. One neonate had an Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score of 8. Four neonates needed CPR, and ROSC was achieved in two of these. Underlying causes were mainly severe hemorrhagic shock, eclampsia, severe pre-eclampsia, and anaphylactic reactions. Poor survival rates in our initial experience of setting up a maternal code blue mechanism as per the guidelines reflect the need for reinforcement of early PMCD, use of cognitive aids, and retraining using mock drills and simulation for better outcomes in the future. In addition, awareness of modified obstetric warning signs in peripheral hospitals is essential so that timely referral to tertiary care centers can help salvage precious lives.

要旨【目的】妊婦が心肺停止に至ったときに，母体救命のため 死戦期帝王切開PMCD（perimortem cesarean delivery）を行うことが考慮される。当院は院外症例の受け入れ体制は整っていたが，院内症例の体制整備はされておらず，心停止から5分以内にPMCDを実施することが可能な体制をつくることとした。【対象】産科病棟で発生したと想定し，問題点の抽出をした。実施場所に関して，手術室で行うには手術申込みや入室認証が必要であったため，少しでも時間を短縮させるため分娩室とした。実施までのフローシート，連絡経路も事前に作成した。PMCDの適応や効果に関して教育を行い，PMCD器材と，新生児蘇生器材とに分けて準備し，シミュレーションを行った。【結果】第1回目のシミュレーションは救急科医の到着を待って，分娩室に移動しPMCDを実施したが，実施までに14分かかった。2回目は，心肺停止を覚知後すぐに患者を分娩室に移動させPMCDを実施し，4分で行うことができた。除細動の適応波形の場合にはどうするべきか，などの新たな問題点が抽出された。【結語】院内発生の妊婦心肺停止症例では，心停止から医療従事者接触までの時間が短く救命できる可能性が高い反面，短時間でPMCD実施の決断や実行が求められるため，シミュレーショントレーニングは重要と考えられる。

Maternal cardiac arrest is an uncommon, devastating event that requires rapid, coordinated action from multiple specialties to give both mother and baby the best chance of survival. We report a 29-year-old woman at 34 weeks and two days of gestation who came to the emergency department with severe preeclampsia and respiratory distress, eventually leading to cardiac arrest. Immediate cardiopulmonary resuscitation (CPR) was started with left uterine displacement (LUD), and return of spontaneous circulation (ROSC) was achieved after five cycles. A lower-segment cesarean section was performed right away, with the baby delivered 15 minutes after ROSC. The neonate was delivered in a state of cardiac arrest, necessitating immediate resuscitation and subsequent admission to the neonatal intensive care unit (NICU). The mother required invasive mechanical ventilation, antihypertensive therapy, and other supportive care. She was discharged to the ward on the third day and was ultimately discharged without apparent neurological sequelae. This case highlights the critical importance of rapid identification and execution of perimortem cesarean section (PMCS) for maternal cardiac arrest to optimize maternal and neonatal survival outcomes. Although perimortem delivery is ideally undertaken within the first few minutes, this case suggests that decisive clinical judgment and effective multidisciplinary coordination, combined with continued high-quality CPR, can yield favorable outcomes even when delivery occurs after 15 to 20 minutes.

Perimortem caesarean section (PMCS), also referred to as resuscitative hysterotomy, is a caesarean section done during maternal cardiac arrest with the ultimate goal to assist maternal resuscitation with a good foetal outcome. Here, we present a report of two cases of PMCS performed in the setting of maternal cardiac arrest in a tertiary care hospital. Both the mothers had underlying cardiac disease and the cause of cardiac arrest was pulmonary embolism in first case and arrhythmia in the other. When there was no return of spontaneous circulation (ROSC) by 5 minutes of resuscitation, PMCS was done at the place of the cardiac arrest. The patients were made supine, left uterine displacement was done and cardio-pulmonary resuscitation (CPR) was continued. The abdomen and the uterus was opened by a scalpel via a midline vertical incision. The baby was handed over to the paediatrician. CPR was continued while the surgery was taking place. The mothers could not be revived in any of the cases, but babies were resuscitated well and later discharged in healthy condition. Clinicians should be aware of the need of PMCS in case of cardiac arrest in pregnant women at or above 20 weeks of gestation.

A manuscript entitled “Maternal Collapse: Challenging the Four-minute Rule” by Benson et al. (2016)), published in EBioMedicine, proposed a new point of view for perimortem Cesarean section (PMCS): one procedure intending not only to save the fetus, but for resuscitation of pregnant women after cardiopulmonary arrest after 20 weeks of gestational age. In obstetrics, obstetric anesthesia, and emergency medicine, the “Four-minute Rule” is regarded as a gold standard for the decision of PMCS; maternal recovery rate after PMCS was significantly decreased when the fetus was delivered over 5 min after maternal cardiac arrest, and a “skilled” obstetrician was expected to complete Cesarean delivery within 1 min of incision. (American Society of Anesthesiologists Task Force on Obstetric Anesthesia, 2007) However, Benson et al. posed the question on this standard that the injury-free survival for mother and baby showed no unique difference between four and five minutes (or any other minutes) of arrest to birth time. And as was expected, their search of the literature proved that many reports of PMCS showed durations longer than 1 min between incision and delivery, regardless of skill. One manuscript describing PMCS from the trainer's point of view was published in 2010 (Dijkman et al., 2010) and showed the increased number of PMCS after training of the procedure. However, in this report, no case of PMCS was completed within 5 min (although 2 out of 3 mothers and all fetuses survived after PMCS 5 to 15 min after arrest), similar to another report to which Benson et al. referred (Einav et al., 2012) (only 4 in 57 cases of PMCS performed and return of spontaneous circulation achieved). The most significant reason for delayed delivery may be hesitation to carry out PMCS; Dijkman claimed that there were no survivors of “out-of-hospital” arrest, even if PMCS was performed (Dijkman et al., 2010). What, then, can we propose next to universalize and improve the results of PMCS? Below are my personal recommendations, beyond the manuscript by Benson et al.: [1] making decisions more quickly, just as quick as possible, [2] changing the 4-minute rule to longer minutes like 10, 15 or 25 min, [3] training all obstetricians or emergency room doctors to complete PMCS within 1 min, or [4] beginning immediate use of mechanical (possibly percutaneous) cardiopulmonary support (or the invention of a new machine usable after shorter preparation). Since [3] and [4] are not realistic, [2] may be the easiest and most reasonable, given that former reports showed expectations of maternal survival at more than 5 min but less than 10 or 15 min (Dijkman et al., 2010, Einav et al., 2012), but as a “rule”, it seems too long. The option [1], proposed in this manuscript by Benson et al., is another possible tactic, but it may cause harsh mental pressure on bystanders to make a decision of non-anesthetic cesarean section within 2 or 3 min after arrest, as it allows only one cycle of cardiac massage and automated external defibrillator (AED) use on basic life support (BLS). However, the latest recommendation by the International Liaison Committee on Resuscitation (ILCOR) also specified that there was no specific time interval by which delivery should begin, which Benson et al. clearly supported in this manuscript (Soar et al., 2015). At least, we must modify the process flow to include PMCS from when we initially encounter cardiac arrest in pregnant women, as a new recommendation.

Dear Editor, Cardiac arrest in pregnancy is a rare event with an incidence of 1 per 30,000 pregnancies in western countries. However, it is important for emergency physicians to be familiar with the indications for performing a perimortem caesarean section (PMCS). We report two cases of PMCS performed during cardiopulmonary resuscitation (CPR). The first case, a 37-year-old female, G1P0, had a medical history of epilepsy. Her pregnancy was complicated at 30 weeks gestation by a single uncomplicated grand mal seizure as a result of low valproate level. She was admitted, at 35 weeks gestation, for pregnancy-induced hypertension. Laboratory results were normal. Two days after admission she was found unresponsive. She had pulseless electrical activity (PEA) and hypoxia due to an epileptic insult was considered the diagnosis. She was treated according to the advanced cardiac life support protocol. Fifteen min after the start of CPR a PMCS was performed. There was an immediate return of spontaneous circulation (ROSC). Unfortunately 2 days later her treatment had to be withdrawn, because of poor neurological prognosis. The male infant (2,300 g; Apgar score 0/6/7) had seizures and was resuscitated. The baby survived, and follow-up 12 months after delivery showed normal growth and slight neurologic development impairment. The second case, a 35-year-old female, G3P1, had an uneventful medical history and was admitted for induction of labour at 41 weeks and 3 days gestation. After spontaneous rupture of membranes the patient suffered from dyspnoea, hypotension, bradycardia, and cyanosis. Supplemental oxygen and left lateral tilt position did not alleviate the symptoms. Upon arrival of the resuscitation team the patient had PEA. Amniotic fluid embolism was considered the diagnosis. Perimortem caesarean section was performed in the delivery room after 4 min, resulting in the immediate ROSC and the birth of a girl (3,450 g; Apgar score 2/6/7). Both were discharged without abnormalities. During CPR in late pregnancy the patient should be positioned in left lateral tilt to alleviate aortocaval compression [1]. If sufficient cardiac output is not achieved within 4 min after cardiac arrest, in a pregnancy of more than 20 weeks gestation, PMCS must be considered [1]. In our cases an important observation was made that immediately after delivery of the infant there was a ROSC, indicating that indeed pooling of blood in the uterus and placenta as well as aortocaval compression played a pivotal role in the prior unsuccessful resuscitation. We performed two PMCS in our hospital. The first PMCS was before the courses based on the Managing Obstetric Emergencies and Trauma (MOET) principles were given at our institution [2, 3]. Important differences between the first and second case were the immediate awareness of the necessity to perform PMCS in the first 4 min after persistent cardiopulmonary arrest, the availability of an emergency PMCS box [4] in the delivery room and the notion to perform the PMCS on the spot. This all resulted in a much faster delivery of the baby and more importantly much faster return of the maternal circulation, resulting in favourable clinical outcome for both mother and child.

To analyze the cause and clinical characteristics of maternal cardiac arrest. The data of all cases of maternal cardiac arrest from January 2005 to December 2009 in Third Affiliated Hospital of Guangzhou Medical College was retrospectively studied. (1) A total of 41 maternal cardiac arrests (6 in prenatal period, 2 in the first stage of labor, 7 in the third stage of labor, 26 in postpartum period) were included. All patients regained spontaneous circulation after basic life support. Twelve (29%) mothers survived. Twelve cardiac arrests occurred in the hospital, and the total delivery number from January 2005 to December 2009 was 17 101, with occurrence rate of 1:1425. (2) The causes of arrest were hemorrhagic shock (12, 29%), amniotic fluid embolism (7, 17%), severe preeclampsia/eclampsia (7, 17%), septic shock (6, 15%), cardiac disease (2, 5%), unidentified cause (2, 5%) and other occasional causes. (3) Thirty-seven (90%) in-hospital maternal cardiac arrest occurred in operation room (16, 39%), ICU (7, 17%), maternity wards (6, 15%), delivery room (5, 12%) and the emergency room (3, 7%). Three (7%) arrest occurred out of hospital and one in the ambulance. Maternal survival rate was 2/3 in the emergency room, 8/16 in the operation room, 1/5 in the maternity wards, and 1/6 in the delivery room. No mother survived in ICU, ambulance or out of hospital. (4) Five of the 12 survived women showed ischemic encephalopathy after cardiac arrest and one of them developed cerebral infarction in the right corona radiate. (5) In 4 of the 8 cases of cardiac arrest in pregnancy, perimortem caesarean section (PMCS) was performed. In the four PMCS, 2 mothers and 2 children survived. In the 4 cases that PMCS was not carried out, no infant survived. Hemorrhagic shock, severe preeclampsia and eclampsia, amniotic fluid embolism are the major obstetric causes of maternal cardiac arrest. Septic shock and cardiac diseases are the major non-obstetric causes. Cardiac arrests occurred in emergency room and operation room has a higher maternal survival rate than those occurred in the delivery room and maternity wards. Timely PMCS may ensure the optimal outcome for mothers and fetuses.

Maternal cardiac arrest is a catastrophic event, with data regarding outcomes and feasibility of timely resuscitative hysterotomy remaining scarce. Our retrospective cohort study identified 31 pregnant or postpartum patients with in-hospital cardiac arrest at a tertiary care center over 15.5 years, an incidence of 2 per 10,000 deliveries (95% CI, 1.4-2.8/10,000 deliveries). Return of spontaneous circulation (ROSC) occurred in 87.1% of the patients (95% CI, 75.2-98.8%) within a median of 2 minutes, and 77.4% (95% CI, 62.6-92.1%) survived until discharge. Eleven instances of cardiac arrest (35.5%) occurred antepartum, predominantly due to anesthetic complications. Two resuscitative hysterotomies were performed, with code-to-delivery time of 4 minutes and 100% neonatal survival. Twenty instances of cardiac arrest (64.5%) were immediately postpartum, primarily after hemorrhage or amniotic fluid embolism. Our findings demonstrate high rates of ROSC and survival in a tertiary care setting, which help to confirm feasibility and utility of rapid resuscitative hysterotomy.

A 9 yr old, unknown weight, intact female domestic shorthair presented for evaluation of dystocia with dyspnea. En route to the hospital for treatment, the owners noted the queen stopped breathing. On presentation, cardiopulmonary arrest was confirmed. The exact cause was unknown but suspected to be secondary to acute fulminant congestive heart failure or acute respiratory distress syndrome due to a large volume of serosanguineous fluid within the mouth and nose. Cardiopulmonary resuscitation (CPR) was immediately started. After 2 min of CPR without return of spontaneous circulation, the owners consented to perimortem Cesarean section. Two kittens were removed via emergency hysterotomy within 3-4 min. Both kittens were successfully resuscitated. CPR efforts were continued on the queen for 2 min after delivery of the kittens, at which time the owners elected to stop further resuscitative efforts. Both kittens were discharged from the hospital and were alive at last follow-up, 2 yr and 4 mo after birth. There are no previous reports regarding the use of a perimortem Cesarean section to deliver neonates in small animal medicine. Therefore, this report represents a novel treatment approach that can be considered in the case of maternal arrest during dystocia.

Rationale: Perimortem caesarean section (PMCS) is an emergency procedure performed in pregnant women over 20 weeks of gestation with cardiac arrest, in order to save the mother and the foetus, or only one of them. The objective of the review was to present clinical traits and evaluate survival of mothers and newborns as well as the complications following PMCS. Materials and methods: A systematic review between March and May 2021 was performed using the PRISMA method with the terms "perimortem caesarean section" "postmortem caesarean section", "maternal cardiac arrest", "perimortem caesarean section "AND "case report" "postmortem caesarean section" AND "case report". Results: 23 papers from 12 countries with 39 cases were counted. Of the total sample, 17.94% of the mothers survived and of these, 42.85% had neurological complications. Of 39 newborns counted, 69.23% survived, 28.20% died and in 2.56% the information was missing. 30.76% of the cases followed the five-minute rule and 56.41% required 6 or more minutes, 12.82% did not specify time. Conclusion: The results of this analysis demonstrated higher mortality in women who had a cardiac arrest during pregnancy related to the neonates who survived. The possibility of performing PMCS should neither be ruled out even if the established five-minute time frame has passed, nor should time be invested in verifying foetal viability.

Survival outcomes and resuscitation process measures in maternal in-hospital cardiac arrest

The optimal treatment of a severe hemodynamic instability from shock to cardiac arrest in late term pregnant women is subject to ongoing studies. However, there is an increasing evidence that early “separation” between the mother and the foetus may increase the restoration of the hemodynamic status and, in the cardiac arrest setting, it may raise the likelihood of a return of spontaneous circulation (ROSC) in the mother. This treatment, called Perimortem Cesarean Section (PMCS), is now termed as Resuscitative Hysterotomy (RH) to better address the issue of an early Cesarean section (C-section). This strategy is in contrast with the traditional treatment of cardiac arrest characterized by the maintenance of cardiopulmonary resuscitation (CPR) maneuvers without any emergent surgical intervention. We report the case of a prehospital perimortem delivery by Caesarean (C) section of a foetus at 36 weeks of gestation after the mother's traumatic cardiac arrest. Despite the negative outcome of the mother, the choice of performing a RH seems to represent up to date the most appropriate intervention to improve the outcome in both mother and foetus.

Maternal cardiac arrest (MCA) requires a multidisciplinary team well versed in the cascade of steps involved during resuscitation. Historically, maternal outcomes were poor, primarily because cardiac arrest management in pregnant women was neither optimum nor standardized. However, current evidence has shown better maternal survival given the young age and reversible causes of death. There are specific interventions such as manual left uterine displacement (MLUD) for relief of aortocaval compression that, if not performed, may undermine the success of resuscitation. The team should simultaneously explore the etiology of MCA, which could be a combination of pregnancy-related causes and comorbid conditions. Resuscitative Hysterotomy or Resuscitative Uterine Interventions (RUI) should be considered if there is no return of spontaneous circulation following 4–5 min of cardiopulmonary resuscitation. Teamwork is critical to success in the high-stakes environment of MCA. This consensus statement was prepared by the experts after reviewing evidence-based literature on maternal resuscitation during MCA.

Resuscitative cesarean delivery: when every second counts.