Cardiac Arrest in Pregnancy: Increasing Use of Perimortem Caesarean Section Due to Emergency Skills Training?

Abstract

Cardiac arrest during pregnancy is rare. A rapid response is critical to improve the likelihood of survival for both the mother and the fetus. Perimortem cesarean section (PMCS) provides a treatment approach recommended by the Managing Obstetric Emergencies and Trauma (MOET) course, which was designed to provide a systematic approach to manage obstetric emergencies. The aim of this retrospective cohort study was to determine whether the use of PMCS was increased in the Netherlands following the introduction of the MOET course in 2003. All cases of cardiac arrest during pregnancy, which were treated with PMCS between 1993 and 2008, were identified through contact with Dutch obstetricians, all MOET instructors, and Advanced Life Support Group (ATLS) instructors. The case information was cross-checked with data from a nationwide severe maternal morbidity study and the Dutch Maternal Mortality Committee. The primary outcome measures were the incidence and case fatality rate of PMCS and comparison of its incidence before and after the introduction of the MOET Course. Maternal and neonatal outcomes following PMCS were analyzed. Of the 55 women identified who had a cardiac arrest during the study period, 12 underwent PMCS. In the 11 years before the introduction of the MOET course, 4 of 32 cases of resuscitation in pregnancy underwent PMCS (0.36/yr), whereas in the 5 years after its introduction, PMCS were performed in 8 of 23 cases (1.6/yr, P = 0.01). None of the women underwent PMCS within the recommended 5 minutes after starting resuscitation. Of the 12 women, 8 (67%) who underwent PMCS regained cardiac output after the procedure. Among the 12 cases of PMCS, the maternal case fatality rate was 83% (10/12) and the neonatal case fatality rate was 58% (7/12). There was unnecessary delay in performing PMCS in the majority of cases. Delay as a result of transporting the woman to the operating theater, and/or by applying fetal monitoring was common. These findings show that the use of PMCS has increased following the introduction of MOET but outcome is still poor. More timely use of PMCS is critical for obtaining improved maternal and fetal outcomes.