Maternal Cardiac Arrest Research Articles

Emergencies in obstetric anaesthesia: a narrative review.

We conducted a narrative review in six areas of obstetric emergencies: category-1 caesarean section; difficult and failed airway; massive obstetric haemorrhage; hypertensive crisis; emergencies related to neuraxial anaesthesia; and maternal cardiac arrest. These areas represent significant research published within the last five years, with emphasis on large multicentre randomised trials, national or international practice guidelines and recommendations from major professional societies. Key topics discussed: prevention and management of failed neuraxial technique; role of high-flow nasal oxygenation and choice of neuromuscular drug in obstetric patients; prevention of accidental awareness during general anaesthesia; management of the difficult and failed obstetric airway; current perspectives on the use of tranexamic acid, fibrinogen concentrate and cell salvage; guidance on neuraxial placement in a thrombocytopenic obstetric patient; management of neuraxial drug errors, local anaesthetic systemic toxicity and unusually prolonged neuraxial block regression; and extracorporeal membrane oxygenation use in maternal cardiac arrest.

Maternal cardiac arrest secondary to choriosepsis after preterm premature rupture of membranes.

KEY POINTS A 28-year-old woman with a history of 3 pregnancies and 2 live births presented to the labour and delivery unit of a district general hospital with preterm premature rupture of membranes (PPROM) at 27 + 4 weeks’ gestation ([Figure 1][1]). Membrane rupture was confirmed on sterile

A modified Delphi approach to determine current treatment advances for the development of a resuscitation program for maternal cardiac arrest

ObjectiveMaternal cardiac arrest is a rare and complex process requiring pregnancy-specific responses and techniques. The goals of this study were to (1) identify, evaluate, and determine the most current best practices to treat this patient population and (2) establish a standardized set of guidelines to serve as a foundation for a future educational simulation-based curriculum.Study designWe used a three-step modified Delphi process to achieve consensus. Twenty-two healthcare experts from across North America agreed to participate in the expert panel. In round 1, 12 pregnancy-specific best practice statements were distributed to the expert panel. Panelists anonymously ranked these using a 7-point Likert scale and provided feedback. Round 2 consisted of a face-to-face consensus meeting where statements that had not already achieved consensus were discussed and then subsequently voted upon by the panelists.ResultsThrough two rounds, we achieved consensus on nine evidence-based pregnancy-specific techniques to optimize response to maternal cardiac arrest. Round one resulted in one of the 12 best practice statements achieving consensus. Round two resulted in six of the remaining 12 gaining consensus. Best practice techniques involved use of point-of care ultrasound, resuscitative cesarean delivery, cardiopulmonary resuscitation techniques, and the use of extracorporeal cardiopulmonary resuscitation.ConclusionThe results of this study provide the foundation to develop an optimal, long-term strategy to treat cardiac arrest in pregnancy. We propose these nine priorities for standard practice, curricula, and guidelines to treat maternal cardiac arrest and hope they serve as a foundation for a future educational curriculum.

Maternal and neonatal outcomes among pregnant women with cardiovascular disease in the Philippines: a retrospective cross-sectional study from 2015–2019

Purpose Several studies link maternal cardiovascular disease (CVD) to maternal and fetal morbidity and mortality. This study describes the profile of maternal, obstetric, and neonatal outcomes among pregnant women with CVD in a tertiary hospital in the Philippines. It identifies the clinical and sociodemographic variables associated with these outcomes. Materials and Methods A single-center, retrospective analysis of pregnant women admitted for delivery at the Philippine General Hospital from 2015 to 2019 was performed. Of these patients, pregnant women with CVD were identified as the cohort for this study. Data on clinical and sociodemographic factors, maternal major adverse cardiovascular events, neonatal adverse clinical events, and obstetric complications were collected. Logistic regression analysis was performed to determine the odds ratio for the risk factors for small-for-gestational-age (SGA) babies and preterm birth. Results Among 30,053 delivery admissions in the Philippine General Hospital from 2015 to 2019, 293 (0.98%) pregnant women had CVD. Of the CVDs present in this cohort, congenital heart diseases (n = 119, 40.6%) were the most common, followed by rheumatic heart disease (n = 109, 37.2%). Maternal adverse events were rarely observed. Four women experienced symptomatic arrhythmias, two presented with worsening heart failure, three experienced thromboembolic events, and one had cerebrovascular infarction. There was no reported maternal death, cardiac arrest, shock, or acute renal failure. The majority (69.3%) of the women included in the study were delivered by spontaneous vaginal delivery and assisted vaginal delivery by vacuum or forceps; however, a significant portion of these women had undergone cesarean section. Almost all the study cohort delivered live births, with most neonates being delivered at 37–38 weeks gestational age (83.6%) and only 16.0% born preterm. However, a significant portion, a third of the neonates, were classified as having low birth weight. Around 17.4% of neonates born from gravidocardiac mothers were admitted neonatal intensive care unit. Conditions associated with preterm birth were low educational attainment, previous history of early neonatal death, maternal low ejection fraction, and abnormal maternal left ventricular geometry. The conditions associated with SGA babies were high gravidity and parity, a history of abortion/stillbirth, a history of previous cesarean section delivery, low ejection fraction, a history of multiple gestations, and higher BMI. Conclusion In this cohort study, adverse maternal outcomes were rarely observed. CVD in pregnancy is associated with an increased risk of preterm birth and SGA babies. We identified certain maternal conditions and sociodemographic factors associated with these outcomes. Despite having CVD, our study cohort had no mortality from the pregnancy.

Staying Current: Developing Just-in-time Evidence-Based Learning Objectives for a Maternal Cardiac Arrest Simulation Curriculum

Background:Our objective was to review the latest evidence on resuscitation care for maternal cardiac arrest (MCA) and gain expert consensus on best practices to inform an evidence-based curriculum.Methods:We convened a multidisciplinary panel of stakeholders in MCA to develop an evidence-based simulation training, Obstetric Life Support™ (OBLS). To inform the learning objectives, we used a novel three-step process to achieve consensus on best practices for maternal resuscitation. First, we reaffirmed the evidence process on an existing MCA guideline using the Appraisal of Guidelines for Research and Evaluation (AGREE II). Next, via systematic review, we evaluated the latest evidence on MCA and identified emerging topics since the publication of the MCA guideline. Finally, we applied a modified Research and Development (RAND) technique to gain consensus on emerging topics to include as additional just-in-time best practices.Results:The AGREE II survey results demonstrated unanimous consensus on reaffirmation of the 2015 American Heart Association (AHA) MCA guideline for inclusion into the OBLS curriculum. A systematic review with deduplication resulted in 11,871 articles for review. After categorizing and synthesizing the relevant literature, we presented twelve additional best practices to the expert panel using a modified RAND technique. Upon completion, the 2015 AHA statement and nine additional just-in-time best practices were affirmed to inform the OBLS curriculum.Conclusions:A novel three-step process including reaffirmation of evidence process, systematic review, and a modified RAND technique resulted in unanimous consensus from experts in MCA resuscitation on existing and new just-in-time best practices to inform the learning objectives for an evidence-based curriculum.

P.173 Maternal cardiac arrest during emergency caesarean section: a likely case of amniotic fluid embolism

P.173 Maternal cardiac arrest during emergency caesarean section: a likely case of amniotic fluid embolism

A Validated Needs Assessment to Inform a Simulation-Based Maternal Cardiac Arrest Resuscitation Curriculum [A47

A Validated Needs Assessment to Inform a Simulation-Based Maternal Cardiac Arrest Resuscitation Curriculum [A47

A Rare Cause of Maternal Cardiac Arrest: Idiopathic Ventricular Fibrillation

Severe preeclampsia is one of the serious hypertensive disorders of pregnancy and is significantly associated with cardiovascular morbidity during delivery. Also, the risk of cardiac arrest is higher in this patients. Sudden cardiac arrest (SCA) usually develops due to ventricular fibrillation (VF) or rapid ventricular tachycardia (VT) in the presence of cardiac pathologies. Idiopathic VF (IVF) is a resuscitated cardiac arrest with documented VF without known cardiac, respiratory, metabolic, toxicological etiology. Maternal cardiac arrest (MCA) is a rare condition but may occur even in the best medical health care systems; fast and specified intervention is required. In this case report, we aimed to present our postpartum patient who developed cardiac arrest due to IVF, which is rare in maternal cardiac arrest, and underwent successful cardiopulmonary resuscitation.

Perimortem and postmortem caesarean section: a systematic review

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.

Effectiveness of calcium administration in maternal cardiac arrest associated with hypermagnesemia: A scoping review

Effectiveness of calcium administration in maternal cardiac arrest associated with hypermagnesemia: A scoping review

Effect of maternal positioning during cardiopulmonary resuscitation: a systematic review and meta-analyses

BackgroundAlthough rare, cardiac arrest during pregnancy is the leading cause of maternal death. Recently, its incidence has been increasing worldwide because more pregnant women have risk factors. The provision of early, high-quality cardiopulmonary resuscitation (CPR) plays a major role in the increased likelihood of survival; therefore, it is important for clinicians to know how to manage it. Due to the aortocaval compression caused by the gravid uterus, clinical guidelines often emphasise the importance of maternal positioning during CPR, but there has been little evidence regarding which position is most effective.MethodsWe searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and OpenGrey (updated on April 3, 2021). We included clinical trials and observational studies with reported outcomes related to successful resuscitations.ResultsWe included eight studies from the 1,490 screened. The eight studies were simulation-based, crossover trials that examine the quality of chest compressions. No data were available about the survival rates of mothers or foetuses/neonates. The meta-analyses showed that resuscitation of pregnant women in the 27°–30° left-lateral tilt position resulted in lower quality chest compressions. The difference is an 19% and 9% reduction in correct compression depth rate and correct hand position rate, respectively, compared with resuscitations in the supine position. Inexperienced clinicians find it difficult to perform chest compressions in the left-lateral tilt position.ConclusionsGiven that manual left uterine displacement allows the patient to remain supine, the resuscitation of women in the supine position using manual left uterine displacement should continue to be supported. Further research is needed to fill knowledge gaps regarding the effects of maternal positioning on clinical outcomes, such as survival rates following maternal cardiac arrest.

Impact of foeto-maternal resuscitation and perimortem caesarean section simulation training: An opinion survey of healthcare participants

Background: The incidence of maternal cardiac arrest is rising in recent years. Medical staff generally lack the experience of performing resuscitation on pregnant patients. Maternal cardiac arrest and perimortem caesarean section simulation training was newly introduced in the Advanced Life Support in Obstetrics provider courses in Hong Kong since April 2021. Objective: To evaluate the course participants’ opinions on maternal cardiac arrest simulation training. Methods: A questionnaire survey was conducted for all participants in the Advanced Life Support in Obstetrics provider course in April 2021 to assess their opinions on the usefulness of this training. Results: There were four Advanced Life Support in Obstetrics provider courses in April 2021 with 36 participants in each course, and 137 questionnaires were received at the end of the course. The response rate was 137/144 (95.1%). After excluding the questionnaires with incomplete information, 134 questionnaires were included for final analysis. Almost all of the participants agreed that the maternal cardiac arrest simulation training could help them in their work (97.8%), could improve their knowledge and skill (98.5%) and could improve team training and co-ordination (97.0%). The majority of them (97.0%) felt more confident in managing maternal cardiac arrest after the training, and 97.8% of participants felt that the perimortem caesarean section model was useful for training. Around 80% of the participants would recommend this course to their colleagues. There were no significant differences in opinions on the usefulness of this training among participants with regard to their specialty, whether they were doctors or nurses, their years of experience and the specific hospital settings. Conclusions: Maternal cardiac arrest simulation training was highly valued by all levels of obstetric, emergency medicine and anaesthesia staff in both public and private hospitals.

The association of obstetric anesthesiologists, India – An expert committee consensus statement and recommendations for the management of maternal cardiac arrest

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.

Perimortem caesarean section

Maternal cardiopulmonary arrest is a very rare event whose prognosis might depend on the response to the event. We present the case of an unbooked G5P4 who had an arrest following two eclamptic fits. She had an on-site perimortem cesarean section and was delivered of a live female baby with a birth weight of 4.95 kg. She was subsequently transferred to the intensive care unit where she later died 5 days postdelivery. The baby was discharged home 4 days postdelivery with no neurological deficit. In managing such cases, multidisciplinary management must be the approach from the point of making the diagnosis to performing a resuscitative hysterotomy, as such reducing cardiac arrest delivery interval to the barest minimum.

The Feasibility of Intensive Care Paramedics Performing a Resuscitative Hysterotomy in Out-of-Hospital Maternal Cardiac Arrest

The Feasibility of Intensive Care Paramedics Performing a Resuscitative Hysterotomy in Out-of-Hospital Maternal Cardiac Arrest

Lessons learned in maternal cardiopulmonary arrest simulation: where should educational efforts be concentrated?

Deficiencies exist in the management of maternal cardiac arrest (MCA). Given the rarity of the event, simulation is vital to determine best practices. We analyzed action-based performance in multidisciplinary, simulated MCA scenarios to determine characteristics of teams that can initiate delivery by 4 minutes, as recommended by the American Heart Association (AHA).

Pilot Study of Simulation-based Resuscitation Curriculum for Maternal Cardiac Arrest, Obstetric Life SupportTM

Pilot Study of Simulation-based Resuscitation Curriculum for Maternal Cardiac Arrest, Obstetric Life SupportTM

A ten-year retrospective review of maternal cardiac arrest: Incidence, characteristics, causes, and outcomes in a tertiary-care hospital in a developing country

ObjectiveMaternal cardiac arrest is rare. We retrospectively reviewed and reported (1) the incidence of maternal cardiac arrests during admissions for delivery; (2) the characteristics and causes of cardiac arrest; and (3) the mortality rate and outcomes in a referral, single-university, teaching hospital in Thailand. Materials and methodsData on 23 cardiac arrests during admissions for delivery in the decade January 2006–December 2015 were retrospectively chart-reviewed. Patients with gestational ages under 24 weeks or cardiac arrests and death occurring before hospital arrival were excluded. The clinical characteristics of the arrests and outcomes were collected. ResultsOf 89,368 deliveries during the decade, 23 women suffered cardiac arrest (incidence, 1:3885), with 3 of those arrests occurring before delivery (incidence, 1:29,789). One patient underwent a perimortem cesarean delivery in the operating theatre. The most common reasons for the arrests were hypertension during pregnancy and cardiovascular causes (30.4% and 21.7%, respectively). Amniotic fluid embolisms were suspected for 2 patients (8.7%) with unidentified causes. The incidence of maternal deaths in peripartum cardiac arrests was 20/23, representing 86.9% (95% CI, 67.9–95.5) or 1:4468 of deliveries. Three patients suffering cardiac arrests after delivery survived to discharge. ConclusionsWe found a high maternal mortality rate following cardiac arrests during hospitalization for delivery. To decrease the incidence of arrests during the peripartum period and diminish the maternal mortality rate, identification of the causes and precipitating factors is vital. High-risk pregnant women require multidisciplinary care to improve the survival-to-discharge rate.

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

Maternal in-hospital cardiac arrest is a rare event with the potential for resuscitation treatment delays because of the difficulty accessing hospital obstetrical units and limited simulation training or resuscitation experience of obstetrical staff. However, it is unclear whether survival rates and processes of care differ between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest. We aimed determine whether to there are delays in process measures and differences in survival outcomes between pregnant and nonpregnant women who have in-hospital cardiac arrest. Using data from 2000 to 2019 in the Get With The Guidelines-Resuscitation registry, we compared resuscitation outcomes between women aged 18 to 50 years with a maternal or nonmaternal in-hospital cardiac arrest. Using a nonparsimonious propensity score, we matched patients with a maternal in-hospital cardiac arrest to as many as 10 women with a nonmaternal in-hospital cardiac arrest. We constructed conditional logistic regression models to compare survival outcomes (survival to discharge, favorable neurologic survival [discharge cerebral performance score of 1], and return of spontaneous circulation) and processes of care (delayed defibrillation [>2 minutes] and administration of epinephrine [>5 minutes]) between women with a maternal in-hospital cardiac arrest vs those with a nonmaternal in-hospital cardiac arrest. Overall, 421 women with a maternal in-hospital cardiac arrest were matched by propensity score to 2316 women with a nonmaternal in-hospital cardiac arrest. The mean age among propensity score-matched women with a maternal in-hospital cardiac arrest was 31.4 (standard deviation, 6.5) years, where 33.7% were of Black race and 86.9% had an initial nonshockable cardiac arrest rhythm. Unadjusted survival rates were higher in women with a maternal in-hospital cardiac arrest than in women with a nonmaternal in-hospital cardiac arrest: survival to discharge of 45.1% vs 26.5%, survival with cerebral performance category 1 status of 36.1% vs 17.7%, and return of spontaneous circulation of 75.8% vs 70.6%. After adjustment, there was no difference in the likelihood of survival to discharge (odds ratio, 1.19; 95% confidence interval, 0.82-1.73) or return of spontaneous circulation (odds ratio, 0.94; 95% confidence interval, 0.65-1.35) between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest. However, women with a maternal in-hospital cardiac arrest were more likely to have favorable neurologic survival (odds ratio, 1.57; 95% confidence interval, 1.06-2.33). Compared with women with a nonmaternal in-hospital cardiac arrest, women with a maternal in-hospital cardiac arrest had similar rates of delayed defibrillation (42.5% vs 34.4%; odds ratio, 1.14 [95% confidence interval, 0.41-3.18]; P=.31) and delayed administration of epinephrine (13.8% vs 10.6%; odds ratio, 0.96 [95% confidence interval, 0.50-1.86]; P=.09). Although concerns have been raised about resuscitation outcomes in women with a maternal in-hospital cardiac arrest, the rates of survival and resuscitation processes of care were not worse in women with a maternal in-hospital cardiac arrest.

Perimortem Caesarean Section - Every Second Counts! A Report of Two Cases

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.