Maternal Resuscitation Research Articles

Enhancing maternal survival in traumatic cardiovascular collapse during pregnancy: A case series on resuscitative hysterotomy (RH) from a level 1 trauma center

Background: Trauma during pregnancy presents multifaceted risks to both the developing fetus and the expectant mother due to pregnancy-induced physiological adaptations that affect the response to traumatic injuries. The infrequent occurrence of cardiac arrest during pregnancy necessitates interventions such as perimortem cesarean section (PMCS), now termed resuscitative hysterotomy. While early resuscitative hysterotomy focused primarily on fetal survival, more recent literature reports substantial maternal benefits. Resuscitative hysterotomy can lead to the restoration of maternal pulse and blood pressure within minutes and has shown potential to improve maternal outcomes. RH has been demonstrated to aid in fetal and maternal survival in hemodynamic unstable pregnant patients before cardiovascular collapse. The linguistic change from PMCS to resuscitative hysterotomy is a shift towards maternal-centric approaches and survival. ObjectiveIn this series, we evaluate the outcomes of resuscitative hysterotomy performed before or after cardiovascular collapse to maximize maternal survival while concurrently optimizing fetal outcomes. MethodsWe performed a retrospective case series review of 4 consecutive pregnant trauma patients who underwent RH due to hemodynamic instability. In addition, we conducted a descriptive analysis of all pregnant patients from 2013 to May 2024 who presented due to a traumatic injury but did not require a RH. ResultsThe average age of patients undergoing RH was 26.5 ± 6.8 years. All patients were in the third trimester with a mean gestational age of 32.3 ± 0.5 weeks. Fifty percent (50 %) of patients were involved in motor vehicle accidents, one (25 %) pedestrian was hit by a vehicle, and one (25 %) had GSW to the head. The median time to RH was 14.5 min. The mean estimated blood loss (EBL) was 625 mL ±108.9 mL. The maternal survival rate was 50 %, with a fetal survival rate of 100 %. Three patients achieved hemodynamic stability; however, one of the patients progressed to death by neurological criteria. Therefore, we achieved 50 % of maternal survival. A resuscitative hysterotomy was performed due to early signs of maternal hemorrhagic shock and suggestive features of ongoing bleeding (persistent maternal tachycardia despite adequate analgesia and resuscitation, persistent maternal bradycardia, gradual decline of BP, and FHR abnormalities) in three patients. The remaining patient was found to have cardiac arrest at the scene with a brief return of spontaneous circulation and received resuscitative hysterotomy in the ED to restore cardiovascular function. ConclusionRH in pregnant patients with traumatic injury and impending hemorrhagic shock or cardiovascular collapse may provide maternal survival benefits by supporting circulatory function and promoting resuscitation with no additional risks to fetal outcomes. Quick decision-making is crucial to the implementation of this life-saving procedure. Further research with a more significant number of patients is needed to validate the efficacy of RH in maximizing maternal survival. This case series adds to the evolving literature on RH, shedding light on practical aspects and maternal outcomes to inform ongoing discussions and strategies for maternal cardiopulmonary resuscitation.

Role of peripartum cesarean section in maternal collapse in pregnancy

Fortunately, maternal cardiopulmonary arrest is an uncommon complication in the field of obstetrics, nevertheless dreaded by the clinicians. Perimortem cesarean section (PMCS), if performed in a timely manner, not only improves the chances of fetal survival but also improves the success rates of maternal resuscitation. In pregnant women over 20 weeks of gestation, if there is no response to correctly performed cardiopulmonary resuscitation within 4 min of maternal collapse or if resuscitation is required to be continued beyond this time, then perimortem cesarean section should be undertaken to assist maternal resuscitation. Delivery of the fetus and placenta reduces oxygen consumption and improves venous return and cardiac output, facilitates chest compressions, and makes ventilation easier. PMCS should be considered a resuscitative procedure, to be performed primarily in the interests of maternal survival. Delivery within 5 min of maternal collapse improves the chances of survival for the baby. A case of maternal collapse due to cardiac tamponade with aortic dissection where a live baby was delivered by perimortem cesarean section is described.

The Management of Pregnant Trauma Patients: A Narrative Review

(Anesth Analg. 2023;136:830–840) In the United States, trauma affects approximately 1 in 12 pregnancies and is the leading non-obstetric cause of maternal mortality. Although parturient patients should receive a comprehensive assessment in the event of trauma, studies suggest that fetal resuscitation is taking priority over maternal resuscitation.

The Management of Pregnant Trauma Patients: A Narrative Review

(Anesth Analg. 2023;136:830–840) Within the United States, trauma affects about 1 in 12 pregnancies and is the leading nonobstetric cause of maternal mortality. While in the event of trauma, parturient patients should receive a comprehensive assessment, studies suggest that fetal resuscitation is taking priority over maternal resuscitation.

Acute fatty liver of pregnancy About 20 cases

Our retrospective study concerned acute hepatic steatosis in pregnancy: diagnostic problems, severity and therapeutic perspectives in the Moroccan context. It concerns a series of 20 cases of SHAG collected in the department of gynecology-obstetrics and maternal resuscitation of the CHU MOHAMED VI in Marrakech over a 5-year period from January 2017 to December 2021. We included in this sample women admitted during pregnancy or post partum for management of SHAG. In our series, the frequency of SHAG was 1 case per 4340 deliveries. The age of the patients ranged from 18 to 45 years, with an average of 28 years and an average gestational age of 32 days and 3 weeks. Thus the majority of patients were multiparous and multigestational with a frequency of 55%. Clinically: polyuria-polydipsia syndrome was present in 20% of patients, nausea-vomiting in 70% and epigastralgia in 60%. Biologically: Hypoglycaemia present in 60%, hyperleukocytosis in 85%, creatinine level above 12mg/l in 70%, hyperuricaemia in 75%, hepatic cytolysis in 90%, hyper bilirubinaemia in 95% with conjugated predominance, prolonged PT in 50% and hyperammonia in 10%. Concerning complications, acute fulminant liver failure was observed in 30% of our patients, it is the most serious and fatal complication. The therapeutic management of SHAG requires, in addition to uterine evacuation associated with adequate medical and surgical resuscitation.

Cardiopulmonary Arrest During Pregnancy: A Review Article.

Massive pulmonary embolism (PE) is an uncommon but severe complication of pregnancy or during the first few weeks after giving birth. Our intention was to thoroughly analyze the information available to its management methods.Significant bleeding of mother survival and early deliveries in fetal survivals were having hemorrhage andwerehaving key outcomes. We found 127 severe PE cases that have had at least one form of treatment (at least 83% big; 23% with cardiac arrest). The 83 women who received thrombolysis had a 94% (95%) survival rate. Cardiac arrest in pregnancy is uncommon, although maintaining current competency can be challenging. While maternal mortality rates have decreased globally over the past 25 years, they have increased in the United States. The intricacy of the maternal mortality issue is a result of a number of clinical and socioeconomic problems such as unequal healthcare access, racial and ethnic disparities, maternal comorbidities, and bias in epidemiologic ascertainment. The importance of doctors being prepared to react to a potential maternal cardiac arrest in any situation where they are providing treatment for pregnant women is highlighted by the rise in maternal mortality. For the treatment of maternal cardiac arrest, an interdisciplinary team with expertise in both the maternal resuscitation procedure and the physiological changes that take place during pregnancy is necessary. Additionally offered are basic and advanced cardiac life support protocols. Techniques to remove obstacles like aortocaval compression that could impair the effectiveness of resuscitation should be used.

Healthcare personnel self-assessed competence and knowledge following implementation of a new guideline on maternal resuscitation in Norway. A repeated measure study.

Cardiac arrest in pregnancy is a rare, yet extremely challenging condition to manage for all healthcare personnel involved. Knowledge deficits and poor resuscitation skills can affect outcomes in cardiac arrest in pregnancy, but research exploring healthcare personnel competence and knowledge about maternal resuscitation is limited. The aim of this study was to explore (1) healthcare personnel self-assessed competence and knowledge about cardiopulmonary resuscitation (CPR) in pregnancy as well as perimortem caesarean section, before and after implementation of a new guideline, (2) whether there were any interprofessional differences in knowledge about maternal resuscitation, and (3) potential differences between different implementation strategies. The study had a prospective repeated measureimplementation design, utilizing a questionnaire before and after implementation of a new guideline on maternal resuscitation after cardiac arrest. All healthcare personnel potentially involved in CPR in six hospital wards, were invited to participate (n = 527). The guideline was implemented through either simulation, table-top discussions and/or an electronical learning course. In total, 251 (48%) participants responded to the pre-questionnaire, and 182 (35%) to the postquestionnaire. The need for education and training/simulation concerning maternal resuscitation were significantly lowered after implementation of the guideline, yet still the majority of respondents reported a high to medium need for education and training/simulation. Participants' self-assessed overall competence in maternal resuscitation increased significantly postimplementation. Regardless of professional background, knowledge about CPR and perimortem caesarean section increased significantly in most items in the questionnaire after implementation. Differences in level of knowledge based on implementation strategy was identified, but varied between items, and was therefore inconclusive. This study adds knowledge about healthcare personnel self-assessed competence and knowledge about maternal resuscitation and perimortem caesarean section in pregnancy. Our findings indicate that there is still a need for more education and training in this rare incident.

Phenylephrine versus cafedrine/theodrenaline (Akrinor) for the treatment of spinal anaesthesia-induced maternal hypotension during caesarean section: a retrospective single-centre cohort study

ObjectiveThe main objective of this study was to assess the impact of phenylephrine and cafedrine/theodrenaline on the mother and newborn after spinal anaesthesia for caesarean section.SettingUniversity teaching hospital.DesignA single-centre retrospective...

Maternal cardiopulmonary resuscitation.

The perinatal resuscitation history in Japan is short, with the earliest efforts in the field of neonatology. In contrast, the standardization and dissemination of maternal resuscitation is lagging. With the establishment of the Maternal Death Reporting Project and the Maternal Death Case Review and Evaluation Committee in 2010, with the aim of reducing maternal deaths, the true situation of maternal deaths came to light. Subsequently, in 2015, the Japan Council for the Dissemination of Maternal Emergency Life Support Systems (J-CIMELS) was established to educate and disseminate simulations in maternal emergency care; training sessions on maternal resuscitation are now conducted in all prefectures. Since the launch of the project and council, the maternal mortality rate in Japan (especially due to obstetric critical hemorrhage) has gradually decreased. This has been probably achieved due to the tireless efforts of medical personnel involved in perinatal care, as well as the various activities conducted so far. However, there are no standardized guidelines for maternal resuscitation yet. Therefore, a committee was set up within the Japan Resuscitation Council to develop a maternal resuscitation protocol, and the Guidelines for Maternal Resuscitation 2020 was created in 2021. These guidelines are expected to make the use of high-quality resuscitation methods more widespread than ever before. This presentation will provide an overview of the Guidelines for Maternal Resuscitation 2020.

Management of pregnant trauma patients in emergency department: a narrative review to provide the most recent evidence

Evaluation of a pregnant trauma patient (PTP) in the emergency department (ED) is somehow challenging, as two patients should be managed simultaneously. Here, we reviewed recently published articles to provide up-to-date information on the management of PTPs. We examined 35 articles and categorized their topics as follows: trauma severity, management of trauma patients, general approach to pregnant women with trauma, primary evaluation of pregnant women with trauma, breathing and ventilation, airway, circulatory system evaluation simultaneous with bleeding control, uterine replacement, blood transfusion, uterine displacement, cardiovascular resuscitation, defibrillation, pneumatic anti-shock garment, and perimortem cesarean section. Concerning trauma during pregnancy, the basic principle should be successful maternal resuscitation, which is vital for fetus survival.

Adverse Perinatal Outcomes of True Knot of the Umbilical Cord: A Case Series and Review of Literature

A true knot of the umbilical cord (TKUC) is an actual knot formed in pregnancy. It is seen in approximately 0.3%-1.2% of all pregnancies. True knots are of significance as they can cause a wide spectrum of adverse perinatal outcomes like small for gestational age (SGA) fetus, low appearance, pulse, grimace, activity, and respiration (Apgar) score at birth, fetal hypoxia, and even fetal demise.Here, we report a case series of three patients with TKUC and the varied adverse perinatal outcomes associated with them. A low-risk primigravida at term gestation had a suspicious non-stress test (NST). Repeat NST after maternal resuscitation became pathological. Emergency cesarean delivery was performed in view of pathological NST persisting despite intrauterine resuscitation. A healthy male baby weighing 2920 g was delivered, and the umbilical cord had a true knot.A multigravida at 33 + 3 weeks of gestation was referred with fetal growth restriction (FGR). Color Doppler examination showed absent end-diastolic flow (AEDF) in the umbilical artery (UA). Cesarean delivery was performed in view of FGR stage two with AEDF in the UA at 34 weeks of gestation as per the Barcelona criteria. A male baby weighing 1505 g was delivered. The umbilical cord had a true tight knot. The baby had an Apgar score of 7 at one minute after birth but was shifted to the neonatal intensive care unit (NICU) in view of low birth weight and prematurity. The baby slowly gained weight and was discharged from NICU after 15 days in stable condition.A multigravida at 32 weeks of gestation was referred with intrauterine fetal demise. Ultrasonography confirmed the presence of a single intrauterine dead fetus corresponding to 30 + 4 weeks of gestation with an estimated fetal weight (EFW) of 1633 g, amniotic fluid index (AFI) equal to nine, and presence of Spalding’s sign. Induction of labor was done, and she expelled a dead macerated male fetus weighing 1825 g. The infantogram was normal. A true umbilical cord knot was found.The umbilical cord is the source of fetal blood supply; therefore, any cord abnormality can have a significant impact on the fetal outcome. There are various factors that can predispose to TKUC, such as polyhydramnios, increased cord length, monoamniotic twins, male baby, grand multiparity, small fetus, and amniocentesis. TKUC can lead to various adverse outcomes in pregnancy and labor like SGA fetus, low Apgar score at birth, fetal hypoxia, and fetal demise. TKUC increases the risk of fetal demise by as much as four times.With the development of advanced techniques such as three-dimensional/four-dimensional color Doppler ultrasounds, TKUC can be diagnosed antenatally in the form of a four-leaf-clover, a “hanging-noose sign,” or by an unusual multicolor pattern in the cord. The prenatal detection rate of TKUC is only 12%. It mostly remains undetected unless visualized incidentally. Although TKUC is not rare and can have serious outcomes, the importance of its antenatal diagnosis has not been determined. It should be suspected in patients with risk factors, and emphasis should be placed on its antenatal diagnosis on ultrasonography to avoid obstetric disasters in otherwise low-risk females. Though there is no specific management of these cases, a good clinical outcome can be achieved if TKUC is diagnosed antenatally and monitored closely until fetal maturity is attained.

Fetal heart rate tracings associated with eclamptic seizures

Although there is a well-known association between fetal bradycardia and maternal eclampsia, the characteristics of fetal heart rate tracings after an eclamptic seizure have not previously been thoroughly described. Fetal heart rate changes are thought to be related to maternal lactic acidemia caused by vasospasm and uterine hyperactivity leading to placental hypoperfusion and fetal hypoxia. The decision to intervene in the case of an abnormal fetal heart rate tracing after an eclamptic seizure is often difficult; however, maternal resuscitation should be the primary focus. This study aimed to quantify and characterize fetal heart rate changes associated with a maternal eclamptic seizure. Moreover, we sought to document subsequent obstetrical management following these seizures complicated by fetal heart rate decelerations. This was a retrospective study of fetal heart rate tracings associated with eclampsia during a 13-year period at a single institution. Eclampsia was diagnosed following the 2013 Executive Summary of the American College of Obstetricians and Gynecologists criteria. Tracings were independently reviewed and classified by 3 physicians using the National Institute of Child Health and Human Development Criteria. Hospital records were reviewed to ascertain obstetrical management after the eclamptic seizure. A total of 107 women were diagnosed with eclampsia from January 2009 to December 2021. Of these women, 31 experienced 34 intrapartum seizures during which time electronic fetal heart rate monitoring was ongoing. During the 34 seizures, fetal heart rate decelerations were documented in 79% of cases. The mean duration of bradycardia was 5.80±2.98 minutes with a range of 2 to 15 minutes. Fetal heart decelerations occurred, on average, 2.7±1.6 minutes after the onset of the eclamptic seizure. In half of the fetuses with fetal heart rate changes, fetal tachycardia followed, and in 48% of cases, there was minimal variability noted. As a result of the fetal heart rate tracings and clinical findings, 4 women underwent an emergent cesarean delivery, including 2 that were diagnosed with placental abruption. In this cohort, there were 4 cases of abruption. The mean duration from the seizure to delivery was 299±353 minutes. The mean neonatal cord pH was 7.20±0.11 with a mean base excess of-8.6±4.4 mmol/L. There was no perinatal death. After an eclamptic seizure, 79% of fetuses demonstrated prolonged decelerations, and half of the fetuses developed fetal tachycardia after recovery from the episode of bradycardia. Despite these periods of fetal heart rate decelerations associated with eclampsia, prioritization of maternal support and stabilization resulted in a favorable perinatal outcome without immediate operative intervention in more than two-thirds of cases.

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.

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

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

An Unexpected Cause of Recurrent Fetal Decelerations

An Unexpected Cause of Recurrent Fetal Decelerations

Sepsis in the Parturient.

Sepsis is a leading cause of maternal morbidity with a high case fatality rate and leads to significant perinatal loss. Early identification and appropriate time management can significantly improve maternal and perinatal outcomes. The physiological changes of pregnancy and puerperium make pregnant women more susceptible to sepsis and also pose a challenge for early diagnosis because of overlap of clinical features and laboratory values. The validation of scoring/warning systems for sepsis in parturient needs further research. Infections during puerperium are commonly polymicrobial in nature and warrant broad-spectrum antibiotics. Maternal resuscitation in antepartum period has to be tailored to ensure fetal well-being and adequate placental perfusion. For the management of sepsis in pregnancy, the guidelines from surviving sepsis campaign (SSC) for general adult population are extrapolated with modifications related to physiological alterations in pregnancy and puerperium. Timing of delivery is based on the obstetric indications unless the source of sepsis is intrauterine.How to cite this articleJain V, Arora A, Jain K. Sepsis in the Parturient. Indian J Crit Care Med 2021;25(Suppl 3):S267–S272.

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.

Resuscitative cardiac arrest during a Caesarean section-When every second counts

Rationale: Cardiac pulmonary arrest is the most challenging and dreaded complication of neuraxial blockade. Patient's concern: A 21-year-old patient at 37 weeks of gestation, with previous lower segment Caesarean section pregnancy presented for elective Caesarean section. Diagnosis: Cardiac arrest after performing a subarachnoid block. Intervention: Maternal resuscitation. Outcome: Return of spontaneous circulation was achieved within 4-5 min of cardiopulmonary resuscitation. A single live healthy male baby was delivered. Lesson: A careful preoperative evaluation, adequate preload, constant vigilant monitoring to recognize vasovagal response at the earliest, and immediate initiation of resuscitative measures play the most important role in saving the precious lives in case of pregnant patients undergoing Caesarean section under subarachnoid block.

Intravenous infusion route in maternal resuscitation: a scoping review

BackgroundThe concept that upper extremities can be used as an infusion route during cardiopulmonary resuscitation in pregnant women is a reasonable recommendation considering the characteristic circulation of pregnant women; however, this method is not based on scientific evidence.Objective of the reviewWe conducted a scoping review to determine whether the infusion route should be established above the diaphragm during cardiopulmonary resuscitation in a pregnant woman.DiscussionWe included randomized controlled trials (RCTs) and non-RCTs on the infusion of fluids in pregnant women after 20 weeks of gestation requiring establishment of an infusion route due to cardiac arrest, massive bleeding, intra-abdominal bleeding, cesarean section, severe infection, or thrombosis. In total, 3150 articles from electronic database were extracted, respectively. After title and abstract review, 265 articles were extracted, and 116 articles were extracted by full-text screening, which were included in the final analysis. The 116 articles included 78 studies on infusion for pregnant women. The location of the intravenous infusion route could be confirmed in only 17 studies, all of which used the upper extremity to secure the venous route.ConclusionPregnant women undergo significant physiological changes that differ from those of normal adults, because of pressure and drainage of the inferior vena cava and pelvic veins by the enlarged uterus. Therefore, despite a lack of evidence, it seems logical to secure the infusion route above the diaphragm when resuscitating a pregnant woman.