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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 118-121

Case series of perimortem caesarean delivery during maternal cardiac arrest: Our initial experience and audit


1 Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Obstetrics and Gynecology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
3 Department of MBBS Student, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission17-May-2021
Date of Acceptance16-Jun-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Dr. Richa Jain
661-B, Aggar Nagar, Ferozepur Road, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOACC.JOACC_35_21

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  Abstract 


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.

Keywords: Challenges in implementation, maternal cardiac arrest, perimortem cesarean delivery


How to cite this article:
Kaur M, Jain R, Gulati A, Taneja A, Sardana S, Grewal A. Case series of perimortem caesarean delivery during maternal cardiac arrest: Our initial experience and audit. J Obstet Anaesth Crit Care 2021;11:118-21

How to cite this URL:
Kaur M, Jain R, Gulati A, Taneja A, Sardana S, Grewal A. Case series of perimortem caesarean delivery during maternal cardiac arrest: Our initial experience and audit. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Nov 28];11:118-21. Available from: https://www.joacc.com/text.asp?2021/11/2/118/327406




  Introduction Top


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, and presence of a compromised fetus. Cardiopulmonary resuscitation (CPR) guidelines worldwide highlight the importance of advanced concurrent cardiac life support (ACLS) and perimortem cesarean delivery (PMCD) interventions for optimal outcomes.[1] Despite defined 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 PMCD or resuscitative hysterotomy. Therefore, it is important that health care facilities institute rigorous protocols and systems of care for this special group of patients with regular audits for continuous quality improvements.

We report herein our initial experiences of maternal CPR after incorporating the maternal code blue team and systems for PMCD over a time span of 1 year.


  Case Series Top


Case 1

A 40-year-old female, gravida four at 31+4 weeks of gestation, was referred to our hospital from a peripheral health care setup with complaints of high blood pressure recordings for the past few days. She was a known case of pre-eclampsia with severe features, gestational diabetes mellitus, severe anemia, with renal insufficiency. She was admitted to labor room for expectant medical management. During the course of her treatment, she was transfused 1 unit of packed red blood cells in view of severe anemia. However, within 15 min of starting blood transfusion, she began to experience shivering, breathlessness, and pain in the epigastrium. Her oxygen saturation fell to 60% at room air with gasping respiratory efforts. She was taken on the bag and mask ventilation with manual left uterine displacement (MLUD). Her vitals remained unstable, and subsequently, she stopped following verbal commands. Maternal code blue was activated immediately. Her carotid pulse was absent, hence high-quality chest compressions were commenced. Return of spontaneous circulation (ROSC) was achieved after 18 min of high-quality CPR. Thus, PMCD was initiated 18 min after cardiac arrest and was performed in the labor operating room (OR), located adjacent to the labor room. The patient experienced re-arrest on arrival in OR, and the maternal code blue team performed high-quality CPR along with PMCD. A 1.48 kg live premature male neonate was delivered with an APGAR score of 3, necessitating neonatal resuscitation resulting in ROSC with an APGAR of 6 at 5 min. However, we could not successfully resuscitate the parturient.

Case 2

A 19-year-old primigravida at 38+2 weeks of gestation presented to our hospital in post-ictal unconscious state with gasping respiratory efforts and oxygen saturation (SpO2) of 58%. Her attendants informed that she had an episode of seizures a few hours back. On arrival, her pulses were palpable, and she experienced another episode of a generalized tonic-clonic seizure (GTCS). Immediate bag-mask ventilation with 100% oxygen was started with a staff deputed for continuous MLUD. High-quality CPR was immediately commenced in view of absent carotid pulse, and the maternal code blue team was notified. The anesthesiologist on duty in the emergency department (ED) secured the airway using a 7.5 mm ID endotracheal tube, and a PMCD was planned on site of cardiac arrest. PMCD was initiated within 2 min of cardiac arrest, and a 2.6 kg term live female baby with APGAR of 8 and 9 at 1 and 5 min of birth, respectively was delivered and shifted to the nursery. However, despite performing high-quality CPR incorporating ACLS interventions for a nonshockable asystolic rhythm for 44 min, ROSC could not be established.

Case 3

A 32-year-old lady gravida four at 32 weeks gestation presented to our hospital emergency in cardiac arrest. Maternal code blue was immediately activated, and high-quality chest compressions were initiated immediately with MLUD. The rhythm on the monitor was asystole, so epinephrine was administered, and ACLS interventions including securing the airway with a second-generation supraglottic device were enforced. History revealed a prior diagnosis of dengue hemorrhagic shock. Fluids were administered rapidly via a wide bore IV access. Eventually, ROSC was achieved within 4–5 min of CPR, and the team decided to perform PMCD. However, logistic issues delayed the initiation of PMCD to 20 min. The mother remained bradycardic with irregularly irregular rhythm despite ROSC and was therefore shifted to the surgical intensive care unit (ICU) after PMCD. The APGAR score of the baby was 0 and could not be resuscitated by the neonatology team. Meanwhile, the mother experienced rearrest in ICU and was successfully resuscitated. She was subsequently discharged with unfavorable neurological status (GCS 10/15).

Case 4

A 25-year--old conscious gravida two at 36+1 weeks of gestation presented to our emergency with epigastric pain and unrecordable blood pressure. Immediate ABCD assessment and interventions were started by the ED team which comprised an anesthesiologist, surgical resident, and ED physician. Focused assessment with sonography in trauma (FAST) ultrasound revealed hemoperitoneum, hence two large-bore intravenous catheters were secured, and IV fluid boluses were administered. Within a few minutes, she became unresponsive with an absent carotid pulse. Maternal code blue was activated and high-quality chest compressions with MLUD were commenced immediately. The monitor showed asystole hence, ACLS interventions were started with immediate administration of epinephrine 1 mg repeated every 4 min, complemented with delivery with continuous high-quality chest compressions, and 10 breaths per min after endotracheal intubation using 100% oxygen. PMCD with resuscitative hysterotomy was performed within 20 min of arrest. ROSC was achieved, and the patient was shifted to the emergency operation theatre for further exploration of hemoperitoneum. Meanwhile, a live 2.4 kg male baby was delivered with no cry at birth and absent pulse. CPR was started immediately, and the neonate was intubated. ROSC was achieved shortly. APGAR score at 5 min was 6. The baby was shifted to the neonatal ICU. In the OR, a ruptured A-V malformation of the maternal splenic vessels was ligated. She was transfused 6 units of packed red blood cells, 8 units of random donor platelets, and 8 units of fresh frozen plasma along with vasopressor support using nor-epinephrine and vasopressin infusions. The mother underwent high-quality CPR in the OR as well and was subsequently shifted to the ICU after ROSC and post-resuscitation stabilization of hemodynamic. She had a prolonged ICU stay and was later discharged home.

Case 5

A 31-year-old female gravida four at 36+3 weeks of gestation presented from a peripheral hospital in an unconscious state with a history of blood-stained vomiting for the past 2 days, severe anemia, and thrombocytopenia. The patient had no carotid pulse, and spontaneous breathing was absent. High-quality CPR with MLUD was started immediately, and a maternal code blue was activated. The rhythm was asystole. Endotracheal intubation was accomplished with a 7 mm ID endotracheal tube while high-quality CPR and ACLS protocol were followed. A provisional diagnosis of dengue shock syndrome or anaphylactoid reaction to blood products administered at a peripheral hospital was suspected and 17 min post-arrest PMCD was conducted. A 2.4 kg male baby with no cry at birth was delivered and could not be resuscitated. CPR of the mother was continued for a total of 55 min, but the patient could not be resuscitated.


  Discussion Top


We analyzed the performance of maternal CPR along with its outcomes and observed major gaps in our processes. Despite initial cognitive training and mock drills, the maternal code blue team encountered resistance and inordinate delays in initiating PMCD at the site of maternal cardiac arrest. These delays which occurred in all except one case of maternal arrest were ascribed to unfamiliarity, reluctance, and lack of confidence to perform a successful PMCD at sites away from OR. In addition, we found non-availability of PMCD kits on our crash carts in the emergency department leading to delays in acquiring them from ORs. Henceforth, this deficiency was corrected by incorporating a PMCD kit in crash carts placed at locations likely to encounter parturients.

The current guidelines suggest that PMCD should be initiated at the site within 5 min of a maternal cardiac arrest to achieve the best possible outcome.[2] This is based on the assumption that irreversible brain damage begins to occur within 4–6 min of cessation of cerebral blood flow.[3] Though the audit of our cases revealed that delays in PMCD led to poor outcomes; however, we did not achieve ROSC in one case wherein PMCD was performed within 2 min of recognition of arrest. Thus, we believe that apart from a prompt PMCD, the quality of CPR, institution of continuous MLUD, underlying causes of arrest along team dynamics play a significant role in ensuring long term favorable outcomes.[2],[4] Lee et al.[5] in their case letter to the editor also pointed out the possible benefit of high-quality resuscitative efforts ongoing with the delivery. We instituted high-quality CPR and continuous MLUD in all our maternal arrest; however, the underlying causes of arrest could have impacted our immediate outcomes (ROSC rates).

Two parturients in our case series arrived hypoxic and unresponsive to our hospital, signifying a likely delay in recognition of clinical deterioration at the peripheral hospitals. Therefore, we advocate that health care providers must use modified obstetric warning signs for in-hospital patients to pre-empt cardiac arrest and intervene timely to refer high-risk parturients to tertiary care centers to help salvage precious lives.

Postcode analysis, summarization, debriefing, and feedback help in identifying gaps and provide us with opportunities to improve in future codes. After the first maternal code, we conducted a multidisciplinary debriefing to enforce PMCD initiation at the site of the arrest and not in OR. The subsequent maternal code identified the absence of PMCD kits and other logistics which were then rectified. In the maternal codes that followed as documented in cases 3, 4, and 5, we aimed to perform PMCD as soon as possible and at the site of cardiac arrest by the most experienced provider. However, we could achieve a time gap of fewer than 5 min in only one case. In addition, poor outcomes despite early PMCD need further investigation. These gaps could be ascribed to the monthly rotation of providers leading to poor coordination and also lack of elements of team dynamics. Repeated mock drills with all providers on rotation are the way forward to combat these gaps. Mc Donnell[6] also recommended that institutions should undertake regular training and practice maternal cardiac arrest drills that involve all levels of staff across all disciplines. The Royal College of Obstetricians and Gynecologists[2] has now recommended that the knowledge of resuscitation should be an auditable standard, further reinforcing the golden rule: “you cannot improve what you do not measure.”

Objectively, we cannot say that all cases would have truly received high-quality CPR even during the performance of PMCD. A high-quality CPR needs to be measured, and hence we proposed to incorporate the use of real-time CPR quality feedback devices in the future. In addition, we have incorporated a mechanism of prespecified role allocation to all members of the maternal code blue team with the member on the defibrillator also performing the role of the CPR coach as per the latest AHA guidelines. This CPR coach will not only ensure high chest compression fraction but also help in the smooth coordination of all interventions like the early placement of definitive airway, MLUD, and PMCD. Indeed, we have placed a second-generation supra-glottic device I-Gel in all our crash carts on labor and emergency department floors, so that the delay to secure an airway till experienced help arrives is minimized without causing interruptions in chest compressions. We have had a hiatus in our mock drills due to the ongoing COVID pandemic, which will result in loss of skills and hesitancy to perform PMCD at the site of the maternal arrest.


  Conclusion Top


To improve the maternal and fetal outcomes following a cardiac arrest, there is a need to increase awareness and training among all health care workers. This is achievable if the key interventions like correctly performed CPR following up-to-date protocols for parturients, left uterine displacement, time-framed PMCD in a failing resuscitation, and specific protocols for massive hemorrhage are followed. Hospitals have a duty to educate, train their staff, adapt guidelines, and evolve appropriate systems for tackling such conditions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
AHA 2020 maternal cardiac arrest guidelines.  Back to cited text no. 1
    
2.
Royal College of Obstetricians and Gynecologists. Maternal Collapse in Pregnancy and the Puerperium (Green-top 56), 2011.  Back to cited text no. 2
    
3.
Parry R, Asmussen T, Smith JE. Perimortem caesarean section. Emerg Med J 2016;33:224-9.  Back to cited text no. 3
    
4.
Jeejeebhoy FM, Zelop CM, Lipman S, Carvalho B, Joglar J, Mhyre JM, et al. Cardiac arrest in pregnancy: A scientific statement from the American Heart Association. Circulation 2015;132:1747-73.  Back to cited text no. 4
    
5.
Lee CY, Kung SW. Perimortem caesarean section: A case report of an out-of-hospital arrest pregnant woman. World J Emerg Med 2018;9:70-2.  Back to cited text no. 5
    
6.
McDonnell NJ. Cardiopulmonary arrest in pregnancy: Two case reports of successful outcomes in association with perimortem Caesarean delivery. Br J Anaesth 2009;103:406-9.  Back to cited text no. 6
    




 

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