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Out-of-Hospital Perimortem Cesarean Delivery Performed in a Woman at 32 Weeks of Gestation: A Case Report

Lenz, Harald MD, PhD*; Stenseth, Liv Berit MD; Meidell, Nina MD, MHA*; Heimdal, Hans Julius MD

doi: 10.1213/XAA.0000000000000429
Case Reports: Case Report
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A 34-year-old pregnant woman experienced cardiac arrest at home. Out-of-hospital perimortem cesarean delivery was performed 27 minutes after the collapse. Both mother and child were resuscitated and had return of spontaneous circulation before they were transported to a university hospital. The mother underwent hysterectomy and developed disseminated intravascular coagulation. Despite intensive treatment, she died 8.5 hours after arrival. The infant was extubated the next day, and her subsequent hospital course was uneventful. She was later diagnosed with cerebral palsy and severe gastroesophageal reflux. At 2 years of age, she communicated by sounds, eye contact, and smiling.

From the *Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital - Ullevaal, Oslo, Norway; and Division of Emergencies and Critical Care, Department of Air Ambulance, Oslo University Hospital, Oslo, Norway.

Accepted for publication August 11, 2016.

Funding: Harald Lenz has a 20% postdoctorate position funded by the Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway.

The authors declare no conflicts of interest.

Address correspondence to Harald Lenz, MD, PhD, Department of Anesthesiology, Oslo University Hospital, Oslo, Norway. Address e-mail to harald.lenz@medisin.uio.no.

Cardiac arrest during pregnancy occurs in approximately 1 of 12,000 women hospitalized for delivery1,2 and is associated with high maternal and fetal mortality.

In the supine position in the second half of pregnancy, the gravid uterus may compress the inferior vena cava and obstruct blood return to the right side of the heart. Low flow states, such as cardiac arrest, exacerbate reductions in blood flow caused by aortocaval compression.

In case reports of cardiac arrest in pregnancy, perimortem cesarean delivery (PMCD) has been temporally associated with return of spontaneous circulation (ROSC).1,3 Based on this observation, PMCD is recommended within 4 minutes after cardiac arrest.4,5

The American Heart Association (AHA) recommends basic and advanced cardiac life support (BLS and ACLS) in the supine position with manual left uterine displacement (LUD) if cardiac arrest occurs out-of-hospital during pregnancy,6 with subsequent transport to a hospital that can perform PMCD.

We describe cardiac arrest in a pregnant woman for whom PMCD was performed out-of-hospital and the child survived. The husband has provided written permission to publish this report.

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CASE DESCRIPTION

The 34-year-old woman was gravida 4, para 3, and at 32 gestational weeks. Her medical history included cholecystectomy and nonspecific proctocolitis 2 years before the event. She was under medical assessment for possible Crohn disease.

During this pregnancy, the patient had bled vaginally at week 19. Ultrasound revealed a 4 × 13 cm hematoma in the uterine posterior wall near the isthmus. The fetus was alive with normal heart activity and spontaneous activity. No treatment was initiated, and the pregnancy was uneventful until the cardiac arrest.

The woman developed serious respiratory distress immediately before she collapsed and became unconscious (time 0). She collapsed on the second floor of her home, which had narrow staircases. Her husband called the Emergency Medical Communication Centre and began BLS. The first ambulance with 2 paramedics reached the scene after 12 minutes. Primary rhythm was asystole. ACLS was initiated in the supine position with LUD. A second ambulance with an anesthesiologist arrived 19 minutes after the collapse. A third ambulance, with a second anesthesiologist and neonatal transport incubator, reached the scene immediately after the second ambulance.

The first anesthesiologist performed another 3 minutes of ACLS, including intubation without any sedation and intravenous (IV) access. IV epinephrine (1 mg) was administered. There was blood in the oral tube after intubation, and suctioning was performed. After 3 minutes, end-tidal CO2 was <7.5 mm Hg, and pulse was not palpable. The anesthesiologist considered the ACLS unsatisfactory, initiated PMCD with a midline incision, and delivered the baby within 1 minute (27 minutes after time 0). Amniotic fluid was dark brown in color and was bloodstained.

ACLS was performed without interruption, and the mother achieved ROSC 1 to 2 minutes after delivery. Her heart rate (HR) was 90 beats per minute. She had sinus rhythm (SR) and palpable radial artery. The placenta was delivered with controlled cord traction 5 minutes after cesarean delivery. Ten international units of oxytocin was administered intravenously, and the uterus was massaged to support contraction; however, the uterus remained atonic. Maternal bleeding was minimal after ROSC and on the way to the hospital. The uterine incision was clamped together by 3 tenaculae, and the abdomen was packed with clean towels before transport. The patient received repeated doses of IV epinephrine before transport because of bradycardia (HR <45 beats/min) and low end-tidal CO2 (<22.5 mm Hg). Transport to the hospital began 22 minutes after ROSC and took 18 minutes.

During transport, the patient had one episode of acute bradycardia (HR, 28 beats/min), which was treated with chest compressions and 1 mg IV epinephrine. She also intravenously received 100 mL of trometamol and 500 mL of Ringer acetate. End-tidal CO2 was 22.5 to 52.5 mm Hg during transport, and HR was >100 beats/min. The patient was mechanically ventilated and she remained unconscious (Glasgow Coma Scale [GCS], 3) during transport. No blood products or sedatives were administered.

The patient arrived at the hospital 1 hour and 8 minutes after collapse. The cumulative dose of IV epinephrine was 8 mg, and she received no other vasopressors. Her pupils contracted to 4 mm during transport and were reactive to light.

A dedicated team was waiting at the university hospital, including trauma and obstetric surgeons, a thoracic surgeon, an interventional radiologist, and anesthesiologists. A cardiologist and a pulmonary physician were also present. The emergency department (ED) has the facilities for advanced surgery and interventional radiology, and all procedures were performed there.

On arrival, the patient was mechanically ventilated with 100% oxygen. Blood pressure (noninvasively measured) was 79/45 mm Hg, pulse was 145 beats/min (SR), and peripheral capillary oxygen saturation (Spo2) was 98%; she was unconscious (GCS, 3). After arrival, she received IV ketamine infusion of 3 mg/kg/h continuously to ensure she remained sedated.

Her uterus remained atonic, and hysterectomy was performed immediately after arrival. During surgery, the patient started to bleed diffusely. A massive transfusion protocol was initiated in the first 10 minutes at the ED because she was hypovolemic with diffuse abdominal bleeding. To control bleeding, an aortic occlusion balloon catheter was placed 27 minutes after arrival. An arterial line was difficult to establish, and arterial blood gas (ABG) was first measured 45 minutes after arrival. By then, she had already received 4 units of packed red blood cells. Arterial measurement revealed pH, 6.95; Paco2, 59.3 mm Hg; Pao2, 126.8 mm Hg; base excess (BE), 19.4 mmol/L; hemoglobin, 9.7 g/dL; oxygen saturation of arterial blood (Sao2), 97% (mechanically ventilated with 100% oxygen); glucose, 380.2 mg/dL; and lactate, 166.7 mg/dL. Sodium, potassium, and chloride values were within normal limits. Disseminated intravascular coagulation was reflected in the blood values: international normalized ratio (INR), 1.4; activated partial thromboplastin time (APTT), >180 seconds, and fibrinogen, <20.4 mg/dL. These values were measured at the same time as the first ABG.

The patient received 22 units of packed red blood cells (250 mL each), 18 units of plasma (200 mL each), and 5 units of thrombocytes (120 × 109 thrombocytes each). She also received fibrinogen (1 g twice), tranexamic acid (1 g), desmopressin (30 µg), and repeated doses of calcium chloride intravenously. INR normalized to 1.0. APTT remained at >180 seconds, and fibrinogen was <20.4 mg/dL after attempts to correct these values. At the time the patient was treated, the hospital did not possess the equipment to do viscoelastic testing. Vacuum-assisted abdominal closure was performed after surgery. Echocardiography demonstrated reduced contractility of the left ventricle. Bronchoscopy showed no signs of aspiration or blood.

Head computed tomography (CT) showed reduced contrast between gray and white matter, possibly because of ischemia. Thoracic CT did not reveal pulmonary embolus, but there were condensations in the left lung. After surgery and CT, the patient was transferred to the intensive care unit (ICU). She remained hypotensive for 3 hours after surgery, with systolic blood pressure 55 to 80 mm Hg, which thereafter deteriorated to <50 mm Hg despite high doses of norepinephrine (up to 0.4 µg/kg/min) and epinephrine (up to 0.6 µg/kg/min). Acute bradycardia occurred 8.5 hours after hospital arrival, followed by cardiac arrest. The cardiac arrest was not treated because the situation seemed hopeless. Postmortem examination did not reveal any obvious cause of death. There was no evidence of pulmonary thrombosis or fetal debris. Coronary arteries were normal, and there were no intracranial abnormalities except for a slightly edematous cerebrum compatible with a long period of hypoxia.

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Neonatal Resuscitation

The second anesthesiologist was in charge of resuscitating the infant. Palpation of the brachial and carotid arteries did not reveal a pulse, and she was not spontaneously breathing. The infant was dried with a towel and stimulated, and positive pressure ventilation was performed for 2 minutes. Chest compressions were also started just after delivery. A femoral pulse was detected approximately 2 minutes after delivery, and the HR was >100 beats/min, as ascertained by stethoscope. She was intubated and received 240 mg surfactant in the tube.

Her Apgar score was 5 (color, 2; HR, 2; reflexes, 0; muscle tone, 1; and breathing 0) after 2 minutes, 6 (2, 2, 0, 1, 1) after 5 minutes, and 7 (2, 2, 1, 1, 1) after 10 minutes.

The infant was transported to the hospital in the neonatal incubator and arrived at the neonatal ICU 1 hour and 20 minutes after the mother collapsed. IV access was not established during transport because this was considered too time consuming.

The infant had a temperature of 35.4°C, HR of 110 beats/min, and Sao2 of 94% (ventilated with 27% oxygen). There was some spontaneous respiratory activity. Venous blood gas was first measured 1.5 hours after the mother’s collapse: pH, 7.24; venous carbon dioxide tension (Pvco2), 52.5 mm Hg; venous oxygen tension (Pvo2), 30.0 mm Hg; BE, 5.2 mmol/L; hemoglobin, 16.9 g/dL; lactate, 85.6 mg/dL; and glucose, 75.2 mg/dL. The infant weighed 2450 g, and her length was 47 cm.

The infant was extubated the next day. Brain magnetic resonance imaging with spectroscopy 2 days after delivery showed a small lactate top in the left basal ganglia, but it was otherwise normal. She was treated for possible convulsive spasms on the first day, but electroencephalography 2 days after delivery was normal.

Examination before discharge to the local hospital noted a girl with open eyes, spontaneous breathing, and normal cardiopulmonary status. She was hypotonic with weak palmar grasp and sucking reflexes and had no demonstrable gag reflex.

The infant was later diagnosed with cerebral palsy and was unable to eat. When she was 6 months old, she underwent percutaneous endoscopic gastrostomy. She had severe gastroesophageal reflux that affected the lungs, and several episodes of aspiration pneumonia occurred because of the reflux. She also developed moderate pulmonary hypertension. At 1.5 years of age, the girl received mechanical ventilation and nitric oxide for a severe respiratory syncytial virus infection.

At 2 years of age, the child could communicate by sounds, eye contact, and smiling.

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DISCUSSION

There are few case reports of out-of-hospital PMCD, and it remains a rare and controversial procedure. In a report of 4 cases during a 15-year period,1 both the mother and child died in all cases. None of the PMCDs were performed <5 minutes after the cardiac arrest.

In 4 additional case reports,7–10 no mothers survived, 2 neonates died, 1 survived with severe brain damage, and 1 survived with slightly reduced neurological development at 4 years of age.

AHA guidelines do not recommend out-of-hospital PMCD.6 In most cases, skilled personnel are not available to perform the PMCD, to manage the ongoing maternal resuscitation, and to provide neonatal resuscitation and transport. However, under optimal conditions, out-of-hospital PMCD should be considered. In our case, PMCD was appropriate, given the presence of skilled personnel to complete the PMCD safely and to resuscitate both the mother and the child, and the availability of a neonatal transport incubator.

The anesthesiologist, who possessed surgical skills, performed ACLS for 3 minutes before considering PMCD. After 3 minutes, he considered the ACLS unsatisfactory (low end-tidal CO2 and no palpable pulse). Moreover, the mother collapsed on the second floor of a house with narrow staircases, and the anesthesiologist estimated it would take approximately 6 minutes to get her out of the house. ACLS would have been unacceptable during the transport down the stairs. Transport to the hospital took approximately 20 minutes, and the estimated time from arrival at the hospital to PMCD was approximately 2 to 3 minutes. This would have delayed the PMCD by approximately 30 minutes, which was considered unacceptable.

Based on case reports, PMCD is optimally performed 4 to 5 minutes after cardiac arrest.4,5 However, a systematic review of case reports suggests a survival benefit for both the mother and the neonate when delivery is completed within 10 minutes of arrest.11 In our case, out-of-hospital PMCD was performed 27 minutes after cardiac arrest, resulting in both maternal and neonatal ROSC shortly after delivery, and neonatal survival, although the neonate suffered neurological injury.

Our experience suggests that out-of-hospital PMCD should be considered in cases in which the necessary surgical skills, personnel, and equipment are present.

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DISCLOSURES

Name: Harald Lenz, MD, PhD.

Contribution: This author helped complete this manuscript.

Name: Liv Berit Stenseth, MD.

Contribution: This author helped complete this manuscript.

Name: Nina Meidell, MD, MHA.

Contribution: This author helped complete this manuscript.

Name: Hans Julius Heimdal, MD.

Contribution: This author helped complete this manuscript.

This manuscript was handled by: Jill M. Mhyre, MD.

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REFERENCES

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2. Mhyre JM, Tsen LC, Einav S, Kuklina EV, Leffert LR, Bateman BT. Cardiac arrest during hospitalization for delivery in the United States, 1998-2011. Anesthesiology. 2014;120:810818.
3. Lipman S, Cohen S, Einav S, et al.; Society for Obstetric Anesthesia and Perinatology. The Society for Obstetric Anesthesia and Perinatology consensus statement on the management of cardiac arrest in pregnancy. Anesth Analg. 2014;118:10031016.
4. Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean delivery. Obstet Gynecol. 1986;68:571576.
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8. Kupas DF, Harter SC, Vosk A. Out-of-hospital perimortem cesarean section. Prehosp Emerg Care. 1998;2:206208.
9. Kue R, Coyle C, Vaughan E, Restuccia M. Perimortem cesarean section in the helicopter EMS setting: a case report. Air Med J. 2008;27:4647.
10. Gatti F, Spagnoli M, Zerbi SM, Colombo D, Landriscina M, Kette F. Out-of-hospital perimortem cesarean section as resuscitative hysterotomy in maternal posttraumatic cardiac arrest. Case Rep Emerg Med. 2014;2014:121562
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