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 Table of Contents  
LETTER TO EDITOR
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 131-133

Failure of resuscitative hysterotomy to rescue peripartum cardiac arrest


1 Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission14-Apr-2021
Date of Acceptance21-May-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Dr. Bharti Sharma
Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOACC.JOACC_30_21

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How to cite this article:
Kunagpa I, Sharma B, Verma P, Siwatch S, Prasad G R, Sharma K. Failure of resuscitative hysterotomy to rescue peripartum cardiac arrest. J Obstet Anaesth Crit Care 2021;11:131-3

How to cite this URL:
Kunagpa I, Sharma B, Verma P, Siwatch S, Prasad G R, Sharma K. Failure of resuscitative hysterotomy to rescue peripartum cardiac arrest. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Dec 9];11:131-3. Available from: https://www.joacc.com/text.asp?2021/11/2/131/327405



Dear Editor,

Cardiac arrest during pregnancy is a rare, with a prevalence of 1 in 12500 pregnancies and it is even rarer during a cesarean.[1],[2],[3],[4]

We report a young 23-year-old second gravida with previous caesarean section and unexplained stillbirth who was scheduled for elective cesarean at 37 weeks of gestation. Her routine investigations were within normal limits (Hemoglobin 12.5 gm%, platelet count 1.80 lacs and PTI 100%, blood urea/serum creatinine 11/0.5 mg/dl), vitals were stable, uterus was relaxed with fetal heart rate of 146 beats per minute. She was ASA physical status II. Subarachnoid block was placed at the L3-L4 space in the sitting position with a 26-gauge Quincke needle; 2 ml of drug was given (1.6 ml i.e., 0.8 mg of heavy Bupivacaine and 20 mcg Fentanyl) in the space with a co-load of 1000 ml. At 8 min following drug injection, there was a sudden drop in systolic blood pressure with the lowest recorded SBP 60 mm Hg with associated tachycardia of 160 bpm.

As per the institute protocol, hypotension was treated aggressively using boluses (100 microgram) of Phenylephrine to target the blood pressure near baseline which failed to correct severe hypotension. This was followed by rhythm disturbances including severe bradycardia, multiple ventricular ectopics, followed by ventricular tachycardia and deterioration of level of consciousness. Patient threw a generalized tonic clonic seizure lasting 30 seconds and became unconscious. As per AHA guielines maternal CPR initiated with decision for perimortem cesarean delivery taken on failure of return of spontaneous circulation after 4 minutes. A baby boy of 2700 grams was delivered with Apgar of 8, 9.

Resuscitative measures continued and inotropes were started with intermittent return of spontaneous circulation. Point of care transthoracic echocardiography revealed air (shower of dots) in the right chambers of the heart. Unfortunately, the patient could not be revived despite maximum resuscitative measures. Family's wishes were respected for denial to consent for autopsy. Newborn was discharged on day 3 of life.

This case illustrates witnessed maternal cardiac arrest during elective cesarean delivery where in spite of performing resuscitative hyserotomy we could only salvage the baby. Performing a perimortem cesarean imposes a significant cognitive load to an obstetrician.The maternal survival following perimortem cesarean is usually low (17 to 59%) as compared to the fetus (61 to 80%) as in index case.[1] Apart from manual lateral displacement of gravid uterus and placement of defibrillators pads, basic resuscitation algorithm in pregnancy remains the same.[1],[4] Due to physiological changes of pregnancy, oxygen demand is higher for a pregnant woman who may become hypoxic rapidly. So, delivery of fetus reduces the aortocaval compression, improves the venous return and aids in more effective cardiopulmonary resuscitation. Along with resuscitation it is crucial to detect and treat the probable cause. In index case, we analyzed the differential diagnosis [Table 1] but could not reach a definitive cause of arrest.[5],[6],[7],[8]
Table 1: Differential Diagnosis for Index Case

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Data on perimortem CD is limited. This case highlights the intense cognitive load for the entire managing team, meaningful steps with only fetal salvage.

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.
Chu J, Hinshaw K, Paterson-Brown S, Johnston T, Matthews M, Webb J, et al. Perimortem caesarean section – why, when and how. Obstet Gynaecol 2018;20:151-8.  Back to cited text no. 1
    
2.
Rose C, Arij Faksh D, Traynor K, Cabrera D, Arendt KW, Brost BC. Challenging the 4- to 5- minute rule: From perimortem cesarean section to resuscitative hysterotomy. Am J Obstet Gynecol 2015;213:653-6.  Back to cited text no. 2
    
3.
Kemp B, Knight M. Maternal mortality in the UK: An update. Obstet Gynaecol Reprod Med 2016;26:26-8.  Back to cited text no. 3
    
4.
Chu J, Johnston TA, Geoghegan J. Royal College of Obstetricians and Gynaecologists. Maternal Collapse in Pregnancy and the Puerperium: Green-top Guideline No. 56. BJOG: An International Journal of Obstetrics & Gynaecology. 2020;127:e14-52.  Back to cited text no. 4
    
5.
Gibbons JJ, Ditto FF. Sudden asystole after spinal anesthesia treated with the “pacing thump”. Anesthesiology 1991;75:705.  Back to cited text no. 5
    
6.
Pollard JB. Cardiac arrest during spinal anesthesia: Common mechanisms and strategies for prevention. Anesth Analg 2001;92:252-6.  Back to cited text no. 6
    
7.
Clark SL. Amniotic fluid embolism. Obstet Gynecol 2014;123:337-48.  Back to cited text no. 7
    
8.
Conde-Agudelo A, Romero R. Amnioticfluid embolism: An evidence-based review. Am J Obstet Gynecol 2009;201:445.e1-13.  Back to cited text no. 8
    



 
 
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