Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training?



We read with great interest the paper entitled, ‘Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training?’, by Dijkman et al.1

In this paper, the authors evaluated perimortem caesarean sections (PMCSs) performed in the Netherlands between 1993 and 2008. In the study period, 55 women suffered from cardiac arrest, 12 of whom underwent PMCS. No PMCS was performed within the recommended 5 minutes after the start of resuscitation.2 The outcome was poor with only two maternal survivors.

We performed a successful PMCS in June 2010 within 5 minutes after the start of cardiopulmonary resuscitation. The patient, a 35-year-old G3 P1, had an uneventful medical history and was referred to the hospital for the induction of labour with misoprostol at 41 weeks and 3 days of pregnancy. Half an hour after spontaneous rupture of the membranes, the patient suffered from dyspnoea, hypotension, bradycardia and cyanosis. The application of 15 l of oxygen per minute, the left lateral tilt and chin lift position did not alleviate the symptoms. The resuscitation team, paediatrician and consultant gynaecologist were alarmed. On arrival of the resuscitation team, the patient had a cardiopulmonary arrest. Cardiopulmonary resuscitation was started in the left lateral tilt position.

Our delivery rooms are equipped with a PMCS box, containing a surgical knife and a Kocher forceps, in accordance with the recommendations of Warraich and Esen.3 Furthermore, local team training courses, based on the Managing Obstetric Emergencies and Trauma (MOET) principles, are given in our department.2 Three minutes after cardiopulmonary resuscitation, the patient still had no output and the resident (first author) started PMCS with a transverse Pfannenstiel incision, resulting in the birth of a girl of 3450 g with Apgar scores of 2/6/7.

During PMCS, the operative field was initially bloodless. Following removal of the placenta, the patient started to lose a lot of blood, because of disseminated intravascular coagulation (DIC). Nineteen units of blood (four uncrossmatched O-negative), 11 units of fresh frozen plasma (FFP) and seven platelet concentrates were administered. Cyklokapron, Sulprostone, Methergine and Eptacog alpha were also administered. After packing of the uterus with gauzes, the fascia was closed and the patient was transferred to the intensive care unit. At the intensive care unit, haemolysis occurred as a result of the transfusion of uncrossmatched blood and DIC, antibiotics were given and hypotensive periods were treated with noradrenaline. Computed tomography did not show any cerebral, pulmonary or abdominal abnormalities. The patient received hydrocortisone because amniotic fluid embolism was the most likely diagnosis. Thirty-six hours after PMCS, DIC resolved and the gauzes were removed by relaparotomy. Extubation followed 24 hours later. The symptoms of a paralytic ileus recovered after the administration of erythromycin in combination with a stomach tube and parenteral feeding.

Following transfer to the maternity ward an uneventful recovery was seen within a few days. The patient started to remember the day of the induction of labour, became able to perform daily activities and started taking care of her daughter. Two weeks after PMCS, both mother and daughter were discharged without any neurological or other abnormalities.