A case of intrapartum cardiac arrest and perimortem cesarean section
Abstract Number: F-22
Abstract Type: Case Report/Case Series
A 38 y.o. black female with chronic hypertension and sickle cell trait (G10,P4 at 38 wks gestation) was admitted for induction of labor due to elevated BP. The patient received labetolol 10 mg IV prn; systolic BP remained <140 mmHg.
Twelve hrs after admission, labor augmentation with oxytocin was initiated. An uneventful CSE with intrathecal bupivicaine 1.25 mg and fentanyl 15 mcg was performed 2 hrs later. Spontaneous rupture of membranes was later witnessed; this was immediately followed by generalized convulsions lasting 10 s. The obstetric and anesthesia teams were called stat. The patient was found to be unresponsive with shallow breathing and a faint pulse; FHR was 50 bpm.
Within 30 s, the patient was noted to be pulseless. Immediate chest compressions were initiated along with bag-mask ventilation with cricoid pressure. A wedge was placed under the right hip to achieve left uterine displacement. Tracheal intubation was carried out with a 7.0 mm cuffed tube by 2 min.
At 6 min post-arrest, the obstetric and anesthesia attending agreed to perform a bedside cesarean section. The patient continued to be pulseless and 1 mg epinephrine was administered IV. Surgical instruments were available within 2 min. Hurried skin preparation with povidone iodine was carried out and a midline subumbilical incision was performed with poor sterile technique. The surgical field was bloodless and tissues appeared dusky.
Resuscitative maneuvers continued throughout. Eleven min post-cardiac arrest a live male infant (Apgar 4/6/8) was delivered by classical uterine incision. Neonatologists carried out resuscitation and transfer to the NICU. Within 2 min of delivery, there was spontaneous return of the maternal circulation: BP146/69 mmHg and HR 143/min.
She was transferred to the OR for wound closure. In the OR, spontaneous movements were noted. The patient was reassured; anesthesia was induced with IV midazolam and fentanyl and maintained with minimal levels of sevoflurane/N20. Internal jugular and dorsal pedis lines were placed. The patient developed DIC (PT 16, INR 1.4, PTT 42, fibrinogen 66) and bled heavily (EBL-3 L). She received 7 u PRBC,7 u FFP, 20 u platelets, 10 u cryoprecipitate and a hysterectomy was ultimately performed. A severe mixed metabolic-respiratory acidosis was also noted, which resolved after 6 hrs. The patient was transferred to the ICU where she remained intubated for 2 days. She was discharged home on day 17. She was neurologically intact except for retrograde memory loss.
Discussion: The presumed diagnosis was amniotic fluid embolism, a rare complication of pregnancy with high morbidity and mortality. Maternal and fetal survival after maternal cardiac arrest relies on effective CPR and prompt cesarean delivery. There were delays in accessing equipment and in making the decision for cesarean delivery. Cardiac arrest simulation training has been shown to enhance preparedness for this rare but catastrophic event