The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study

Development of a cost-effective, reusable, resuscitative hysterotomy task trainer for emergency medicine trainees

We designed, developed, and constructed a reusable, durable, low-cost resuscitative hysterotomy (RH) task trainer with functional and structural fidelity for repetitive practice and education for emergency medicine trainees. The availability of commercial caesarean task trainers is limited, and their high cost often poses a barrier to training. Although similar procedures, RH and traditional caesarean section are unique, and to the authors' knowledge there are currently no commercial task trainers specifically designed for RH. Current RH literature recommends completing the procedure within five minutes to improve the survival chances of both the fetus and the mother during active or imminent cardiac arrest. While RH is not a technically complex procedure relative to other procedures, it involves specific technical steps and requires clinicians to act decisively. Our RH task trainer was created using low-cost expired materials sourced from our hospital system and additional items purchased online. The RH task trainer was designed to be easily assembled, have minimal recurring material costs, and with quick set-up and clean-up for repetitive practice. When used within a simulation-based scenario, learners are also challenged with the decision to proceed with an RH; thus, providing experiential development of this decision-making step which is unparalleled in comparison to most traditional training formats. Overall, our RH trainer can be built for approximately 230 US dollars. The ability to create low-cost and easily accessible opportunities for repetitive practice of RH contributes to the limited pool of non-commercial RH task trainers, offering valuable experiential instruction for this unique, high-acuity, low-occurrence procedure. Brief description We developed a reusable, durable, low-cost resuscitative hysterotomy (RH) task trainer with functional and structural fidelity for repetitive practice and education for emergency medicine trainees at a tertiary care training hospital. Further, we aimed to create a task trainer that enhanced the cognitive and procedural skills required for performing RH within a high-stress clinical environment.

Maternal and neonatal outcomes following resuscitative hysterotomy for out of hospital cardiac arrest: A systematic review

OBJECTIVE

To examine maternal and neonatal outcomes following Resuscitative Hysterotomy for out of hospital cardiac arrest (OHCA) and to compare with timing from cardiac arrest to delivery.

METHODS

The review was registered with PROSPERO (CRD42023445064). Studies included pregnant women with out of hospital cardiac arrest and resuscitative hysterotomy performed (in any setting) during cardiac arrest. We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL), from inception to 25th May 2024, restricted to humans. We included randomised controlled trials, observational studies, cases series or case reports. Two reviewers independently assessed study eligibility, extracted study data, and assessed risk of bias using validated tools. Data are summarised in a narrative synthesis.

RESULTS

We included 42 publications (one cohort study, three case series and 38 case reports) including a total of 66 women and 68 neonates. Maternal and newborn survival to hospital discharge was 4.5% and 45.0% respectively. The longest duration from collapse to resuscitative hysterotomy for maternal survival with normal neurological function was 29 min and for neonates was 47 min. There were reported neonatal survivors born at 26 weeks gestation with good outcomes. The certainty of evidence was very low due to risk of bias.

CONCLUSION

There are low rates of maternal survival following resuscitative hysterotomy for OHCA. There are documented neonatal survivors after extended periods of maternal resuscitation, and at extremely preterm gestations (<28 weeks). Further prospective research should assess both maternal and neonatal outcomes to better inform future clinical practice.

Enhancing maternal survival in traumatic cardiovascular collapse during pregnancy: A case series on resuscitative hysterotomy (RH) from a level 1 trauma center

BACKGROUND

Trauma during pregnancy presents multifaceted risks to both the developing fetus and the expectant mother due to pregnancy-induced physiological adaptations that affect the response to traumatic injuries. The infrequent occurrence of cardiac arrest during pregnancy necessitates interventions such as perimortem cesarean section (PMCS), now termed resuscitative hysterotomy. While early resuscitative hysterotomy focused primarily on fetal survival, more recent literature reports substantial maternal benefits. Resuscitative hysterotomy can lead to the restoration of maternal pulse and blood pressure within minutes and has shown potential to improve maternal outcomes. RH has been demonstrated to aid in fetal and maternal survival in hemodynamic unstable pregnant patients before cardiovascular collapse. The linguistic change from PMCS to resuscitative hysterotomy is a shift towards maternal-centric approaches and survival.

OBJECTIVE

In this series, we evaluate the outcomes of resuscitative hysterotomy performed before or after cardiovascular collapse to maximize maternal survival while concurrently optimizing fetal outcomes.

METHODS

We performed a retrospective case series review of 4 consecutive pregnant trauma patients who underwent RH due to hemodynamic instability. In addition, we conducted a descriptive analysis of all pregnant patients from 2013 to May 2024 who presented due to a traumatic injury but did not require a RH.

RESULTS

The average age of patients undergoing RH was 26.5 ± 6.8 years. All patients were in the third trimester with a mean gestational age of 32.3 ± 0.5 weeks. Fifty percent (50 %) of patients were involved in motor vehicle accidents, one (25 %) pedestrian was hit by a vehicle, and one (25 %) had GSW to the head. The median time to RH was 14.5 min. The mean estimated blood loss (EBL) was 625 mL ±108.9 mL. The maternal survival rate was 50 %, with a fetal survival rate of 100 %. Three patients achieved hemodynamic stability; however, one of the patients progressed to death by neurological criteria. Therefore, we achieved 50 % of maternal survival. A resuscitative hysterotomy was performed due to early signs of maternal hemorrhagic shock and suggestive features of ongoing bleeding (persistent maternal tachycardia despite adequate analgesia and resuscitation, persistent maternal bradycardia, gradual decline of BP, and FHR abnormalities) in three patients. The remaining patient was found to have cardiac arrest at the scene with a brief return of spontaneous circulation and received resuscitative hysterotomy in the ED to restore cardiovascular function.

CONCLUSION

RH in pregnant patients with traumatic injury and impending hemorrhagic shock or cardiovascular collapse may provide maternal survival benefits by supporting circulatory function and promoting resuscitation with no additional risks to fetal outcomes. Quick decision-making is crucial to the implementation of this life-saving procedure. Further research with a more significant number of patients is needed to validate the efficacy of RH in maximizing maternal survival. This case series adds to the evolving literature on RH, shedding light on practical aspects and maternal outcomes to inform ongoing discussions and strategies for maternal cardiopulmonary resuscitation.

Challenges during cardiac arrest in pregnancy

A 36-year-old woman at 23 weeks and 3 days of gestation experienced a witnessed cardiopulmonary collapse. Bystander cardiopulmonary resuscitation (CPR) was initiated immediately. After advanced life support, she was transferred under mechanical CPR to a hospital for extracorporeal membrane oxygenation (ECMO). There, a delayed perimortem caesarean section (PMCS) was performed. Consideration to initiate ECMO following the PMCS was ultimately discontinued due to extensive intra-abdominal haemorrhage and the elapsed time of over one hour since the collapse. A full body computed tomography (CT) scan following ROSC revealed bilateral pulmonary embolisms and grade 4 liver laceration with active bleeding due to mechanical CPR. Despite the prolonged duration of cardiac arrest (69 min) and significant metabolic derangements, the patient had a favourable recovery and was discharged after 42 days with a good neurological outcome. This case illustrates the challenges of timely perimortem caesarean section in out-of-hospital cardiac arrest, where guidelines recommend performing the procedure within 4 min of maternal collapse. It also highlights the risks associated with mechanical chest compression devices.

Improving Comfort in Obstetric Skills of Emergency Medicine Residents With Lecture- and Simulation-Based Training

Objectives The study aimed to determine whether obstetrician-led lecture- and simulation-based training improves Emergency Medicine (EM) residents' comfort in managing complicated obstetric conditions. Methods Residents from Mercy St. Vincent Medical Center Emergency Medicine residency program in Toledo, Ohio participated in the study. Four clinical scenarios were chosen: shoulder dystocia, breech vaginal delivery, severe hypertensive disorder of pregnancy, and resuscitative hysterotomy. Participants attended a two-hour lecture series and subsequent simulation training with live-action situations for each chosen clinical scenario. Participants completed pre- and post-training surveys, which assessed comfort in performing the selected obstetric practices using the Likert Scale. Survey responses were analyzed for each item and presented by frequency count and percentage. Results Thirty-two EM residents completed a survey before the education and 25 of these residents completed a survey after the training. Before education, comfort levels performing obstetric procedures were low: three (9%) residents were comfortable knowing and performing maneuvers for shoulder dystocia, one (3%) for breech vaginal delivery, and one (3%) for resuscitative hysterotomy. Ten (31%) residents were comfortable managing severe hypertensive disorder. After education, the percentage of residents who reported being comfortable significantly increased (p<,0.05) in all clinical scenarios. Twenty-two (88%) residents strongly agreed that targeted lecture- and simulation-based training from an Obstetrician Gynecologist (OBGYN) will improve their comfort in assessing and treating complicated obstetric problems. Conclusions Obstetrician-led lecture- and simulation-based training can improve EM residents' comfort in managing complicated obstetric conditions, and a collaborative, interdepartmental approach likely optimizes success in training EM residents.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Cardiopulmonary resuscitation in obese patients: A scoping review

Background

Given the increasing global prevalence of obesity, the International Liaison Committee on Resuscitation (ILCOR) commissioned this scoping review to explore current evidence underpinning treatment and outcomes of obese patients (adult and children) in cardiac arrest.

Methods

This scoping review, conducted using Arksey and O'Malley's framework and reported according to PRISMA-ScR guidelines, included studies of CPR in obese patients. 'Obese' was defined according to each individual study. Medline, EMBASE and Cochrane were searched from inception to 1 October 2024. Narrative synthesis was guided by Synthesis Without Meta-Analysis (SWiM) reporting guidelines.

Results

36 studies were included: 2 paediatric and 34 adult studies. Fourteen studies reported on out-of-hospital cardiac arrest (OHCA), 12 on in-hospital cardiac arrest (IHCA), eight on both OHCA and IHCA: cardiac arrest location was not reported in two studies. The most common outcomes were survival (n = 29), neurological outcome (n = 17) and ROSC (n = 7). In adults there were variable results in neurological outcome, survival to hospital discharge, longer term survival (months to years), and ROSC. In children, there were two studies suggesting that obese children had worse neurological outcomes, lower survival and lower ROSC than normal weight children. Few studies reported resuscitation quality indicators or techniques, and no studies reported adjustments to CPR techniques.

Conclusion

The variability in results does not suggest an urgent need to deviate from standard CPR protocols, however there was some evidence that CPR duration may be longer in obese adults, which may have staffing and resource implications.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

High Neuraxial Block in Obstetrics: A 2.5-Year Nationwide Surveillance Approach in the Netherlands

BACKGROUND

High neuraxial block is a rare but serious adverse event in obstetric anesthesia that can ultimately lead to respiratory insufficiency and cardiac arrest. Previous reports on its incidence are limited to populations in the United Kingdom and the United States. Little is known about the incidence and clinical features of high neuraxial block in the Netherlands, where the presence of anesthesiologists in the labor and delivery unit is comparatively lower. We aimed to assess the incidence and clinical features of high neuraxial block in obstetrics and to formulate ways to improve obstetric anesthesia on a national level.

METHODS

This nationwide, prospective, population-based cohort study was designed to identify cases of high neuraxial block requiring ventilatory support (with supraglottic airway device or tracheal intubation) or cardiopulmonary resuscitation between November 2019 and May 2022. Cases were prospectively collected using the Netherlands Obstetric Surveillance System (NethOSS) in all hospitals with a maternity unit. Complete case file copies were obtained to determine risk factors and clinical course.

RESULTS

During the study period, 5 cases of high neuraxial block requiring tracheal intubation were identified. The estimated incidence of high neuraxial block requiring tracheal intubation was 1 in 29,770 neuraxial procedures in labor (95% confidence interval, 1:12,758-1:91,659). Three of 5 identified cases occurred in the operating room after single-shot spinal anesthesia for Cesarean delivery after epidural analgesia in labor. One case developed in the labor ward due to an inadvertent intrathecal or subdural catheter placed for labor analgesia. The fifth case followed single-shot spinal anesthesia for elective Cesarean delivery. All 5 patients were successfully extubated in the operating room after Cesarean delivery, without the need for intensive care admission. There were no cardiac arrests and no neonatal deaths.

CONCLUSIONS

High neuraxial block requiring tracheal intubation is a rare but impactful complication in obstetric anesthesia, potentially affecting both mother and fetus. Spinal anesthesia after epidural analgesia in labor is a common cause of high neuraxial block. Meticulous follow-up of epidurals in labor facilitates conversion to surgical anesthesia and may therefore reduce the need for spinal anesthesia after epidural analgesia. Large-scale surveillance systems in obstetric anesthesia are needed to identify those at risk, as well as to formulate further strategies to mitigate this burden.

Cardiac arrest in pregnancy with successful stabilization and delivery on veno-arterial extracorporeal membrane oxygenation: a case report

Background

Cardiac arrest in pregnancy is rare. Clinicians need to adapt management to the altered anatomy and physiology of pregnancy, and the well-being of two patients (mother and foetus) may come into consideration. The medical literature has limited reports on outcomes following extracorporeal membrane oxygenation (ECMO) in pregnancy.

Case summary

We report the evaluation, management, and outcome of a woman with cardiac arrest and severe left ventricle (LV) dysfunction in mid-trimester of pregnancy. The previously well woman had tolerated two prior term pregnancies without complication. At 25 weeks of gestation, she presented to the hospital with breathlessness and vomiting after a pre-syncopal episode at home. She then had in-hospital cardiac arrest, managed initially with cardiopulmonary resuscitation. The LV was dilated, thin walled, and severely impaired (LV ejection fraction 14%), and there was a secundum atrial septal defect (ASD). She was supported with veno-arterial ECMO. Planned birth occurred 5 days post-arrest for maternal indication. Coronary angiography demonstrated 99% proximal left anterior descending artery stenosis and aneurysm, raising the possibility of previous subclinical Kawasaki disease. She underwent surgical revascularization and ASD closure. Both mother and infant made a good recovery.

Discussion

We report a case of cardiac arrest in pregnancy as first presentation of severe LV dysfunction. The case highlights the role of ECMO for cardiac arrest in pregnancy and outlines specific interventions and management concepts in this setting.

Peripartum management of cardiac arrhythmias: a narrative review

Cardiac arrhythmias are responsible for a significant portion of cardiovascular disease among pregnant people. As the incidence of arrhythmias in pregnancy continues to increase, anesthesiologists who care for obstetric patients should be experts managing arrhythmias in pregnancy. This article examines the most common arrhythmias encountered in pregnancy, including risk factors, diagnosis, and management strategies. Peripartum monitoring and labor analgesia recommendations are discussed. Additionally, management of cardioversion, management of pacemakers and implantable cardioverter-defibrillators, and advanced cardiac life support in the setting of pregnancy is reviewed.

Total spinal anaesthesia following obstetric neuraxial blockade: a narrative review

BACKGROUND

Total spinal anaesthesia (TSA) is an emergency caused by high neuraxial blockade. It is a recognised complication of all neuraxial techniques in obstetric anaesthesia. Its incidence and outcomes have not been evaluated. There is compelling evidence that TSA continues to be a problem in contemporary practice, having the capacity to cause significant morbidity and mortality if not recognised early and promptly treated. This review based on a literature search aims to clarify the epidemiology of TSA, summarise its pathophysiology, and identify risk factors and effective treatments.

METHODS

We performed a literature search using PubMed, Web of Science and Google Scholar databases using specified search terms for materials published using search terms. For each case, the type of block, the difficulty of the procedure, the dose of local anaesthetic, positivity of aspiration before and after the event, maternal outcome, Apgar score, onset of symptoms, cardiorespiratory and neurological manifestations, cardiorespiratory support employed, admission to an intensive care unit, cardiac arrest events and duration of mechanical ventilation were extracted.

RESULTS

A total of 605 cases were identified, of which 51 were sufficiently detailed for analysis. Although TSA is described after all neuraxial techniques, spinal after epidural was a particular concern in recent reports. Respiratory distress was universal but apnoea was not. The onset of apnoea was variable, ranging from 1 to 180 min. Hypotension was not invariable and occurred in approximately half of cases. Multiple fatalities and neurological injuries were reported, often in under-resourced areas when providers were not skilled in airway management or when recognition and intervention were delayed. In the most recent reports good outcomes were achieved when effective treatments were rapidly provided.

CONCLUSIONS

The available literature confirms that TSA remains an active clinical problem and that with prompt recognition and treatment good outcomes can be achieved. This requires anticipation and preparedness in all clinical areas where neuraxial techniques are performed.

Cardiac arrest in obstetric patients receiving anaesthetic care: results from the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri-operative cardiac arrest. Additional inclusion criteria for obstetric anaesthesia were: cardiac arrest associated with neuraxial block performed by an anaesthetist outside the operating theatre (labour epidural analgesia); and cardiac arrest associated with remifentanil patient-controlled analgesia. There were 28 cases of cardiac arrest in obstetric patients, representing 3% of all cardiac arrests reported to NAP7, giving an incidence of 7.9 per 100,000 (95%CI 5.4-11.4 per 100,000). Obstetric patients were approximately four times less likely to have a cardiac arrest during anaesthesia care than patients having non-obstetric surgery. The single leading cause of peri-operative cardiac arrest in obstetric patients was haemorrhage, with underestimated severity and inadequate early resuscitation being contributory factors. When taken together, anaesthetic causes, high neuraxial block and bradyarrhythmia associated with spinal anaesthesia were the leading causes overall. Two patients had a cardiac arrest related to labour neuraxial analgesia. There were no cardiac arrests related to failed airway management or remifentanil patient-controlled analgesia.

Obesity at term: What to consider? How to deliver?

Obesity presents significant challenges during pregnancy, increasing the risk of complications and adverse outcomes for both mother and baby. With the rising prevalence of obesity among pregnant women, questions arise regarding optimal management, including timing of delivery and choice of delivery mode. Labour induction in obese women may require a combination of mechanical and pharmacological methods due to increased risk of failed induction. Caesarean section in obese women presents unique challenges, requiring comprehensive perioperative planning and specialized care to optimize outcomes. However, specific guidelines tailored to obese patients undergoing caesarean sections are lacking. Postpartum care should include vigilant monitoring for complications. Addressing obesity in pregnancy necessitates a multidisciplinary approach and specialized care to ensure the best outcomes.

Case report: Maternal cardiac arrest at 12 hours postpartum

Maternal cardiac arrest is a rare occurrence. In this case report, we present a detailed account of a 37-year-old pregnant woman with preeclampsia with severe features who underwent cesarean delivery. The patient experienced dyspnea and hypoxia at 12 hours postpartum, leading to cardiac arrest in the maternity ward. Advanced cardiac life support measures, including 15 minutes of chest compressions, were performed until spontaneous circulation was restored. This study explores the underlying factors contributing to maternal cardiac arrest during the postpartum period. Additionally, it highlights the effective strategies employed by our multidisciplinary team in managing and resolving this critical medical event.

Comparison of perioperative outcomes and anesthetic-related complications of morbidly obese and super-obese parturients delivering by cesarean section

OBJECTIVE

To compare the perioperative outcomes and anesthetic-related complications of morbidly obese and super-obese parturients delivering by cesarean section.

METHODS

A retrospective analysis of 6 years of data was performed. Exclusions were cases with gestational ages <24 weeks, placenta accreta spectrum, polyhydramnios, or multiple gestations.

RESULTS

The study included 494 patients whose body mass index (BMI) exceeded 40 kg/m² at delivery. Of these, 469 were morbidly obese (BMI 40-49.9; mean, 42.9 ± 2.4), and 25 were super obese (BMI >50; mean, 54.5 ± 4.2). Twenty-four (5.1%) morbidly obese women received general anesthesia. The other 445 patients (94.9%) in the morbid obesity group underwent cesarean delivery under regional anesthesia; however, some (2.2%; 10/445) received general anesthesia after regional anesthesia failed. In the super-obesity group, 23 patients (92.0%) received regional anesthesia, while two patients (8.0%) received general anesthesia. There were no cases of pulmonary aspiration, maternal deaths, or difficult or failed intubation. There was one episode of cardiac arrest in a patient with a BMI of 47.9. Among the morbidly obese and super-obese women given regional anesthesia, the super-obese patients had significantly greater volumes of ephedrine and norepinephrine consumption (p = 0.027 and 0.030), intravenous fluids (p = 0.006), and bleeding during surgery (p = 0.017). They also had more hypotensive episodes (p = 0.038). The two groups' incidences of neonatal birth asphyxia, postpartum hemorrhage, blood transfusion, and uterine atony did not differ significantly. The lengths of stay in the hospital were also comparable.

CONCLUSIONS

Among the women receiving regional anesthesia, the super-obese parturients had greater intraoperative bleeding, a higher proportion of hypotensive episodes, and a greater vasopressor requirement than the morbidly obese parturients. Anesthesiologists must prepare for the adverse perioperative events that such women risk experiencing during a delivery by cesarean section.

www.clinicaltrials.gov ID: NCT04657692.

Assisted vaginal delivery in the obese patient

Appropriate use of ventouse or obstetric forceps as options in the management of the second-stage of labor is good medical practice. The instruments are not inherently dangerous, however, the manner in which they are used may be. In addition to a working knowledge of the instruments, the operator must have the willingness to abandon an unsuccessful procedure. Awareness that failure of assisted vaginal delivery is more likely in women with BMI >30, hence, gives pause to consider trial in theatre with early recourse to cesarean delivery if unsuccessful Awareness that obesity is associated with increased risk of intrapartum complications, such as the need for second-stage assistance to achieve delivery, shoulder dystocia and postnatal complications, such as obstetric anal sphincter injury and febrile morbidity.

Successful Management and Birth After Perimortem Cesarean Delivery and Stillbirth Due to Anaphylaxis

Perimortem cesarean delivery is an effective procedure for cardiopulmonary resuscitation during pregnancy. However, there are no reports documenting long-term outcomes in perimortem cesarean delivery survivors. This may be the first report of a successful live birth, occurring two years after perimortem cesarean delivery. A 29-year-old primipara was transferred to the emergency center on account of cardiopulmonary arrest, at 33 weeks of gestation. She was resuscitated 47 min after cardiopulmonary arrest by perimortem cesarean delivery amongst other treatment modalities, although the fetus died. Two months later, she was discharged with a preserved uterus, and no neurological damage. The couple suffered from posttraumatic stress disorder, which they overcame with the support of the multidisciplinary team, then gave birth to a healthy baby 2 years later. To overcome cardiopulmonary arrest during pregnancy, a seamless approach by a multidisciplinary team is essential for a good patient outcome.

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

[Prehospital perimortem cesarean section during cardiopulmonary resuscitation for traumatic cardiac arrest : Case report and lessons learned]

The following case report discusses the resuscitation of a pregnant woman in traumatic cardiac arrest after a fall from a height with consecutive resuscitative hysterotomy for maternal and fetal salvage. The report illustrates all lessons learned from critical appraisal amid new guideline recommendations and gives an overview of the published literature on the matter. Despite extensive resuscitation efforts, ultimately both the mother and the newborn were pronounced life extinct at the scene. Prehospital treatment of (traumatic) cardiac arrest in a pregnant patient as well as performing a perimortem cesarean section remain infrequent but challenging scenarios.

Management of the Pregnant Trauma Patient: A Systematic Literature Review

INTRODUCTION

Trauma during pregnancy is the leading cause of non-obstetric maternal death and complicates up to 5%-7% of pregnancies. This systematic review without meta-analysis explores the current literature regarding the assessment and management of pregnant trauma patients to provide evidence-based recommendations to guide the general surgeon regarding the prognostic value of laboratory testing including Kleihauer-Betke testing, duration of maternal and fetal monitoring, the use of tranexamic acid, the safety of radiographic studies, and the utility of perimortem cesarean section to improve maternal and fetal mortality.

MATERIALS AND METHODS

A systematic search of MEDLINE (Ovid), the Cochrane Library (Wiley), and Embase (Elsevier) was performed. The reference lists of included studies were reviewed for relevant citations.

RESULTS

Of the 45 studies included in this review, there was reasonable evidence to suggest that the minimally injured pregnant trauma patient should be observed for a minimum of 4 h, CT scans to rule out traumatic injury are necessary and safe, perimortem cesarean sections should be performed as soon as maternal cardiac arrest occurs.

CONCLUSIONS

We recommend delivery by perimortem cesarean section as soon as possible after maternal cardiac arrest, to provide TXA to the hemorrhaging pregnant trauma patient, to obtain trauma CT scans as indicated, and to observe the injured pregnant patient for a minimum of at least 4 h. Additional high-quality studies focusing on the prognostic potential of KB tests and other laboratory studies are needed.

Trauma in Pregnancy

Trauma is the leading cause of nonobstetric maternal death. Pregnant patients have a similar spectrum of traumatic injuries with a noted increase in interpersonal violence. A structured approach to trauma evaluation and management is recommended with several guidelines expanding on ATLS principles; however, evidence is limited. Optimal management requires understanding of physiologic changes in pregnancy, a team-based approach, and preparation for interventions that may including neonatal resuscitation. The principles of trauma management are the same in pregnancy with a systematic approach and initial maternal focused resuscitation..

Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity

Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.

Self-Confidence, Satisfaction, and Knowledge of Nursing Students with Training in Basic Life Support in Pregnant Women: A Cross-Sectional Study

Background: A flipped classroom integrating clinical simulation has been shown to be effective for basic life support (BLS) competencies in nursing students. Cardiopulmonary arrests (CPAs) in pregnant women have a low incidence but high morbidity and mortality. Current trends show an increasing incidence; however, most official university nursing training curricula do not include specific training modules for BLS in pregnant women. This study aims to know the satisfaction and self-confidence of nursing students with respect to a training intervention regarding in BLS in pregnant women. Additionally, it aims to assess the adequacy of this intervention for acquiring the necessary knowledge on the subject. Methods: A cross-sectional study was conducted at the University of Jaen in 2022. Data were collected on sociodemographic factors, previous contact with the topic, and topic knowledge in addition to the use of an SCLS questionnaire to measure satisfaction. Participants took the BLS training (a flipped classroom integrating clinical simulation on this topic) before answering the questionnaire. Results: A total of 136 students participated. The mean score on the BLS questionnaire was 9.10 out of 10 (SD = 1.01). The mean score for the SCLS questionnaire for females was 62.36 (SD = 7.70) and 56.23 (SD = 16.94) for the male group. Age showed a statistically significant association with SCLS score: the score decreased with an increase in age (p < 0.001). Conclusions: The flipped classroom, integrating simulation for BLS in pregnant women, improves self-confidence, satisfaction, and knowledge on the topic.

Maternal sudden death: A nationwide retrospective study

OBJECTIVE

To determine the prevalence of maternal sudden death (MSD) and to compare the characteristics of death between women with explained and unexplained sudden death.

DESIGN

A national retrospective study in France.

POPULATION

Maternal deaths related to an unexpected sudden cardiac arrest were extracted from the French National Confidential Enquiry into Maternal Deaths database for 2007-2012.

METHODS

Maternal, pregnancy, sudden death characteristics and maternal investigations were compared between women with explained and unexplained cause of death.

RESULTS

A total of 83 maternal sudden deaths and 4 949 890 live births occurred over the period studied, thus accounting for 16% of all maternal deaths (n = 510). Death was explained in 51 (61%) women and unexplained in 32 women (39%). Compared with women with unexplained death, women with explained death were more often found to have in-hospital cardiac arrest (47% versus 12%, P < 0.01), witnessed cardiac arrest (86% versus 62%, P = 0.03) and in-hospital death (82% versus 47%, P < 0.01). Postmortem investigations such as autopsy and/or CT scan (65% versus 31%, P < 0.01) were also more often carried out in women with explained death. The proportion of deaths for which the preventability factors could not be assessed was 58% among unexplained MSD and 7% among explained MSD.

CONCLUSION

Maternal sudden death is a rare event but accounts for a high proportion of all maternal deaths. This highlights the importance of providing training in diagnostic and management strategy for care providers. Systematic postmortem investigations are required to help understand causes and improve practices.

Maternal cardiopulmonary resuscitation

The perinatal resuscitation history in Japan is short, with the earliest efforts in the field of neonatology. In contrast, the standardization and dissemination of maternal resuscitation is lagging. With the establishment of the Maternal Death Reporting Project and the Maternal Death Case Review and Evaluation Committee in 2010, with the aim of reducing maternal deaths, the true situation of maternal deaths came to light. Subsequently, in 2015, the Japan Council for the Dissemination of Maternal Emergency Life Support Systems (J-CIMELS) was established to educate and disseminate simulations in maternal emergency care; training sessions on maternal resuscitation are now conducted in all prefectures. Since the launch of the project and council, the maternal mortality rate in Japan (especially due to obstetric critical hemorrhage) has gradually decreased. This has been probably achieved due to the tireless efforts of medical personnel involved in perinatal care, as well as the various activities conducted so far. However, there are no standardized guidelines for maternal resuscitation yet. Therefore, a committee was set up within the Japan Resuscitation Council to develop a maternal resuscitation protocol, and the Guidelines for Maternal Resuscitation 2020 was created in 2021. These guidelines are expected to make the use of high-quality resuscitation methods more widespread than ever before. This presentation will provide an overview of the Guidelines for Maternal Resuscitation 2020.

Healthcare personnel self-assessed competence and knowledge following implementation of a new guideline on maternal resuscitation in Norway. A repeated measure study

Introduction

Cardiac arrest in pregnancy is a rare, yet extremely challenging condition to manage for all healthcare personnel involved. Knowledge deficits and poor resuscitation skills can affect outcomes in cardiac arrest in pregnancy, but research exploring healthcare personnel competence and knowledge about maternal resuscitation is limited.

Aims

The aim of this study was to explore (1) healthcare personnel self-assessed competence and knowledge about cardiopulmonary resuscitation (CPR) in pregnancy as well as perimortem caesarean section, before and after implementation of a new guideline, (2) whether there were any interprofessional differences in knowledge about maternal resuscitation, and (3) potential differences between different implementation strategies.

Research Methodology

The study had a prospective repeated measure implementation design, utilizing a questionnaire before and after implementation of a new guideline on maternal resuscitation after cardiac arrest.

Setting

All healthcare personnel potentially involved in CPR in six hospital wards, were invited to participate (n = 527). The guideline was implemented through either simulation, table-top discussions and/or an electronical learning course.

Results

In total, 251 (48%) participants responded to the pre-questionnaire, and 182 (35%) to the postquestionnaire. The need for education and training/simulation concerning maternal resuscitation were significantly lowered after implementation of the guideline, yet still the majority of respondents reported a high to medium need for education and training/simulation. Participants' self-assessed overall competence in maternal resuscitation increased significantly postimplementation. Regardless of professional background, knowledge about CPR and perimortem caesarean section increased significantly in most items in the questionnaire after implementation. Differences in level of knowledge based on implementation strategy was identified, but varied between items, and was therefore inconclusive.

Conclusion

This study adds knowledge about healthcare personnel self-assessed competence and knowledge about maternal resuscitation and perimortem caesarean section in pregnancy. Our findings indicate that there is still a need for more education and training in this rare incident.

Maternal collapse in pregnancy

Maternal collapse is a rare life-threatening event that can occur at any stage of pregnancy or up to 6 weeks postpartum. Prompt identification and timely intervention by a multidisciplinary team that includes an obstetrician, midwifery staff and an obstetric anaesthetist are essential to improve maternal and fetal outcomes. Standard adult resuscitation guidelines need to be followed with some modifications, taking into account the maternal-fetal physiology, which clinicians should be familiar with. During cardiac arrest, the emphasis is on advanced airway management, manual uterine displacement to relieve aortocaval compression and performing a resuscitative hysterotomy (peri-mortem caesarean delivery) swiftly in patients who are more than 20 weeks gestation to improve maternal survival. Annual multidisciplinary simulation training is recommended for all professionals involved in maternity care; this can improve teamwork, communication and emergency preparedness during maternal collapse.

Anesthesia and Analgesia for the Obese Parturient

Obesity is a worldwide epidemic and is associated with an increased risk of hypertension, diabetes, and obstructive sleep apnea. Pregnant patients with obesity experience a higher risk of maternal and fetal complications. Anesthesia also poses higher risks for obese parturients and may be more technically challenging due to body habitus. Safe anesthesia practice for these patients must take into consideration the unique challenges associated with the combination of pregnancy and obesity.

Perioperative Anesthetic Management of the Pregnant Patient With Congenital Heart Disease Undergoing Cardiac Intervention: A Systematic Review

Maternal congenital heart disease is increasingly prevalent, and has been associated with a significantly increased risk of maternal, obstetric, and neonatal complications. For patients with CHD who require cardiac interventions during pregnancy, there is little evidence-based guidance with regard to optimal perioperative management. The periprocedural management of pregnant patients with congenital heart disease requires extensive planning and a multidisciplinary teams-based approach. Anesthesia providers must not only be facile in the management of adult congenital heart disease, but cognizant of the normal, but significant, physiologic changes of pregnancy.

Uterine rupture in the third trimester of a pregnancy subsequent to a cesarean section by transverse uterine fundal incision: A case report and literature review

Cesarean section via a transverse uterine fundal incision is performed in patients with placenta previa to reduce blood loss. We describe a case of uterine rupture in a pregnant woman who previously underwent a cesarean section and recovered from cardiac arrest by multidisciplinary management.

Spontaneous Pulmonary Embolism Leading to Sudden Cardiac Arrest and Perimortem C-Section in a 39-Week Parturient During Induction of Labor: A Case Report

We report the successful salvage of mother and baby after a perimortem cesarean delivery (PMCD) complicated by a 21-minute asystolic maternal cardiac arrest (MCA) that was precipitated by a pulmonary embolism during the early stages of induction of labor. With rapid PMCD, recovery of maternal quality of life is possible even after prolonged resuscitation.

Emergencies in obstetric anaesthesia: a narrative review

We conducted a narrative review in six areas of obstetric emergencies: category-1 caesarean section; difficult and failed airway; massive obstetric haemorrhage; hypertensive crisis; emergencies related to neuraxial anaesthesia; and maternal cardiac arrest. These areas represent significant research published within the last five years, with emphasis on large multicentre randomised trials, national or international practice guidelines and recommendations from major professional societies. Key topics discussed: prevention and management of failed neuraxial technique; role of high-flow nasal oxygenation and choice of neuromuscular drug in obstetric patients; prevention of accidental awareness during general anaesthesia; management of the difficult and failed obstetric airway; current perspectives on the use of tranexamic acid, fibrinogen concentrate and cell salvage; guidance on neuraxial placement in a thrombocytopenic obstetric patient; management of neuraxial drug errors, local anaesthetic systemic toxicity and unusually prolonged neuraxial block regression; and extracorporeal membrane oxygenation use in maternal cardiac arrest.

Septic Shock and Cardiac Arrest in Obstetrics: A Practical Simplified Clinical View

Septic shock and cardiac arrest during pregnancy, despite being uncommon, carry a high mortality rate among pregnant individuals. Basic initial management strategies are fundamental to improve clinical outcomes; obstetricians and maternal-fetal medicine specialists need to be familiar with such interventions.

Out-of-hospital cardiac arrest in pregnant women: a 55-patient French cohort study

AIM

To describe a cohort of pregnant women having suffered an out-of-hospital cardiac arrest (OHCA) and to compare them with nonpregnant women of childbearing age having suffered OHCA.

METHODS

Study data were extracted from the French National OHCA Registry between 2011 and 2021. We compared patients in terms of characteristics, care and survival.

RESULTS

We included 3,645 women of childbearing age (15-44) who had suffered an OHCA; 55 of the women were pregnant. Pregnant women were younger than nonpregnant victims (30 vs. 35 years, p=0.006) and were more likely to have a medical history (76.4% vs. 50.5%, p<0.001) and a medical cause of the OHCA (85.5% vs. 57.2%, p<0.001). Advanced Life Support was more frequently administered to pregnant women (98.2%, vs. 72.0%; p<0.001). In pregnant women, the median time of MICU arrival was 20 minutes for the Medical Intensive Care Unit with no difference with nonpregnant women. Survival rate on admission to hospital was higher among pregnant women (43.6% vs. 27.3%; p=0.009). There was no difference in 30-day survival between pregnant and nonpregnant groups (14.5% vs. 7.3%; p=0.061). Fetal survival was only observed for OHCAs that occurred during the pregnancy second or third trimester (survival rates: 10.0% and 23.5%, respectively).

CONCLUSIONS

Our results show that resuscitation performance does not meet European Resuscitation Council's specific guidelines on OHCA in pregnant women. Although OHCA in pregnancy is rare, the associated prognosis is poor for both woman and fetus. Preventive measures should be reinforced, especially when pregnant women have medical history.

Effect of maternal positioning during cardiopulmonary resuscitation: a systematic review and meta-analyses

Background

Although rare, cardiac arrest during pregnancy is the leading cause of maternal death. Recently, its incidence has been increasing worldwide because more pregnant women have risk factors. The provision of early, high-quality cardiopulmonary resuscitation (CPR) plays a major role in the increased likelihood of survival; therefore, it is important for clinicians to know how to manage it. Due to the aortocaval compression caused by the gravid uterus, clinical guidelines often emphasise the importance of maternal positioning during CPR, but there has been little evidence regarding which position is most effective.

Methods

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and OpenGrey (updated on April 3, 2021). We included clinical trials and observational studies with reported outcomes related to successful resuscitations.

Results

We included eight studies from the 1,490 screened. The eight studies were simulation-based, crossover trials that examine the quality of chest compressions. No data were available about the survival rates of mothers or foetuses/neonates. The meta-analyses showed that resuscitation of pregnant women in the 27°–30° left-lateral tilt position resulted in lower quality chest compressions. The difference is an 19% and 9% reduction in correct compression depth rate and correct hand position rate, respectively, compared with resuscitations in the supine position. Inexperienced clinicians find it difficult to perform chest compressions in the left-lateral tilt position.

Conclusions

Given that manual left uterine displacement allows the patient to remain supine, the resuscitation of women in the supine position using manual left uterine displacement should continue to be supported. Further research is needed to fill knowledge gaps regarding the effects of maternal positioning on clinical outcomes, such as survival rates following maternal cardiac arrest.

Impact of foeto-maternal resuscitation and perimortem caesarean section simulation training: An opinion survey of healthcare participants

Background:

The incidence of maternal cardiac arrest is rising in recent years. Medical staff generally lack the experience of performing resuscitation on pregnant patients. Maternal cardiac arrest and perimortem caesarean section simulation training was newly introduced in the Advanced Life Support in Obstetrics provider courses in Hong Kong since April 2021.

Objective:

To evaluate the course participants’ opinions on maternal cardiac arrest simulation training.

Methods:

A questionnaire survey was conducted for all participants in the Advanced Life Support in Obstetrics provider course in April 2021 to assess their opinions on the usefulness of this training.

Results:

There were four Advanced Life Support in Obstetrics provider courses in April 2021 with 36 participants in each course, and 137 questionnaires were received at the end of the course. The response rate was 137/144 (95.1%). After excluding the questionnaires with incomplete information, 134 questionnaires were included for final analysis. Almost all of the participants agreed that the maternal cardiac arrest simulation training could help them in their work (97.8%), could improve their knowledge and skill (98.5%) and could improve team training and co-ordination (97.0%). The majority of them (97.0%) felt more confident in managing maternal cardiac arrest after the training, and 97.8% of participants felt that the perimortem caesarean section model was useful for training. Around 80% of the participants would recommend this course to their colleagues. There were no significant differences in opinions on the usefulness of this training among participants with regard to their specialty, whether they were doctors or nurses, their years of experience and the specific hospital settings.

Conclusions:

Maternal cardiac arrest simulation training was highly valued by all levels of obstetric, emergency medicine and anaesthesia staff in both public and private hospitals.

Parada cardiorrespiratória obstétrica: construção e validação de instrumento para avaliar o conhecimento da enfermagem

RESUMO Objetivo Construir e validar instrumento para avaliar o conhecimento da enfermagem sobre parada cardiorrespiratória obstétrica. Métodos Estudo metodológico composto pela construção do instrumento, validação de conteúdo por 23 especialistas e validação da consistência interna com 74 profissionais da enfermagem e 99 estudantes de enfermagem. Foram considerados válidos os itens com concordância mínima de 90%, verificada a partir do Índice de Validação de Conteúdo, Razão de Validade de Conteúdo e teste binomial. O alpha de Cronbach foi utilizado para verificar a consistência interna e o valor superior a 0,6 classificado como aceitável. Resultados O instrumento foi composto por16 questões de múltipla escolha, dos 16 itens avaliados, oito possuíram concordância de 100% e seis 95%. A menor razão de validade de conteúdo foi de 0,82 e o alpha de Cronbach foi de 0,694. Conclusões O instrumento foi construído e validado, recomendando-se sua utilização para avaliação do conhecimento em parada cardiorrespiratória obstétrica.

Obstetric cardiopulmonary arrest: construction and validation of an instrument to assess nursing knowledge

ABSTRACT Objective To build and validate an instrument to assess nursing knowledge about obstetric cardiopulmonary arrest. Methods A methodological study consisting of the construction of the instrument, content validation by 23 experts and validation of internal consistency with 74 nursing professionals and 99 nursing students. Items with a minimum agreement of 90%, verified from the Content Validation Index, Content Validity Ratio and binomial test were considered valid. Cronbach’s alpha was used to verify internal consistencyand a value greater than 0.6 was classified as acceptable. Results The instrument consisted of 16 multiple-choice questions, from the 16 items evaluated, eight had 100% agreement by the experts and six had 95%. The lowest content validity ratio was 0.82 and Cronbach’s alpha was 0.694. Conclusions The instrument was constructed and validated, and its use is recommended to assess knowledge in obstetric cardiopulmonary arrest.

CARDIOPULMONARY RESUSCITATION IN PREGNANT WOMEN: CREATION AND VALIDATION OF A CHECKLIST TO EVALUATE THE NURSING PRACTICE

ABSTRACT Objective to create and validate a checklist to evaluate the Nursing practice in cardiopulmonary resuscitation in pregnant women. Method a methodological study developed from May to August 2019, conducted from creation of the instrument and content validation in charge of 11 nurses specialized in Urgencies and Emergencies and 12 obstetric nurses. A Likert-type scale was used to assess language, clarity, objectivity, content, relevance and pertinence of the instrument. The validation criterion was agreement above 80%, analyzed by means of the Content Validation Index and the Binomial Test. Results the final version of the instrument consisted of 54 questions that contemplated the sequence of actions to be adopted by the health professionals in the face of obstetric cardiopulmonary arrests. The minimum agreement level obtained was 91% and the mean Content Validity Index was 0.99. Conclusion the validated instrument can be used by professors involved in the teaching of obstetric cardiopulmonary arrest and contribute to the assessment of skills in the Nursing practice, to be carried out in research studies that test the effectiveness of educational interventions and training sessions.

RESSUSCITAÇÃO CARDIOPULMONAR EM GESTANTES: CONSTRUÇÃO E VALIDAÇÃO DE CHECKLIST PARA AVALIAR PRÁTICA DA ENFERMAGEM

RESUMO Objetivo construir e validar checklist para avaliar a prática da enfermagem na ressuscitação cardiopulmonar em gestantes. Método estudo metodológico, desenvolvido de maio a agosto de 2019 realizado a partir da construção do instrumento e validação de conteúdo por 11 enfermeiros especialistas em urgência e emergência e 12 em obstetrícia. Foi utilizada escala do tipo Likert, acerca da linguagem, clareza, objetividade, conteúdo, relevância e pertinência instrumento. O critério de validação foi concordância superior a 80%, analisada mediante o Índice de Validação de Conteúdo e do Teste Binomial. Resultados a versão final do instrumento foi composta por 54 questões que contemplaram a sequência de condutas a serem adotadas pelo profissional de saúde, diante de uma parada cardiorrespiratória obstétrica. A concordância mínima obtida foi de 91% e a média do Índice de Validação de Conteúdo foi de 0,99. Conclusão o instrumento validado pode ser utilizado por docentes envolvidos no ensino da parada cardiorrespiratória obstétrica e contribuir com a avaliação da habilidade na prática da enfermagem, a ser realizada em pesquisas que testem a efetividade de intervenções educativas e treinamentos.