Emergency caesarean section in cardiac arrest before the 3rd trimester.
Date First Published:
June 9, 2008
Last Updated:
October 29, 2008
Report by:
Helene Svinos, Medical Student (University of Manchester)
Search checked by:
Anna O' Malley, University of Manchester
Three-Part Question:
In [a second trimester pregnant female in cardiac arrest] is [emergency caesarean section effective] at [improving outcome for mother and foetus]?
Clinical Scenario:
A pregnant patient who was the restrained passenger in a motor vehicle accident was brought in my ambulance 10 minutes ago unconscious, all of a sudden she goes into cardiac arrest. CPR is commenced and you wonder if the next thing to do would be a caesarean section but she is only 24 weeks pregnant.
Search Strategy:
Medline 1950 to 07/2008 using Ovid Interface
EMBASE 1980-2008 Week 1
The Cochrane Library
EMBASE 1980-2008 Week 1
The Cochrane Library
Search Details:
[{exp pregnancy/ OR pregnancy.mp. OR exp pregnancy complications/ OR pregnancy complications.mp.} AND { exp heart arrest/ OR cardiac arrest.mp.} AND {exp caesarean section/ OR caesarean section.mp.} AND {perimortem.mp. OR resuscitation.mp. OR exp cardiopulmonary resuscitation}] LIMIT to human and English language
Outcome:
15 papers were identified of which 4 were relevant to the issue of caesarean section in the second trimester.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Cardiac arrest in pregnancy and somatic support after brain death. Mallampalli A, Guy E. 2005 USA | Pregnant women in cardiac arrest | Review of literature | States that there is little information on whether the delivery of a pre-viable foetus would improve maternal outcome as the haemodynamic benefits would not be expected to be as significant as later in pregnancy. | Perimortem caesarean may improve maternal outcome in cardiac arrests. The report does not recommend caesareans in cases of <24 weeks gestation and suggests CPR should be continued to achieve restoration of the circulation of the mother. | The review primarily deals with medical support following brain death in the mother in order that the foetus can reach full term. The review also states that the primary goal of a Perimortem caesarean section is the survival of the foetus. |
| Perimortem caesarean section. Strong TH, Lowe RA. 1989 USA | Pregnant patients in cardiac arrest over 24 weeks pregnant | Review | Initiate procedure if it is clear mother has little chance of recovery continue resuscitation for maximum uteroplacental perfusion | If foetus is over 24 weeks carry out a PMCS in the hope of foetal salvage. | No search strategy Aim of PMCS is seen to be foetal salvage as opposed to restoring circulation to the mother |
| Cardiopulmonary resuscitation and somatic support of the pregnant patient. Mallampalli A, Powner DJ, Gardner MO. 2004 USA | Pregnant patients | Narrative review | Primary goal is foetal salvage, not known if PMCS on gestation less than 24 weeks will improve outcome as haemodynamic effects caused by the gravid uterus may not have come into play | A perimortem caesarean section is not recommended if the gestational age is less than 24 weeks | No search strategy Views PMCS in terms of foetal viability |
| Cardiopulmonary resuscitation in pregnancy. Atta E, Gardner M. 2007 USA | Pregnant patients | Narrative review | It is not known if perimortem caesarean section carried out earlier in pregnancy to produce a pre-viable foetus is beneficial to maternal outcome. | It may be reasonable to perform a PMCS when the gestational age is 20 -23 weeks. | No search strategy |
Author Commentary:
In a pregnant patient presenting with cardiac arrest a fundus that extends quite high above the umbilicus causes aortocaval compression and can make CPR difficult and ultimately unsuccessful. The gestational age that this will usually occur as commonly quoted in the literature found for this BET will be from approximately 20-24 weeks. However, it is important to note that in the literature found from the search for the BET concerning fundal height (see BET on is fundal height an accurate indicator of gestational age at http://www.bestbets.org/bets/bet.php?id=1633) it has been found that the fundus may reach the umbilicus between 15 and 19 weeks gestation. A caesarean section performed within 4 minutes of the arrest has been known to increase maternal survival. There is still much debate over the issue of what age a foetus can survive and this procedures ultimate aim is that of a life-saving one for the mother, not of foetal salvage.
Bottom Line:
If the fundus extends high above the level of the umbilicus carry out a PMCS regardless of the gestational age and hence viability of the foetus as there is a high possibility that circulation may be restored to the mother.
References:
- Mallampalli A, Guy E.. Cardiac arrest in pregnancy and somatic support after brain death.
- Strong TH, Lowe RA.. Perimortem caesarean section.
- Mallampalli A, Powner DJ, Gardner MO. . Cardiopulmonary resuscitation and somatic support of the pregnant patient.
- Atta E, Gardner M. . Cardiopulmonary resuscitation in pregnancy.