OHCA CRISIS AMIDST COVID-19 PANDEMIC: A PERIMORTEM CAESAREAN DELIVERY ON MATERNAL COVID-19 PATIENT

Abstract

Introduction: There is a global surge in out-of-hospital cardiac arrests (OHCA) during COVID-19 pandemic. Pregnant women have a higher risk of developing COVID-19 complications and cardiac arrest. Perimortem Caesarean delivery (PCD) is a medical intervention to aid resuscitation of pregnant mothers and fetus.

Case description: A 32-year-old lady G3P2 at 29 weeks gestation was found unresponsive at home 50 minutes before her arrival to Emergency Department (ED). She was having fever, cough, and shortness of breath for a week. As the ambulance was delayed, she was brought to the hospital by a good Samaritan. En route cardiopulmonary  resuscitation (CPR) was not initiated. In ED, the patient was noted to be in asystole, thus resuscitation as per Advanced Cardiac Life Support was commenced immediately. The rapid antigen test for COVID-19 was positive. Decision for PCD was made by the obstetrics team. The baby was delivered in 5 minutes but unfortunately was pronounced dead after 45 minutes of resuscitation. Maternal resuscitation was continued for 28 minutes and spontaneous circulation was achieved 17 minutes post-delivery. The patient was acidotic and required exceedingly high ventilator settings. Her CXR was consistent with severe pneumonia. A joint decision between emergency and obstetric teams was made not for further CPR due to futility. The husband accepted the explanation and the patient succumbed to death.

Discussion: The chain of survival in OHCA have been disrupted in the pandemic due to changes in public behaviour, lockdowns, the stigma of contracting COVID-19, reluctance bystander CPR, and a decrease in ambulance response time. Numerous guidelines recommend performing PCD within five minutes of the collapse. PCD will result in physical alterations that aid maternal resuscitation. However, in the Covid-19 pandemic where healthcare provisions have been stretched beyond capacity, should intense resuscitation be reserved to those with better prognosis? Furthermore, the risk of COVID-19 exposure to healthcare providers should be justified by the decision to save a mother and the child.

Conclusion:  Multiple ethical dilemmas have arise in Covid-19 resuscitation. Despite these obstacles, clinicians must consider each case as unique and endeavor for the best outcomes for their patients while remaining vigilant of existing local resources.