WHEN EVERY SECOND COUNTS: RESUSCITATIVE HYRTEROTOMY FOR MATERNAL COLLAPSE

Abstract

Introduction:

The incidence of cardiac arrest in pregnancy is fortunately very low, estimated 1 in 36000 pregnancies. Therefore, resuscitative hysterotomy (RH) is rarely required. RH formerly known as perimortem caesarean section (PMCS) is resuscitative maneuver perform in a pregnant lady more than 20 weeks of gestation during cardiac arrest in order to improve maternal outcome. Herein, we present a case of maternal collapse of a COVID-19 mother with RH performed.

Case report:

A 36-year-old pregnant lady, Gravida 3 Para 2 at 25-weeks was brought into Emergency Department (ED) with no signs of life. Resuscitation was commenced immediately as per Advanced Life Support (ALS) protocol and Red Alert was activated. RH was performed at the 15th minute of collapse with ongoing chest compression. Unfortunately, resuscitation was futile; both mother and baby succumbed. Further history, the patient had fever and cough for 1 week and developed shortness of breath on the day of presentation. She collapsed upon arrival at ED. Her post-mortem PCR swab for COVID-19 was positive.

Discussion:

RH is a preferred term compared to PMCS as this is a resuscitative procedure and it gives the mother a physiological advantage by improving the chances of survival. Delivering the baby helps to relieve aorto-caval compression allowing better venous return and reduces maternal oxygen demand. After delivery, pulmonary mechanics is enhanced. When should one initiate the procedure during resuscitation? Traditional teaching of the 4-minute rule is a myth and is not evidence-based. It should not be used as a cut-off point to determine futility. Recent data shows maternal survival up to 15-minutes post-arrest and neonatal survival as late as 30-minutes post-arrest with RH. The clinical significance here is to initiate resuscitation as per ALS to reverse the potential cause and perform RH as soon as possible. The decision to perform RH is relentless stressful for the clinician in view of its rarity. However, it is noteworthy as its resuscitation benefits is paramount for both mother and fetus.

Conclusion:

RH improves maternal resuscitation. Simulation and practice help clinicians to act rapidly and confidently. Timing equals survival.