Perimortem Cesarean Delivery

Excerpt

Delivery by cesarean section(C-section) dates to 800 BCE. Unfortunately, at the time, the procedure was only done on a deceased or dying pregnant patient. It was not until the late 19th and 20th centuries that the first cases of perimortem cesarean section use for salvage of the fetus were described. During the 1980s, additional case reports described its use to improve the mother's survival.

One of the most daunting scenarios to face during an emergency department (ED)/critical care shift is the sudden, adverse change in a pregnant patient's health. These rare occurrences result from pre-existing conditions with severe, unforeseen medical and obstetric complications. This is also the scenario when patients arrive in extremis from a traumatic insult. An astute physician must be prepared and ready to do what is appropriate to save the life of the mother and the fetus. This includes considering a perimortem cesarean section (PMCS). A PMCS is defined as a C-section performed during imminent cardiac arrest or active cardiac arrest, with the ultimate goal of successfully resuscitating the mother and improving fetal survivability. It is also referred to as resuscitative hysterotomy.

PMCS is now a rarely performed procedure as the pregnancy-related death rates are overall low. Although the incidence of PMCS has not been well documented, the incidence of cardiac arrests during pregnancy is 1/30,000. Prior to 1986, only 188 cases were reported. From 1986 to 2004, only 38 additional cases were reported in the United States. Most were performed in the emergency department; occasional reports document pre-hospital scenarios. Despite the scarcity of data, with expedited deliveries, fetal survivability can be as high as 70% with successful maternal resuscitations. Of the 38 case reports mentioned earlier, additional data revealed that the most common causes of maternal arrest requiring PMCS were trauma, pulmonary embolism, cardiac causes, sepsis, and eclampsia. In the Netherlands, a retrospective questionnaire and medical survey review over 15 years (1993-2008) revealed 55 pregnant patients who suffered cardiac arrest, and only 12 (22%) of them had a PMCS. Other risk factors that have been documented from prior case series include obesity and advanced maternal age older than 35.