Resuscitation of traumatic maternal cardiac arrest: A case report and summary of recommendations from Obstetric Life Support™

Abstract

Traumatic maternal cardiac arrest (MCA) is a challenging scenario for the healthcare team. Expanding the focused assessment with sonography for trauma (FAST) and modifying cardiopulmonary resuscitation (CPR) is necessary. Critical components in the resuscitation of reproductive-age women with traumatic cardiac arrest are highlighted using recommendations from Obstetric Life Support™. A morbidly obese female presented to the Emergency Department (ED) with ongoing CPR and massive hemorrhage from two gunshot wounds to the chest. Ultrasound used during secondary survey, revealed an intrauterine pregnancy, with uterine fundus palpated above the umbilicus. Four minutes after arrival at the ED, the trauma surgeon initiated a resuscitative cesarean delivery (RCD) by transverse abdominal incision. The on-call obstetrician completed the procedure, and the neonate was resuscitated and transferred to the neonatal intensive care unit (NICU). Multiple agents and surgical techniques were required to control ongoing uterine and abdominal wall hemorrhage during intermittent return of spontaneous circulation (ROSC). Despite ongoing CPR and management of the patient's chest, pelvic and abdominal wounds, eventually, there was no return of cardiac activity, no organized cardiac rhythm, no measurable end-tidal carbon dioxide, and no palpable pulse. Further resuscitation and initiation of extracorporeal cardiopulmonary resuscitation (ECPR) were deemed futile by the multidisciplinary team and stopped at the 60-minute mark. Our case summarizes essential techniques addressing MCA recommended in OBLS™ courses. Including 1) expanding the FAST exam to assess for pregnancy status, 2) estimating gestational age by fundal height or point-of-care ultrasound, 3) performing a RCD via midline vertical incision at 4 min if pregnancy is suspected to be ≥20 weeks' gestation (fundal height at or above the umbilicus, femoral length of ≥30 mm or biparietal diameter of ≥45 mm), and 4) execution of ECPR for refractory cardiac arrest.

Keywords: Maternal cardiac arrest; Resuscitative cesarean delivery.

Fig. 1

OBLS™ algorithm for maternal cardiac arrest. Note: This algorithm was produced by the creators of OBLS™ summarizing the steps to follow when facing maternal cardiac arrest. It is reproduced with permission; copyright 2020 Varda5, LLC.