Grand round presentation on the Emergency Department perspective to the critically ill pregnant patient and the role of peri-mortem C-section.

1. Perimortem C-section In The ED
EMERGENCY MEDICINE DIVISION
GRAND ROUNDS
November 20, 2014
Presenters : Dr Olseath
Bowen

2. The Case

3. The Case 2
YES, IT WAS AN ED C-SECTION.
HOW DID YOU KNOW ?

4. Case of ??
Dr. Olsheath Bowen
Junior resident
Accident and Emergency

5. Case
Date of presentation: 25th of August 2014
Time of presentation: 10:30pm
Historian: The patient
PC:
29 weeks’ gestation
SOB 3
7
swelling to the lower extremities 3
7

6. History of presenting complaint
 P.B.
 26-year-old female
 of a Kingston address
 GA 29
40 weeks
 LMP 2/2/2014
 EDD of 9/11/2014.
 travelled from the Cayman Islands to Jamaica 9
7 days prior to presentatio

7. History
Three days prior to presentation:
SOB at rest
 She accounted for by the heat of the day
~six hours later she noted swelling of both fee

8. History
 Two days prior to presentation:
 Complained of central chest pain
 Sticking and tightening in nature
 Severity
6
10
 Not radiating and constant

9. History
 Day of presentation
 P.B. complain of cough
productive of thick yellow
sputum and streaks of blood
 Visited her private practitioner
 Referred her to the UHWI for further management

10. History
 3 pillow orthopnea
 PND
 Peluritic chest pain
 PV discharge
 Fetal movement
°fever
°wheezing
°calf pain
°flashing lights
°blurred vision
°seizure like activities

11. History
 PMHx: unremarkable
 Meds: Prenatal vitamins
 Allergies : NKDA
 OB/GynHx:
 USG x 3 normal during pregnancy,
 last USG one done 1
12 prior to presentation
 Regular menses “every month”
 Previous pregnancies were normal
 Last PAP smear 2013
 SHx:
 Was living in the Cayman Islands with boyfrien
 9
7 returned to Jamaica for delivery
 Lives with mother
 °Smoking
 °Alcohol

12. Physical Examination
Vital Signs:
Temperature: 99.0°F
Heart Rate: 125x’
Blood Pressure:
198
136
mmHg
198
136
-
198
184
-
188
133
-
175
117
-
165
118
-
160
104
-
171
113
-
163
105
Respiratory Rate: 32x’

Oxygen Saturation: 95% on RA.
Young female laying
in no obvious
cardio-pulmonary
distress
Mucous
membranes: pink,
moist
Anicteric
Acyanotic

13. Cardiovascular
 Apex beat in the 5th LICS MCL
 Pulses of regular rhythm, normal volume
 JVP not distended
 S1,S2,°S3,°S4,°M
 Oedema 3+ of the lower extremities extending
to the tibial tuberosity

14. Respiratory
 No obvious deformities
 Bilateral chest wall expansion
 Trachea central
 Bilateral AE
 Crepitation through out
 °Rhonchi

15. Abdomen
 Soft
 Adipose ++
 Non-tender
 Gravid uterus ~ 3 finger breath supra umbilicus
 No-fetal movement felt
 VE: deferred

16. Central Nervous System
Awake
Alert
Oriented in:
Time
Place
Person
Bulk and Tone Normal
Power
5
5

17. What are your thoughts on DDx?

18. Assessment
Severe preeclampsia with pulmonary edema
R/O Pulmonary Embolism

19. Investigations
ABG:
pH - 7.29
pCO2 - 28
pO2 - 150
SpO2 - 99%
HCO3 - -22
BE - 4
ECG: Sinus rhythm, normal axis, HR 102bpm
Bedside US: placenta posterior with Fetal heart beat noted

20. Management
Oxygen via face mask at 10 L/min
Cardiac Monitor
ECG
IVA, CBC, PT/PTT, U+Es, LFTs, Uric Acid, Group + x
ABG
C13, VDRL

21. Management
Labetalol 20mg IV stat , titrate to MAP of 126mmHg
Heparin 6400IU IV stat, then 1440IU/hr
Lasix 20mg IV stat
Magnesium Sulfate 10mg IM stat
Dexamethazone 8mg IM stat then Q6hrly X4doses

22. Management
Strict Input-Output monitoring
Hourly urine analysis
Refer to Obstetrics team on duty
Refer to Internal Medicine team on
duty

23. While in the a&E department
Time: 31
2 hrs after presentation
Patient’s new complaints:
Worsening SOB
Not able to breath
On observation:
Sitting up-right
Agitated
Removing face mask
Diaphoretic
Tachypnea at 42 breaths per minute

24. Repeat Vitals
Vital Signs:
Temperature: 99.0°F
Heart Rate: 125
Blood Pressure:
188
123
mmHg
198
136
-
198
184
-
188
133
-
175
117
-
165
118
-
160
104
-
171
113
-
163
105
Respiratory Rate: 42,
Oxygen Saturation: 86% on 15 L/min via non-rebreather mask

25. Investigations
 Available Results:
 Hb - 9.5
 PCV - 0.31
 PLT - 280
 WBC - 14.6
 PT - 11.6
13.4
 PTT - 26.3
32.3
 Na - 138
 K+ - 3.7
 Cl - 102
 HCO3 - 22
 Urea - 5.5
 Creat - 95
 Alb - 27
 CPK - 193
ABG:
pH - 7.26
pCO2 - 47
pO2 - 63
SpO2 - 88%
HCO3 - -20
BE - 6

26. What are your thoughts on DDx?

27. Re-assessment of the patient
Obstetric and Gynecologist Assessment:
Severe Pre-Eclampsia with Pulmonary Edema
Severe Respiratory Distress
Impending Respiratory Failure
Congestive Cardiac Failure

28. Management
 ICU team in attendance prepared to secure the
airway
 Patient had a Cardio- Pulmonary Arrest ~
10minutes post deterioration
 CPR was commenced according to the ACLS
protocol
 ~ 3 minutes into resuscitation efforts:
 Bed side USG – Live intrauterine fetus

29. Questions raised during
resuscitation?
An important question was raised during the
resuscitation of this patient:
”4 section or not
in the Emergency
Department”

30. CASE 2
• 24 year old gravid female patient 36/40
was attempting to disembark from a taxi
cab at the gate of the hospital. She was
struck by another taxi which was
attempting to overtake. She was brought
into A/E c/o severe abdominal pains
associated with dizziness and weakness.
There was no associated LOC, vomiting or
head injury.
• Denies vaginal bleeding or fluid

31. • On presentation vitals signs recorded:
T 36.5 P125 R24 Bp 110/72
She appears to have some abrasions to the
extensor aspects of both forearms and over the
umbilical region of her abdomen
Fetal heart rate is heard at 110b/min on
presentation and approx 2 mins later there are
no fetal heart tones heard

32. Any Questions ? Comments ?

33. Questions?
• Is the gestational age correct?
• Is the timeline of arrest reliable?
• Could immediate surgical intervention worsen
the prognosis?
• Is this setting sterile enough?
• Is the equipment available? Lighting,
scalpels, resucitar
• How challenging will it be?
• How long is too long

35. Perspective
• Maternal mortality rate:
– 13.95 deaths per 100,000 maternities
• 8/13.95 are due to maternal cardiac
arrests
• Cardiac arrest in pregnancy is rare
• Lewis G, ed. The Confidential Enquiry into Maternal and Child
Health(CEMACH). Saving mothers’ lives: reviewing maternal deaths to
make motherhood safer—2003–2005. The Seventh Report on Confidential
Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH.
2007

36. Cardiac arrest in pregnancy
• Varies between1/20,000-1/50,000
• Frequency has remained stable over the
years 1998-2011 for inpatients in the US
• Survival rate - 6.9%

37. Etiology
• 1) Pulmonary Embolism 29%
• 2) Haemorrhage 17%
• 3) Sepsis 13%
• 4) Peripartum cardiomyopathy 8%
• 5) Stroke 5%
• 6) Preeclampsia/eclampsia 2.8%
• 7) Complications related to anaesthesia
2%
• Cardiopulmonary resuscitation and the parturient.
• Suresh MS, LaToya Mason C, Munnur U.
Best Pract Res Clin Obstet Gynaecol. 2010 Jun;24(3):383-400

38. BEAU-CHOPS
• Bleeding
• Embolism:
– Pulmonary
– Amniotic fluid
• Anesthetic Complication
• Uterine Atony
• Cardiac disease
• HTN:
– Preeclampsia
– Eclampsia
• Other:
– Mg toxicity
• Placenta abruptio/previa
• Sepsis

39. Critical principles of ill pregnant
patients in the ED
• Two patients rather than one
• Best hope of fetal survival is maternal survival
• Fetal health, as a rule, is maximized when
maternal medical condition is optimized
• Changes in maternal physiology; therefore,
changes in normal values
• Deteriorate precipitously

40. Review of Anatomical and
Physiological changes of pregnancy

41. Metabolism & Respiration
• Oxygen consumption increases by 40-60%
• Progressive rise in metabolic needs of
fetus, uterus, and placenta
• Secondarily due to increased maternal
cardiac and respiratory work

42. Lung Volumes and Capacities
• Tidal volume increases 45%
• No change in FEV1
• No change FEV1/FVC ratio
• FRC reduced by 20%
• FRC further decreased
(30%) in the
supine position

43. Oxygen Changes In Pregnancy
• Increase in oxygen consumption
• Small increase in PaO2: usually >100 mm
Hg on room air
• Reduced A-V O2 difference
• Widening of A-a gradient
• Slight decrease in affinity of hemoglobin
for oxygen

44. Normal Arterial Blood Gas in
Pregnancy
• Mild chronic compensated respiratory
alkalosis
• pH ~7.44
• PaCO2 28-32 mm Hg
• PaO2 >100 mm Hg
• HCO3- 18-22 mEq/L

45. Cardiovascular Changes
• Plasma volume increases 40-50%
– Greater with multiple gestations
• Red cell mass increases 20-30%
• Physiologic hemodilution and decrease in
blood viscosity
• Blood pressure decreases 10-20%, with
diastolic more affected; returns toward
non-pregnant norms by the end of the third
trimester

46. Central Hemodynamics
• Cardiac output 50%
• Stroke volume 25%
• Heart rate 25%
• LVEDV, EF
• CVP:
• SVR, PVR 20%

48. Aortocaval Compression:
• Effect of Supine Position on
Hemodynamics: Enlarging uterus can
compress vena cava when patient is
supine (less commonly, aortic
compression)
– Effects: decreased preload, decreased CO,
decreased BP (“supine hypotension”)
– After 20 weeks, maintain left uterine
displacement while
recumbent

49. Hemodynamic Changes in
Puerperium
• Relative hypervolemia and increased
venous return
• Attributed to relief of caval compression,
loss of intervillous circuit and, thus,
autotransfusion
• CVP rises
• SV and CO increase by up to an additional
75% immediately postpartum

50. Changes in Renal Function
• Anatomic: dilation of the collecting system
• Renal plasma flow & GFR: increase 50%
– Serum creatinine <0.6 mg/dl, BUN <10
• Renal tubular function: increased sodium
reabsorption, increased glucose excretion,
decrease in uric acid reabsorption

51. GI and Hepatic Changes
• Decrease in LES tone, increase in resting
intragastric pressure => favor reflux
• Decreased gastric motility => delayed
gastric emptying
• Acid secretion higher in third trimester
than nonpregnant
• Overall effect: more prone to acid
aspiration

52. Changes in Liver Function
• Alkaline phosphatase: x 2-4
• Total cholesterol x 2
• Fibrinogen 50%
• Albumin, total protein 20%
• Transaminases no change

53. Hematology and Coagulation
Changes
• Hgb, Hct decrease as plasma volume
increases
• Overall enhanced platelet turnover,
clotting, and fibrinolysis
• Hypercoagulability
• Placenta contains thromboplastin, which
can induce formation of fibrin and bypass
intrinsic pathway

54. Principles of Resuscitation

55. • Call for Help / Call a maternal code
• Multidisciplinary approach
– Adult resuscitation team
– Obstetrics
– Anesthesiology
– Medicine
– Neonatology
– Cardio-thoracic surgery ?

56. • Once the uterus is above the umbilicus,
lateral uterine displacement is advocated:
– minimizes aorta-caval compression (supine
hypotension syndrome)
– Optimize venous return (preload)
– Generates adequate stroke volume during
CAB Sequence

57. Estimation of Gestational Age
– Place the patient
in supine position
– If the uterus is
above the
umbilicus or
obviously gravid,
displace the
uterus left laterally

58. Methods of uterine displacement
• Manual Uterine Displacement
• Operating table tilt
• Placement of pillows/towels/blanket under
patient
• Wood or foam resuscitation board
• Rescurer’s thigh as wedge

59. – One handed or two handed to gain 1.5 inches
displacement
– Allows the upper torso to remain supine for maximal
chest compression, airway procedures and
defibrillation

60. • Kundra P, Khanna S, Habeebullah S, Ravishankar M.
Manual displacement of the uterus during Caesarean
section. Anaesthesia. 2007 May;62(5):460-5
• Manual displacement of the uterus
effectively reduces the incidence of
hypotension and ephedrine requirements
when compared to 15 degrees left lateral
table tilt in parturients undergoing
Caesarean section

61. Rees GA, Willis BA. Resuscitation in late pregnancy.
Anaesthesia. 1988 May;43(5):347-9.
• The maximum chest compression force
produced by eight physicians was
measured as a function of angle of
inclination using an inclined plane
• At an angle of 27 degrees, force is 80% of
that in the supine position
• Resuscitation of the manikin on the Cardiff
wedge was found to be as efficient as in
the supine position.

63. • Start chest compression immediately with high
quality CPR
– 30:2
– Place hands slightly higher on the sternum
– Assess quality with waveform capnography
• But if chest compression remain inadequate?
• Large bore IVA should be placed above the level of
the diaphram
• Drugs as per ACLS protocol
Circulation

64. Airway
• Your faced with:
– Potentially difficult airway
– Increased risk of aspiration
– Rapid desaturation
• This is critical to use:
– BMV and suctioning
optimally
• Prepare for advanced airway management early
– Experienced provider

65. • Do not forget:
You should look for visible chest rise
Breathing
• Support Oxygenation/
Ventilation
• Monitor SPO2 Closely

66. Defibrillation
• The Facts:
– It is safe
– Concern about arcing around external &
internal fetal monitors??
• There is no evidence
• But reasonable to remove them
– Defibrillation dose??
• An AED* should be apply as soon as possible
* Automated external defibrillator

67. • Defibrillate using standard ACLS
defibrillation doses
• There is no evidence that shocks from a
direct current defibrillator have adverse
effects on the heart of the fetus
• Nanson J, Elcock D, Williams M, Deakin CD. Do
physiological changes in pregnancy change
defibrillation energy requirements? Br J
Anaesth. 2001; 87:237–239.

69. So what’s D??
• Differential Dx
• Recall:
– Hs & Ts
– BEAU-CHOPS

70. • Hypovolemia
• Hypoxia
• Hydrogen ion
• Hypo/Hyperkalemia
• Hypothermia
• Toxin
• Tamponade
• T.P
• Thrombosis
(coronary or
pulmonary)

71. 4 min after cardiac arrest
• ROSC* has not been achieved
• So what’s are you going to do?
* Return of spontaneous circulation

72. Perimortem C/S

73. History
• Asklepios -“to cut open”
• The “god of medicine” was
delivered by Hermes by cutting
the unborn child out of his dead
mother’s womb
• His father Apollo, had sent
Artemis to kill Coronis for
unfaithfulness

74. • 237 BC- Pliny the Elder reported the birth of
Scipio Africanus by cesearaen section
• 715 BC – Numa Pompilius decreed that if a
woman died whilst pregnant, the child must
be cut from her abdomen
• Middle Ages – Catholic church and municipal
authorities released edicts requiring post
mortem c-section to save the soul of the child

75. • 1984 Berlin - 3 infant survivals from 147
postmortem c-sections 1
• Before 1986 -188 Perimortem C-sections
reported 2
• 1986 – 2004 – 38 additional cases 2
1. Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean delivery.
Obstet Gynecol. 1986 Oct;68(4):571-6. Review. PubMed PMID: 3528956
2. Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: were
our assumptions correct?. Am J Obstet Gynecol. Jun 2005;192(6):1916-
20; discussion 1920-1.

76. Indications
• No ROSC after 4 min of cardiac arrest
– Despite good BLS & ACLS and correction of
reversible causes
• Unsuccessful chest compressions
• Obvious nonsurvivable mother injury with
viable fetus

77. So this is called
Emergency C/S
• Do not forget continuing BLS & ACLS before
and after Emergency C/S

78. Factors to Consider
• Gestational Age
• Resources of the institution
• Fetal Viability
• Timeframe from maternal arrest
• Fear of litigation
• Consent

79. Gestational Age
• This information is sometimes difficult to
obtain in an emergency situation
• Ultrasonographic estimate is not practical
• A gross visual estimate may be necessary

80. Resources of the Institution
• Under ideal circumstances (i.e skilled
personnel and in a controlled setting), fetal
salvageability may range from 23 to 28
weeks of EGA
• PMCS is probably not indicated for the
sake of the fetus if <24 weeks

81. Fetal Viability
• Documenting fetal heart tones before
PMCS is not required
• Maternal indications for the procedure are
emergency concerns regardless of fetal
status

82. Timeframe from maternal arrest
• Early intervention is strongly supported at
advanced gestational age.
• The latest reported survival was of an infant
delivered 30 minutes after a maternal suicide
• Best outcomes in terms of infant neurologic
status appear to occur if the infant is
delivered within 5 minutes of maternal
cardiac arrest
• The decision to operate must be made and
surgery begun by 4 minutes into the arrest

83. • Literature review in 2005 reported 7 infant
survivals in deliveries occurring more than
15 minutes after maternal cardiac arrest
• Maternal status did not worsen in any case
in which a PMCS was undertaken and
seemed to improve in 13 of 20 cases
published
Timeframe from maternal arrest
• Katz V, Balderston K, DeFreest M. Perimortem
cesarean delivery: were our assumptions correct?. Am
J Obstet Gynecol. Jun 2005;192(6):1916-20

84. Timeframe from maternal arrest
• Of 4 survivors (out of 5), 3 cases had
PMCS initiated 6-14 minutes after
maternal arrest, and initial follow-up was
encouraging in all 4 infants
• Consider PMCS even if there has been
some delay after a diagnosed cardiac
arrest
• Baghirzada L, Mrinalini B. Maternal Cardiac Arrest in a
Tertiary Care Centre during 1989-2011: a Case
Series. Can J Anesth. September/2013;60:1077-1084

85. Consent
• Emergency procedure – no time to
consent
• A special case of PMCD involves a woman
who is deemed brain dead but is
maintained on artificial support for the
purpose of allowing fetal maturity
• Full informed consent from the next of kin
is mandatory.

86. Legal and Ethical Considerations
• Fear of litigation may prevent intervention
in what would be, by all medical judgment,
appropriate circumstances for a PMCS
• No lawsuits filed on the basis of wrongful
performance of PMCD have been reported
in the literature

87. Legal and Ethical Considerations
• Only 1 legal penalty has been levied in
regard to PMCD—the death penalty, which
was given in the 18th century for failure to
perform the procedure
• The emergency physician has the legal
right and responsibility to provide the
unborn fetus with every possible chance of
survival when there is no hope of maternal
survival.

88. Legal and Ethical Considerations
• There is no standard of care relating to
emergency physicians performing a
postmortem cesarean delivery
• In the absence of obstetric backup
immediately at hand, it is reasonable for the
emergency physician to proceed with delivery
of the child if the mother cannot be
resuscitated.

89. Contraindications
• Known gestation less than 24 weeks
• Return of spontaneous circulation after
brief period of resuscitation

90. Institutional Preparation
• A&E protocol (multidisciplinary input)
• Lighting
• Equipment

91. Equipment
• Scalpel with a No. 10 blade
• Bandage scissors (large scissors)
• Bladder retractor
• Large retractors (2)
• Forceps
• Lap or gauze sponges
• Hemostats (curved and straight)
• Suction
• Obstetric pack/ Abdominal major kit

92. The Technique
• Available equipment is likely to be minimal
• Equipment if present, not neatly arranged
• Provider safety is at higher risk in
emergency situations
• Avoid needle sticks, scalpel cuts
• Lighting, and provider experience may also
be lacking

93. • Using the scalpel, a midline vertical incision is
made through the abdominal wall extending
from the symphysis pubis to the umbilicus
and carried through all abdominal layers to
the peritoneal cavity
• Use retractors to pull the abdominal wall
laterally on both sides, and bluntly dissect
down until the peritoneum is entered
• A bladder retractor may be used to reflect the
bladder inferiorly and gain better visualization
of the uterus.
The Technique

94. • The bladder; if full is aspirated to
evacuate it and permit better
access to the uterus
• While avoiding the bowel and
bladder a vertical incision is made
through the lower uterine
segment until amniotic fluid is
obtained or until the uterine cavity
is clearly entered

95. • The index and middle fingers are
then inserted into the incision and
used to lift the uterine wall away
from the fetus.
• A bandage scissors is used to
extend the incision vertically to the
fundus until a wide exposure is
obtained

96. • The infant is then gently
delivered, the nose and mouth
suctioned, and the cord clamped
and cut.
• Neonatal resuscitation should be
carried out as immediately

97. Closure
• Careful layered technique if the
resuscitation team believes the mother
has a chance of survival
• Rapid closure for aesthetics if mother’s
condition is deemed hopeless

98. Maternal resuscitation
• CPR should be initiated on the mother at the
time of cardiac arrest and continued throughout
the procedure
• Relief of IVC compression improves maternal
hemodynamics
• Maternal pulses should be checked and CPR
continued after delivery of the infant.

100. Infant survival
• Most literature involves only small
numbers of cases
• Emphasis mainly on successful cases so
survival statistics difficult to ascertain.
• Survival rates range from 11-70%.
• Perimortem Cesarean Delivery E Jedd Roe lll, MD, MBA, FACEP,
FAAEM, MSF, CPE; Medscape Website. Available at
http://emedicine.medscape.com/article/83059-overview Accessed
November 7,2014

101. Factors influencing infant survial
• Gestational age
• Time from maternal arrest to infant
delivery
• Adequacy of resuscitative efforts
• Access to neonatal intensive care
resources.

102. • Katz V, Balderston K, DeFreest M. Perimortem
cesarean delivery: were our assumptions correct?. Am
J Obstet Gynecol. Jun 2005;192(6):1916-20;
discussion 1920-1

103. Maternal Survival
• Uteroplacental blood flow may require up to
30% of a woman’s cardiac output
• Several animal and laboratory models and a
growing body of clinical evidence suggest
that cardiac compressions are more effective
after delivery
• Delivery of the near-term fetus provides a 30-
80% improvement in cardiac output
• Prompt and appropriate intervention is critical
to maximize the survival possibilities for the
mother and baby.

104. • Katz V, Balderston K, DeFreest M. Perimortem
cesarean delivery: were our assumptions correct?. Am
J Obstet Gynecol. Jun 2005;192(6):1916-20;
discussion 1920-1

105. Recommendations
• Emergency C-section kit to be kept in A&E
• Continued staff education
• PMCS Protocol

106. PITFALLS IN CASE MANAGEMENT

107. Summary
• Cardiac arrest in pregnancy is uncommon
• Uterine displacement and high quality CPR
are more beneficial if commenced early
• Drugs and Defibrillation should be
administered as per ACLS protocol
• After 4 minutes of resuscitation, consider
PMCS if fetus is deemed salvagable
• PMCS improves both fetal and maternal
outcomes

108. A “good” rule
There are some procedures in EM that entail
technical difficulty and moderate patient
discomfort. Any hesitancy to perform the
procedure must be put aside when it is clearly
indicated. As it can be tricky knowing whether
one of these procedures is truly needed, we
come to rely on clinical instinct. Thus the rule,
‘think of it - do it’