Peri-Mortem C-Section in the Emergency Department : Dr Peter Soltau et al.

Perimortem C-section In The ED

EMERGENCY MEDICINE DIVISIONGRAND ROUNDS

November 20, 2014

Presenters : Dr Olseath Bowen

Dr. Peter Soltau

The Case

The Case 2YES, IT WAS AN ED C-SECTION.

HOW DID YOU KNOW ?

Case of ??

Dr. Olsheath BowenJunior resident

Accident and Emergency

GRAND ROUNDS

CaseDate of presentation: 25th of August

2014

Time of presentation: 10:30pm

Historian: The patient

PC:29 weeks’ gestation SOB swelling to the lower extremities

History of presenting complaint P.B.

26-year-old female

of a Kingston address

GA weeks

LMP 2/2/2014

EDD of 9/11/2014.

travelled from the Cayman Islands to Jamaica days prior to presentation.

HistoryThree days prior to presentation:

SOB at rest

She accounted for by the heat of the day

~six hours later she noted swelling of both feet

History Two days prior to presentation:

Complained of central chest pain

Sticking and tightening in nature

Severity Not radiating and constant

History Day of presentation

P.B. complain of coughproductive of thick yellow sputum and streaks of blood

Visited her private practitioner

Referred her to the UHWI for further management

History 3 pillow orthopnea PND Peluritic chest pain PV discharge Fetal movement

°fever°wheezing°calf pain°flashing lights°blurred vision°seizure like

activities

History PMHx: unremarkable

Meds: Prenatal vitamins

Allergies : NKDA

OB/GynHx:

USG x 3 normal during pregnancy,

last USG one done prior to presentation

Regular menses “every month”

Previous pregnancies were normal

Last PAP smear 2013

SHx:

Was living in the Cayman Islands with boyfriend

eturned to Jamaica for delivery

Lives with mother

°Smoking

°Alcohol

Physical ExaminationVital Signs:

Temperature: 99.0°F

Heart Rate: 125x’

Blood Pressure: mmHg - - - - - - -

Respiratory Rate: 32x’ Oxygen Saturation: 95% on RA.

Young female laying in no obvious cardio-pulmonary distress

Mucous membranes: pink, moist

Anicteric

Acyanotic

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

Respiratory No obvious deformities

Bilateral chest wall expansion

Trachea central

Bilateral AE

Crepitation through out

°Rhonchi

Abdomen Soft

Adipose ++

Non-tender

Gravid uterus ~ 3 finger breath supra umbilicus

No-fetal movement felt

VE: deferred

Central Nervous SystemAwake

Alert

Oriented in:

TimePlacePerson

Bulk and Tone Normal

Power

What are your thoughts on DDx?

AssessmentSevere preeclampsia with pulmonary edema

R/O Pulmonary Embolism

InvestigationsABG:

pH - 7.29pCO2 - 28pO2 - 150SpO2 - 99% HCO3 - -22BE - 4

ECG: Sinus rhythm, normal axis, HR 102bpm

Bedside US: placenta posterior with Fetal heart beat noted

ManagementOxygen via face mask at 10 L/min

Cardiac Monitor

ECG

IVA, CBC, PT/PTT, U+Es, LFTs, Uric Acid, Group + x match

ABG

C13, VDRL

ManagementLabetalol 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

ManagementStrict Input-Output monitoring

Hourly urine analysis

Refer to Obstetrics team on duty

Refer to Internal Medicine team on duty

While in the a&E departmentTime: 3 hrs after presentationPatient’s new complaints:

Worsening SOBNot able to breath

On observation:Sitting up-rightAgitatedRemoving face maskDiaphoreticTachypnea at 42 breaths per minute

Repeat VitalsVital Signs:

Temperature: 99.0°F

Heart Rate: 125

Blood Pressure: mmHg - - - - - - -

Respiratory Rate: 42, Oxygen Saturation: 86% on 15 L/min via non-rebreather mask

Investigations Available Results:

Hb - 9.5 PCV - 0.31 PLT - 280 WBC - 14.6

PT - PTT -

Na - 138 K+ - 3.7 Cl - 102 HCO3 - 22 Urea - 5.5 Creat - 95 Alb - 27 CPK - 193

ABG:pH - 7.26pCO2 - 47pO2 - 63SpO2 - 88% HCO3 - -20BE - 6

What are your thoughts on DDx?

Re-assessment of the patientObstetric and Gynecologist Assessment:

Severe Pre-Eclampsia with Pulmonary Edema

Severe Respiratory Distress

Impending Respiratory Failure

Congestive Cardiac Failure

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

Questions raised during resuscitation?

An important question was raised during the resuscitation of this patient:

”4 section or not in the Emergency Department”

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

• 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 abdomenFetal heart rate is heard at 110b/min on presentation and approx 2 mins later there are no fetal heart tones heard

Any Questions ? Comments ?

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

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

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%

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

BEAU-CHOPS• Bleeding

• Embolism:– Pulmonary– Amniotic fluid

• Anesthetic Complication

• Uterine Atony

• Cardiac disease

• HTN:– Preeclampsia– Eclampsia

• Other: – Mg toxicity

• Placenta abruptio/previa

• Sepsis

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

Review of Anatomical and Physiological changes of pregnancy

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

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

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

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

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

Central Hemodynamics• Cardiac output

50%• Stroke volume

25%• Heart rate

25%• LVEDV, EF• CVP: • SVR, PVR

20%

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

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

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

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

Changes in Liver Function • Alkaline phosphatase: x 2-4• Total cholesterol x 2• Fibrinogen 50%

• Albumin, total protein 20%

• Transaminases no change

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

Principles of Resuscitation

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

• 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 CPR

CAB Sequence

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

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

– 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

• 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

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.

• 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

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

• Do not forget: You should look for visible chest rise

Breathing

• Support Oxygenation/ Ventilation

• Monitor SPO2 Closely

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

• 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.

So what’s D??• Differential Dx

• Recall:–Hs & Ts–BEAU-CHOPS

• Hypovolemia

• Hypoxia

• Hydrogen ion

• Hypo/Hyperkalemia

• Hypothermia

• Toxin

• Tamponade

• T.P

• Thrombosis (coronary or pulmonary)

4 min after cardiac arrest

• ROSC* has not been achieved

• So what’s are you going to do?

* Return of spontaneous circulation

Perimortem C/S

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

• 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

• 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.

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

So this is called

Emergency C/S

• Do not forget continuing BLS & ACLS before and after Emergency C/S

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

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

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

Fetal Viability• Documenting fetal heart tones before

PMCS is not required

• Maternal indications for the procedure are emergency concerns regardless of fetal status

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

• 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

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

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.

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

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.

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.

Contraindications• Known gestation less than 24 weeks

• Return of spontaneous circulation after brief period of resuscitation

Institutional Preparation• A&E protocol (multidisciplinary input)

• Lighting

• Equipment

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

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

• 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

• 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

• 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

• 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

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

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.

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

Factors influencing infant survial

• Gestational age • Time from maternal arrest to infant

delivery• Adequacy of resuscitative efforts• Access to neonatal intensive care

resources.

• 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

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.

• 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

Recommendations• Emergency C-section kit to be kept in

A&E

• Continued staff education

• PMCS Protocol

PITFALLS IN CASE MANAGEMENT?

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

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’