Perimortem caesarean section in COVID-19 era

Abstract

Cardiac arrest in pregnancy is very rare. Various methods have been proposed to return spontaneous circulation and prevent mortality, such as Perimortem Caesarean Section (PMCS). Since 2019, the COVID-19 pandemic has added to the difficulty in decision making and performing PMCS. Infection prevention being a priority due to the rapid spreading of the virus could cause hesitation upon initiating an emergency procedure, especially PMCS. We have reviewed the issues impacting on basic and advanced life support in adults with suspected or confirmed COVID-19.

Keywords:

• Perimortem caesarean section
• COVID-19
• cardiac arrest
• cardiopulmonary resuscitation

Introduction

Cardiac arrest in pregnant woman is a rare case with the incidence of 1 in 12.500 pregnancy (Chu et al. 2018). Several have reported on various methods to return spontaneous circulation and prevent maternal death (Katz et al. 1986; Katz 2012). One such method is Perimortem Caesarean Section (PMCS). PMCS is defined as ‘a caesarean delivery performed after initiation of cardiopulmonary resuscitation’. Previous studies stated that in order to achieve the desired outcome, PMCS should be done within 4 minutes after the onset of maternal cardiac arrest (Einav et al. 2012; Katz 2012; Drukker et al. 2014; Chu et al. 2018). The target is to deliver the foetus within 5 minutes after maternal cardiac arrest occurred in order to reach optimum mother and foetus survival (Chu et al. 2018).

Cardiac arrest in pregnant women, based on American Heart Association (AHA), is similar to cardiac arrest in adults. However, in pregnancy, there are physiological changes that make maternal resuscitation more challenging than the general adult population. Therefore, several adjustments should be made to increase the efficiency of maternal resuscitation.

As cardiac arrest in pregnancy is reportedly rare, the management methods of this condition including PMCS might be difficult to some doctors or other health professionals. Since 1992, AHA established that PMCS is the standard of care for cardiac arrest in pregnancy (Drukker et al. 2014). Furthermore, the current Covid-19 pandemic add a significant layer of difficulty. On the other hand, the rarity of the case lead to a lack of exposure for relevant physicians to this problem. Consequently, there is relatively low number of opportunities to exercise the decision making and technical procedure for PMCS.

Maternal cardiac arrest

As mentioned earlier, pregnancy leads to several physiological changes related to cardiopulmonary system. In pregnant women, there is an increase of blood volume (hypervolemia) which can reach to 40–45% higher than non-pregnant women. This increase in blood volume is also accompanied by decreased vascular resistance and increased heart rate leading to increased overall cardiac output (Hu and Hong 2020). If a pregnant woman with late pregnancy lies in supine position, the huge uterus will compress the inferior vena cava and abdominal aorta which will decrease venous return thus reducing cardiac output. In pregnancy, the oxygen requirement increases by 20% than in standard adults (Cunningham et al. 2018). This increase in oxygen requirement makes it easier for pregnant woman to fall into hypoxia after the onset of apnoea (Summers and Flett 2019).

Upon maternal cardiac arrest, resuscitation should follow Basic Life Support (BLS) and Advance Cardiac Life Support (ACLS) guidelines by AHA. Performing effective chest compression in a non-pregnant adult with cardiac arrest will give 30% of normal adult cardiac output. In pregnant woman lying in supine position, the acquired cardiac output is decreased by another 60% as the uterus compress the aorta and vena cava inferior (Katz 2012). As such, this pressure significantly influences the effectivity of cardiopulmonary resuscitation (CPR). Therefore, several adjustments are needed when performing CPR in a pregnant woman. Those adjustments include manual uterine displacement or put the mother into left lateral tilt position to an angle of 30° (Chu et al. 2018; Zelop et al. 2018). Furthermore, resuscitation in maternal cardiac arrest needs at least 2 intravenous (IV) lines. When the IV access cannot be established, intraosseous access or central line access should be done. As large uterus size cause compression of vena cava inferior, it is important to note that all the access should be done above the level of diaphragm to ensure quick entry of fluids into the circulation (Jeejeebhoy and Morrison 2013; Hu and Hong 2020).

Besides those challenges in giving chest compression to pregnant woman, airway management in pregnancy is also considered more difficult. In pregnancy, the compression of the stomach by the large uterus and gastropharyngeal sphincter relaxation (influenced by progesterone) will lead to increased risk of gastric content aspiration (Chu et al. 2018; Hickey et al. 2020). Furthermore, pregnancy also cause edoema of the upper respiratory tract and change of anatomical positions which might affect the intubation (Chu et al. 2018; Zelop et al. 2018). Therefore, a competent anaesthesiologist should secure the airway by doing early intubation. Oxygen supplementation should be given to maintain the oxygen saturation above 95% (Hu and Hong 2020).

Perimortem caesarean section

As previously mentioned, the uterine mass is a major factor that decrease venous return by compressing the abdominal aorta and vena cava inferior which will lead to decrease cardiac output (Hickey et al. 2020). Therefore, in early gestational age, when the uterine size is relatively small, PMCS is deemed unnecessary (Drukker et al. 2014). The 22–26 weeks of gestational age (or after 24–25 weeks) was argued as the accepted range to utilise PMCS during cardiac arrest (Katz 2012; Drukker et al. 2014). AHA guidelines (2015) suggested that PMCS should be done above 20 gestational weeks (Zelop et al. 2018). In this case, the discussion includes the survival rate of foetus and considered to be the most beneficial time frame for mother’s survival. It is important to note that even with this consideration, mother’s survival is the main concern instead of survival of the foetus. This should remain the emphasis for consideration when the foetus survival rate is low, especially under 22 weeks old.

Most reviews have mentioned the importance of PMCS in under 4 minutes after onset of cardiac arrest. After the supposed prompt initiation of CPR, relevant medical personnel should decide to adopt PMCS in under 4 minutes if there is no return to spontaneous circulation (ROSC) during that time. Based on AHA statement, it is important to deliver the foetus in timely manner because of 2 main reasons. One is through mitigation of aortocaval pressure hence assisting venous return. Another, to further prevent severe neurologic damage by swift delivery of the foetus (Healy et al. 2016). In addition, due to its urgency, it is strongly recommended that PMCS is executed where the patient was already located during cardiac arrest. Notable sources have even suggested the use of minimal equipment, specifically curved no.10 blade and cord clamps to begin the procedure. These strategies are to prevent loss of critical time if the patient is to be transported to a more specialised surgical theatre (Chu et al. 2018).

Exploration of cardiac arrest aetiology in the mother must be explored adequately. AHA have listed possible cardiac arrest neatly in alphabetical order shown in Table 1.

Table 1. Differential Diagnosis of Maternal Cardiac Arrest according to AHA (Zelop et al. 2018).

Anaesthetic Causes
Accidents	Trauma
Bleeding	Uterine atony, coagulopathy, abnormal placenta
Cardiovascular	Valvular abnormality, congenital heart disease, Ischaemia and atherosclerosis, arrythmia, rupture or dissection
Drugs	Tocolytic agents, magnesium, uterotonics, anaphylaxis, drug overdose
Embolism	Amniotic fluid embolism, venous embolism
Feveri	Sepsis, ARDS
General	Metabolic abnormalities, electrolyte imbalance
Hypertension	Stroke, preeclampsia, eclampsia, HELLP syndrome

Regarding incision techniques, lower abdominal vertical inline incision (midline incision just below the umbilicus) is mostly recommended (Healy et al. 2016). This is due to the speed of access to the abdominal space and ease of foetus delivery. Midline incision also enable observation of abdominal space for conditions such as bleeding or possible organ damage. It is important to note that uterine incision technique considerations are mostly dependent on the operator. If the operator familiar with caesarian section procedure, incision can be done in the lower uterine segment. In cases where the operators might not be specifically experienced in caesarian section, recommendations include vertical midline incision.

After the foetus is delivered, several articles report that it is acceptable to leave the placenta in the uterus (Chu et al. 2018). Yet, others have discussed that delivering the placenta is not found to be detrimental (Chu et al. 2018). During cardiac arrest the placenta will mostly be void of blood due to the mother’s lack of blood flow. Whichever the team decided about the placenta, all involved parties must continue to maintain high quality CPR. Importantly, after ROSC, the involved team must note of possible bleeding from usual suspects such as atonic uterine, incision wound, or placenta residues. There was suggestion for manually separate the placenta (Healy et al. 2016). Then the uterus should be quickly wiped clean and uterus incision is closed with running locking stitch of absorbable suture, continued with standard closure of the abdominal wall. If maternal resuscitation is successful, giving antibiotics and oxytocin should be considered with caution due to the reason that oxytocin could precipitate rearrest (Jeejeebhoy et al. 2015).

Another possible point of contention is the necessity of informed consent from next of kin. Cardiac arrest is considered as an emergency of the highest degree. Thus, similar to other emergency procedures, PMCS does not require informed consent. Despite a previous report of legal challenge, it was ultimately rejected and protected the relevant medical personnel. The concept of life-saving procedure for the mother supersedes the necessity for consent.

Until now, PMCS success rate remain in contention. In one report by (Einav et al. 2012) they mentioned that number of maternal deaths was high. This was attributed to the low number of PMCS initiated in the optimal time, which is under 4 minutes after mother’s cardiac arrest. On the other hand, the report also noticed a secondary time threshold, that showed reasonable neonate survival rate when PMCS procedure started in under 10 minutes (Einav et al. 2012). In the literature review found that the average time to perform PMCS was 23 minutes with maternal and foetal survival rate was 38.8% and 66.6%, respectively. Several studies showed that foetus is still rescuable after 1 hour of maternal cardiac arrest (Cerovac et al. 2021).

Although the success rate of PMCS is still not fully discovered, the current literature emphasises the need to improve decision making and preparation to allow PMCS initiation in under 4 minutes post cardiac arrest and deliver the foetus within 5 minutes after the onset of maternal cardiac arrest, hence significantly improving mother’s and foetus’s survival chance (Bennett et al. 2016).

Overlooking all sides of the discussion, it becomes apparent that PMCS procedure may require support from other medical departments. Notable specialties other than ObGyn that should be involved include resuscitation team, neonatologist and anaesthetist (Jeejeebhoy and Morrison 2013). As emphasised previously, a swift decision to initiate PMCS is imperative to maintain high success rate. It is reasonable to suggest an appropriate session or information package to all parties to ensure smooth cooperation between all medical personnel involved.

Covid-19 pandemic

The Covid-19 pandemic have been a significant challenge in around the word and especially every aspect of medical discipline. The still-increasing rate of infection in Indonesia and other parts of the world have often become an added complication in daily medical practice and can be found to challenge services related to Ob-Gyn (Hosapatna Basavarajappa and Saha 2020). Due to the rapid spread of the virus and its relatively novel pathogenic mechanisms, previously deliberated medical situation might enter unknown territory. One such case is the use of PMCS in birth that involved complications that arose from Covid-19 or in a place heavily challenged by the pandemic’s effects.

In the pandemic, medical infrastructure become highly pressured by technical issues that may be detrimental to management of cardiac arrest in mothers. American Journal of Obstetrics and Gynaecology have covered various factors to ensure proficient management of necessary emergency caesarean delivery in pregnant woman with Covid-19 (Ashokka et al. 2020). We deem it necessary to consider these factors and more to fully comprehend the potential pitfalls and possible suggestions to manage them.

1. The necessity of personal protective gear is a crucial factor to ensure safety for medical personnel and maintain safety while continuing health services (Chu et al. 2020; Degesys et al. 2020; Seidelman et al. 2020). However, often the process to equip protective gear may take a significant amount of time and, in bigger hospital, may even require the supporting administration to distribute and assist personnel during equipping the gear. Due to the tight time frame to increase success rate, steps to ensure quick availability of protective gear is necessary to ensure preparedness of protected medical officers to initiate PMCS under 4 minutes after mother’s cardiac arrest or as soon as possible.

2. With current situation of increasing new infection numbers, it is reasonable to expect higher load of patients. The nature of the pandemic itself may increase the burden of health centres with false emergencies due to general society anxiety (Grandi et al. 2020; Salsi et al. 2020). Overall, this may negatively affect the presence of qualified Ob-Gyn specialist trained for emergencies that require PMCS procedure. Appropriate training or short courses can be prepared to ensure availability of qualified medical personnel if the decision must be taken to execute PMCS.

3. An important step during the pandemic is quick detection of infection status (Sutton et al. 2020). However, with the rapid increase of new infections, it is predictable that admission might overwhelm testing capacity and patients admitted with unknown infection status. With infection prevention being a priority, it could be predicted that medical personnel might hesitate upon initiating an emergency procedure. PMCS can be considered as a highly invasive procedure, and as surgical interventions often do, would include various management that ideally develop into an interdisciplinary approach (Weber LeBrun et al. 2020). To ensure rapid decision making in emergencies that may require PMCS, a proper guideline could be circulated around relevant personnel to further add possibility of success through quick decision making.

In 2020, AHA has conducted a new interim guidance for basic and advanced life supports in adult with suspected or confirmed COVID-19. New protocols are as follow (Edelson et al. 2020):

1. The new interim does not abolish the ‘immediate high-quality chest compression and defibrillation’ concept, but to compile to the newest outbreak situation in which personal protective equipment are mandatory to compromise the safety of rescuers.

2. Chest compression and advanced airway establishment is highly aerosol-generating procedure, so the healthcare workers are indeed the highest-risk professional for contracting the disease. During these procedures, viral particle can remain suspended in the air with a half time of ∼1 hour and can be inhaled by nearby personnel. Resuscitation also requires a teamwork that make close proximity to each other inevitable, therefore personnel should be limited to those essential for patient care.

3. In context to COVID-19 pathophysiology, the central goal for resuscitating is to reverse hypoxaemia as soon as possible.

4. In an advanced hospital setting, replacing the manual chest compression to mechanical CPR device can be considered to reduce the number of rescuers.

5. Rescuers should prioritise oxygenation and ventilation with lower aerosolisation. Minimise the likelihood of failed intubation by assigning experienced physician or nurse for intubation, then immediately inflate the cuff to secure aerosolisation. Compared to previous AHA guideline, chest compression should be stopped while attempting advanced airway establishment (Panchal et al. 2020).

6. Video laryngoscopy may reduce exposure to the rescuer from aerosolized particles and should be considered if available.

7. Consider passive oxygenation with nonrebreathing mask covered by a surgical mask compared to bag-mask device.

8. Supraglottic airway or bag-mask device with HEPA filter should be considered if the intubation delayed.

9. Once advanced airway established, minimise closed circuit disconnections.

10. Adjust ventilator setting to allow asynchronous ventilation:

    1. Increase the FiO2 to 1.0.

    2. Use pressure or volume control and limit pressure or tidal volume to generate adequate chest rise (4–6 mL/kg ideal body weight).

    3. Adjust the trigger to ‘off’ to prevent auto-triggering with chest compresssions.

    4. Set respiratory rate to 10 breaths/minute.

    5. Adjusts alarms to deliver full breaths with asynchronous chest compressions.

    6. If return of spontaneous circulation is achieved, set ventilator according to patient’s clinical condition.

11. In out-of-hospital setting that CPR must be done by community, hand-only CPR should be prioritised and the patient must wear mask to minimise aerosolisation.

Maternal physiological changes may worsen the acute decompensation, especially in critically ill pregnant patients. We must made aware that due to progesterone effect to lower oesophageal sphincter, mothers are put on a high risk of aspiration of gastric content. The mortality rate of chemical pneumonitis caused by gastic content have a high mortality rate up to 70%. In an emergency setting, we might not have a detailed history of the patient. We must aware that the patient also might have an underlying cause the cardiac arrest, such as malignant arrhythmia, cardiomyopathies or myocardial infarct (Habek et al. 2021). Prompt oxygenation should be done and while CPR being performed, foetal heart rate monitoring should be postponed as it might disturbs the algorithm (American Heart Association 2020). Attending physicians should be aware to perform perimortem delivery after 4 minutes of resuscitation.

After ROSC is achieved, the maternal prognosis is also at stake. An international, multicentered study showed that 30-day post operative mortality rate is higher Covid-19 vs non-Covid 19 group, with the highest rate is among the most recent infection group. Most will fall into ARDS as the cause of death (COVIDSurg and GlobalSurg Collaborative 2021).

Conclusion

This article recognise that maternal cardiac arrest occurrence is reportedly low. However, the difficulty of the matter, especially in the current challenging pandemic, we urge all relevant medical personnel to remain vigilant. PMCS is a recommended method following maternal CPR to ensure highest possible chance of ROSC. To strengthen the effectiveness of PMCS, it is imperative to initiate SC procedure in under 4 minutes after cardiac arrest and the foetus should be delivered under 5 minutes. This article should also be a reminder of the importance to take anticipatory steps such as circulating a guideline to properly equip interdisciplinary medical personnel with efficient work flow for high quality patient care in emergencies.

Acknowledgment

We wrote a literature review on perimortem cesarean section without involving any human subjects in it.

Disclosure statement

No potential conflict of interest was reported by the author(s).