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Emerg Med Clin North Am 2019 May 8;37(2):351-363. Epub 2019 Mar 8.

Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, 110 Irving Street Northwest, Suite 4B-42, Washington, DC 20010, USA. Electronic address:

Many health care providers lack familiarity with maternal physiologic changes and the distinctive underlying etiology of cardiac arrest in pregnancy. Knowledge of what changes are expected in pregnancy and an understanding of how to adapt clinical practice is essential for the care of the pregnant woman in the emergency department. Amniotic fluid embolism should be recognized as a rare cause of cardiac arrest in pregnancy, characterized by the triad of cardiovascular collapse, hypoxic respiratory failure, and coagulopathy. Read More

MedEdPORTAL 2018 Oct 26;14:10768. Epub 2018 Oct 26.

Perinatal Patient Safety Coordinator, NewYork-Presbyterian Hospital.

Introduction: Cardiac arrest in pregnancy is rare. Advanced Cardiovascular Life Support courses rarely address interventions specific to obstetric patients, and knowledge gaps are frequent among providers. The Society for Obstetric Anesthesia and Perinatology and American Heart Association have published guidelines regarding management of cardiac arrest in pregnancy, and interdisciplinary simulation training has been advocated to reinforce key management points for this clinical scenario. Read More

Taiwan J Obstet Gynecol 2019 Jan;58(1):43-45

Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan; MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan. Electronic address:

Objective: The aim of this study is to share a valuable experience of perimortem Cesarean delivery (PMCD) when no signs of spontaneous circulation were detected after 4 min of resuscitation. The time interval between maternal cardiac arrest and neonatal delivery was evaluated and reviewed.

Case Report: We present the case of an out-of-hospital cardiac arrest (OHCA) in a nulliparous woman who survived a car accident with only seatbelt injuries. Read More

J Obstet Gynaecol Res 2019 Mar 22;45(3):724-728. Epub 2018 Nov 22.

Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Japan.

Resuscitative hysterotomy (RH) is a resuscitation technique, allowing the restoration of a pregnant patient's heartbeat. Here, we reported a case of RH performed in a patient with cardiac arrest as a complication of a peripartum cardiomyopathy. A 29-year-old woman with suspected hemolysis, elevated liver enzymes, low platelet syndrome was admitted to the hospital. Read More

J Obstet Gynaecol Res 2019 Feb 25;45(2):325-330. Epub 2018 Sep 25.

Department of Maternal and Fetal Medicine, Miyagi Children's Hospital, Sendai, Japan.

Aim: Perimortem cesarean section (PCS) is a procedure performed as part of cardiopulmonary resuscitation (CPR). This study aims to clarify maternal and neonatal prognosis and establish PCS's utility and limitations.

Methods: We sent structured questionnaires to obstetrics facilities regarding the cases of PCS performed in Japan between April 2010 and April 2015. Read More

J Matern Fetal Neonatal Med 2018 Sep 23:1-3. Epub 2018 Sep 23.

a Department of Maternal-Neonatal Care , DAIMI, Careggi University Hospital , Florence , Italy.

Cardiac arrest in pregnancy is a rare event due to different cause. When it occurs after spinal anesthesia a cause that can explain this event is the Bezold-Jarish Reflex (BJR). A cardiac arrest occurs in a pregnant women after spinal anesthesia admistered for urgent caesarean section. Read More

Curr Treat Options Cardiovasc Med 2018 Jun 19;20(7):57. Epub 2018 Jun 19.

Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, USA.

Purpose Of Review: The goal of this review is to elucidate what is known about the science of maternal resuscitation and how treatment guidelines have developed to optimize management.

Recent Findings: There is limited data on maternal cardiac arrest. Case reports are providing some insight into safety and efficacy of certain mechanisms of treatment, including use of extracorporeal membranous oxygenation and thrombolysis, for example. Read More

J Obstet Gynaecol India 2018 Jun 26;68(3):155-163. Epub 2018 Mar 26.

2Department of Anaesthesiology, Pain & Critical Care, AFMC, Pune, India.

Maternal mortality is disastrous news for the society, family, newborn, and the obstetrician. Yet, we all who are care providers to these apparently healthy women carrying another life within them are dumbfounded by the clinical conditions arising due to the pregnancy or the effects of the pregnancy, that it becomes difficult to provide an ideal care to them. The rapid uprising of a condition and the worsening of commonly occurring benign conditions-preeclampsia, hemorrhage, etc. Read More

Am J Obstet Gynecol 2018 Jul 2;219(1):52-61. Epub 2018 Jan 2.

Southern Colorado Maternal Fetal Medicine, Colorado Springs, CO.

While global maternal mortality has decreased in the last 25 years, the maternal mortality ratio in the United States has actually increased. Maternal mortality is a complex phenomenon involving multifaceted socioeconomic and clinical parameters including inequalities in access to health care, racial and ethnic disparities, maternal comorbidities, and epidemiologic ascertainment bias. Escalating maternal mortality underscores the importance of clinician preparedness to respond to maternal cardiac arrest that may occur in any maternal health care setting. Read More

Semin Perinatol 2018 02 13;42(1):33-38. Epub 2017 Dec 13.

Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814. Electronic address:

Cardiac arrest in pregnancy is a rare and frightening event. Although not every obstetrician will encounter cardiac arrest in pregnancy during their career, it is imperative to be prepared to manage this acute emergency. The management is particularly complex due to maternal physiologic changes from pregnancy and the simultaneous management of two patients, the mother and fetus. Read More

J Matern Fetal Neonatal Med 2019 Apr 22;32(8):1262-1266. Epub 2017 Nov 22.

a Department of Anesthesia, and Sackler Faculty of Medicine , Rabin Medical Center, Beilinson Hospital, Petach Tikvah Israel, Tel Aviv University , Tel Aviv , Israel.

Introduction: Amniotic fluid embolism (AFE) is a rare and potentially lethal obstetric complication, commonly occurring during labor, delivery, or immediately postpartum. There is a paucity of data regarding incidence, risk factors, and clinical management. Our primary objective in this study was to evaluate clinical presentation of AFE and delineate anesthesia management of these cases. Read More

Acute Med Surg 2017 10 17;4(4):467-471. Epub 2017 Aug 17.

Rinku General Medical Center Senshu Trauma and Critical Care Center Izumisano Osaka Japan.

Cases: Perimortem cesarean delivery (PMCD) is the only way to resuscitate pregnant women in cardiac arrest, and has been found to increase maternal resuscitation rate by increasing circulating plasma volume. However, many obstetricians have not experienced a case of PMCD, as situations requiring it are rare. We report our strategy for cases of maternal cardiac arrest, on the basis of a review of published work, and present two case reports from our medical center. Read More

Isr Med Assoc J 2017 09;19(9):586-589

Department of Jewish History, Ben-Gurion University of the Negev, Beer Sheva, Israel.

Background: Maternal cardiac arrest during gestation constitutes a devastating event. Training and anticipant preparedness for prompt action in such cases may save the lives of both the woman and her fetus.

Objectives: To address a previous Jewish guideline that a woman in advanced pregnancy should not undergo any medical procedure to save the fetus until her condition is stabilized. Read More

Emerg Med J 2017 May 7;34(5):326-330. Epub 2017 Mar 7.

Academic Department of Clinical Traumatology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.

The need for prehospital resuscitative hysterotomy/perimortem caesarean section is rare. The procedures can be daunting and clinically challenging for practitioners. Maternal death can be averted by swift and decisive action. Read More

BJOG 2017 Aug 24;124(9):1374-1381. Epub 2017 Feb 24.

University Hospitals of Leicester NHS Trust, Leicester, UK.

Objective: To describe the incidence, risks, management and outcomes of cardiac arrest in pregnancy in the UK population, with specific focus on the use of perimortem caesarean section (PMCS).

Design: A prospective, descriptive study using the UK Obstetric Surveillance System (UKOSS).

Setting: All UK hospitals with maternity units. Read More

J Obstet Gynaecol Can 2016 Dec 4;38(12S):S665-S687. Epub 2017 Jan 4.

Toronto (Ont.).

A A Case Rep 2017 Feb;8(4):72-74

From the *Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital - Ullevaal, Oslo, Norway; and †Division of Emergencies and Critical Care, Department of Air Ambulance, Oslo University Hospital, Oslo, Norway.

A 34-year-old pregnant woman experienced cardiac arrest at home. Out-of-hospital perimortem cesarean delivery was performed 27 minutes after the collapse. Both mother and child were resuscitated and had return of spontaneous circulation before they were transported to a university hospital. Read More

Int J Obstet Anesth 2017 Feb 15;29:81-84. Epub 2016 Nov 15.

Department of Obstetrics and Gynaecology, Hutt Valley District Health Board, Lower Hutt, New Zealand.

Cardiac arrest in pregnancy is rare (about 1:30000 pregnancies) and out-of-hospital cardiac arrests are even less frequent. Resuscitation of the pregnant mother is challenging and requires attention to the altered physiology, specific pathologies and the presence and well-being of the fetus. Once circulation has been restored, the lack of high-grade evidence regarding delivery of the baby and post-resuscitation care makes decision making complex. Read More

Aust N Z J Obstet Gynaecol 2016 Dec 5;56(6):662-665. Epub 2016 Oct 5.

Department of Obstetrics and Gynaecology, University of Otago, Wellington, New Zealand.

Perimortem caesarean section is a term many obstetricians are familiar with despite few encountering it first-hand. It is estimated the intervention will be needed every 53 000 maternities. Despite this rarity it is vital clinicians are trained in detecting and intervening where perimortem caesarean is required. Read More

Middle East J Anaesthesiol 2016 10;23(6):603-4

J Perinat Neonatal Nurs 2016 Jul-Sep;30(3):259-64

PeriGen, Princeton, New Jersey.

Thirty years ago seems like yesterday: a time of immense socioeconomic changes, explosion of an "Internet" computer concept, and identification of human immunodeficiency virus. Like all events of the past, transformations in obstetrics developed over time. Cesarean birth can be better understood in a broader context when one considers how the art of obstetric practice has evolved. Read More

Middle East J Anaesthesiol 2016 Feb;23(4):381-3

J Emerg Med 2016 Aug 29;51(2):172-7. Epub 2016 Jun 29.

Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania.

Background: Maternal resuscitation in the emergency department requires planning and special consideration of the physiologic changes of pregnancy. Perimortem cesarean delivery (PMCD) is a rare but potentially life-saving procedure for both mother and fetus. Emergency physicians should be aware of the procedure's indications and steps because it needs to be performed rapidly for the best possible outcomes. Read More

EBioMedicine 2016 Apr 2;6:253-257. Epub 2016 Mar 2.

Center for Biomedical Research Informatics, NorthShore Research Institute, United States.

Introduction: The current approach to, cardiopulmonary resuscitation of pregnant women in the third trimester has been to adhere to the "four-minute rule": If pulses have not returned within 4min of the start of resuscitation, perform a cesarean birth so that birth occurs in the next minute. This investigation sought to re-examine the evidence for the four-minute rule.

Methods: A literature review focused on perimortem cesarean birth was performed using the same key words that were used in formulating the "four-minute rule. Read More

Int J Obstet Anesth 2016 Aug 3;27:46-54. Epub 2016 Mar 3.

Anaesthetic Department, Queen Alexandra Hospital, Portsmouth, Hampshire, UK.

Although cardiac arrest in pregnancy is rare, it is important that all individuals involved in the acute care of pregnant women are suitably trained, because the outcome for both mother and fetus can be affected by the management of the arrest. Perimortem caesarean delivery was first described in 715 BC. Initially the procedure was performed principally for religious or political reasons. Read More

Am J Obstet Gynecol 2016 07 31;215(1):129-31. Epub 2016 Mar 31.

Clinical Associate Professor, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Stanford University School of Medicine, Stanford, CA 94305. Electronic address:

Ugeskr Laeger 2016 Mar;178(12):V12150959

Perimortem caesarean section can be decisive for the outcome of a cardiac arrest in pregnancy for both mother and fetus. We describe a case story of the management of cardiac arrest in early labour where perimortem caesarean section proved to be life-saving for both mother and child. The child was delivered alive seven minutes after recorded cardiac arrest, and the mother had return of spontaneous circulation one minute after delivery. Read More

J Obstet Gynaecol Can 2015 Jun;37(6):553-74

Saint John, NB.

Objective: Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient. Read More

Am J Obstet Gynecol 2015 Nov 26;213(5):653-6, 653.e1. Epub 2015 Jul 26.

Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC.

Although perimortem delivery has been recorded in the medical literature for millennia, the procedural intent has evolved to the current fetocentric approach, predicating timing of delivery following maternal cardiopulmonary arrest to optimize neonatal outcome. We suggest a call to action to reinforce the concept that if the uterus is palpable at or above the umbilicus, preparations for delivery should be made simultaneous with initiation of maternal resuscitative efforts; if maternal condition is not rapidly reversible, hysterotomy with delivery should be performed regardless of fetal viability or elapsed time since arrest. Cognizant of the difficulty in determining precise timing of arrest in clinical practice, if fetal status is already compromised further delay while attempting to assess fetal heart rate, locating optimal surgical equipment, or transporting to an operating room will result in unnecessary worsening of both maternal and fetal condition. Read More

Emerg Med J 2016 Mar 24;33(3):224-9. Epub 2015 Feb 24.

Emergency Department, Derriford Hospital, Plymouth, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Birmingham, UK.

This review describes a simple approach to perimortem caesarean section (PMCS) that can be used by a doctor in the resuscitation room or prehospital environment when faced with a mother of more than 20 weeks gestation in cardiac arrest. It explores the indications for and contraindications to the procedure, the physiological rationale behind it, equipment needed, technical aspects of the procedure and reviews recent literature on maternal and fetal outcomes. Like other uncommon procedures such as emergency department thoracotomy, rehearsal and preparation for a PMCS is essential to give both mother and baby the best chance of survival. Read More

A A Case Rep 2015 Feb;4(4):41-3

From the Department of Anesthesiology, North Shore/LIJ Health System, New Hyde Park, New York.

Cardiopulmonary arrest during pregnancy is a devastating event necessitating rapid intervention from experienced practitioners to reduce the incidence and severity of adverse maternal and fetal outcomes. Perimortem cesarean delivery is rarely performed within the recommended time frame to meet these goals. We describe a case of a successful perimortem cesarean delivery after the "4-minute rule" in a morbidly obese parturient with goiter and preeclampsia. Read More

Case Rep Emerg Med 2014 30;2014:121562. Epub 2014 Oct 30.

Bergamo 118 Operative Dispatch Center, Azienda Regionale Emergenza Urgenza (AREU), Via Campanini 6, 20124 Milan, Italy.

The optimal treatment of a severe hemodynamic instability from shock to cardiac arrest in late term pregnant women is subject to ongoing studies. However, there is an increasing evidence that early "separation" between the mother and the foetus may increase the restoration of the hemodynamic status and, in the cardiac arrest setting, it may raise the likelihood of a return of spontaneous circulation (ROSC) in the mother. This treatment, called Perimortem Cesarean Section (PMCS), is now termed as Resuscitative Hysterotomy (RH) to better address the issue of an early Cesarean section (C-section). Read More

Arch Gynecol Obstet 2015 Apr 4;291(4):945-9. Epub 2014 Dec 4.

KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore,

Cardiac arrest in pregnancy is a rare but catastrophic obstetric emergency, with a quoted incidence of 1:20,000 pregnancies. Speedy multidisciplinary interventions are crucial for good maternal and foetal outcomes. A perimortem caesarean section (PMCS) initiated within 4 min of onset of cardiac arrest to minimise the effect of aortocaval compression on cardiopulmonary resuscitation (CPR) has been recommended as a key intervention, which is likely to improve survival of both mother and foetus. Read More

Am Fam Physician 2014 Nov;90(10):717-22

Uniformed Services University of the Health Sciences, Bethesda, MD, USA.

Trauma complicates one in 12 pregnancies, and is the leading nonobstetric cause of death among pregnant women. The most common traumatic injuries are motor vehicle crashes, assaults, falls, and intimate partner violence. Nine out of 10 traumatic injuries during pregnancy are classified as minor, yet 60% to 70% of fetal losses after trauma are a result of minor injuries. Read More

Acta Obstet Gynecol Scand 2014 Dec 10;93(12):1333. Epub 2014 Oct 10.

Department of Obstetrics and Gynecology, Shaare Zedek Medical Center.

Acta Obstet Gynecol Scand 2015 Jan 30;94(1):121. Epub 2014 Sep 30.

Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi, Japan.

Acta Obstet Gynecol Scand 2014 Oct 27;93(10):965-72. Epub 2014 Aug 27.

Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel.

Cardiopulmonary arrest is a rare event during pregnancy and labor. Perimortem cesarean section has been resorted to as a rare event since ancient times; however, greater awareness regarding this procedure within the medical community has only emerged in the past few decades. Current recommendations for maternal resuscitation include performance of the procedure after five minutes of unsuccessful cardiopulmonary resuscitation. Read More

Best Pract Res Clin Obstet Gynaecol 2014 May 29;28(4):607-18. Epub 2014 Mar 29.

Division of Maternal Fetal Medicine, Mount Sinai Hospital Toronto and Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Toronto, Canada.

Cardiac arrest in pregnancy is a rare event in routine obstetric practice, but is increasing in frequency. Resuscitation of cardiac arrest is more complex for pregnant women because of a number of factors unique to pregnancy: the altered physiologic state induced by pregnancy; the requirement to consider both maternal and fetal issues during resuscitation; and the consequent possibility of perimortem caesarean section during resuscitation. These extra considerations create a unique clinical emergency and decision pathway requiring the co-ordinated response of medical, obstetric, and neonatal teams. Read More

Can J Anaesth 2013 Nov 14;60(11):1077-84. Epub 2013 Sep 14.

Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada,

Purpose: To review and report maternal and neonatal outcomes after cardiac arrest during pregnancy in a large tertiary care centre and to consider steps to improve the outcomes.

Clinical Features: We performed a retrospective chart review of maternal cardiac arrest in the Mount Sinai Hospital, University of Toronto health records database for the period 1989-2011. Five cases were identified for an incidence of 1:24,883 deliveries (0. Read More

Emerg Med Pract 2013 Apr;15(4):1-18; quiz 18-9

Vanderbilt University Medical Center, Nashville, TN, USA.

The management of acute trauma in the pregnant patient relies on a thorough understanding of the underlying physiology of pregnancy. This issue reviews the evidence regarding important considerations in pregnant trauma patients, including the primary and secondary survey as well as the possibility for Rh exposure, placental abruption, uterine rupture, and the need for a prompt perimortem cesarean section in the moribund patient. Because ionizing radiation is always a concern in pregnancy, the circumstances where testing provides benefits that outweigh risks to the fetus are discussed. Read More

J Med Case Rep 2013 Apr 29;7:119. Epub 2013 Apr 29.

Obstetrics and Gynecology Department, Obstetrics and Gynecology Research Group, IBIMA, University Carlos Haya Hospital, Arroyo de Los Angeles Avenue, Málaga, 29011, Spain.

Introduction: Thrombotic thrombocytopenic purpura is a type of occlusive thrombotic microangiopathy that is not specific to pregnancy but occurs with an increased frequency during it. Prognosis of thrombotic thrombocytopenic purpura greatly depends on early diagnosis and treatment. As delivery does not generally cause resolution of thrombotic thrombocytopenic purpura, pregnancy termination is not initially considered, especially under 34 weeks, although it may be required under some conditions such as preeclampsia. Read More

Simul Healthc 2013 Feb;8(1):49-51

Division of Emergency Medicine, Washington University in St Louis, St Louis, MO 63110, USA.

Introduction: Perimortem cesarean section is a rare, time-critical, and potentially life-saving procedure for both the fetus and mother. This makes perimortem cesarean section an ideal and recommended subject for simulation learning and practice.

Methods: Various attempts have been made to produce models to simulate emergency caesarian sections. Read More

Anesth Analg 2013 Jan 7;116(1):162-7. Epub 2012 Dec 7.

Department of Anesthesia, Stanford University, 300 Pasteur Dr., MC5640, Stanford, CA 94305, USA.

Background: The purpose of this study was to compare cardiopulmonary resuscitation (CPR) for simulated maternal cardiac arrest rendered during transport to the operating room with that rendered while stationary in the labor room. We hypothesized that the quality of CPR would deteriorate during transport.

Methods: Twenty-six teams composed of 2 providers (obstetricians, nurses, or anesthesiologists) were randomized to perform CPR on the Laerdal Resusci Anne SkillReporter™ mannequin during transport or while stationary. Read More

Emerg Med Clin North Am 2012 Nov;30(4):949-59

Department of Emergency Medicine, University of Maryland School of Medicine, 6th Floor, Suite 200, 110 South Paca Street, Baltimore, MD 21201, USA.

Cardiovascular emergencies in pregnancy are rare but often catastrophic. This article reviews the diagnosis and management of venous thromboembolism, aortic dissection, acquired heart disease and cardiomyopathy, acute myocardial infarction, and cardiac dysrhythmias in the setting of pregnancy. It also reviews updated resuscitation guidelines for cardiac arrest and perimortem cesarean section. Read More

Emerg Med Clin North Am 2012 Nov;30(4):937-48

Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA.

The treatment of pregnant patients with traumatic injuries requires knowledge of the fundamentals of general trauma management as well as the specific anatomic and physiologic changes brought about by pregnancy. This article provides a review of the spectrum of trauma prevention and treatment in pregnant women, from counseling strategies that can be used during any emergency department visit to a step-by-step evaluation protocol for patients with trauma during pregnancy and the severe injuries that might be encountered by providers during the treatment of these women, including maternal cardiopulmonary arrest and the perimortem cesarean section. Read More

Injury 2013 Jan 22;44(1):151-2. Epub 2012 Aug 22.

Prehospital Emergency Medical Service, BMP (Bataillon des Marins Pompiers), Marseille, France.

Arch Gynecol Obstet 2013 Feb 15;287(2):389-90. Epub 2012 Aug 15.

Anesth Analg 2012 Nov 2;115(5):1122-6. Epub 2012 Aug 2.

The Israel Center for Medical Simulation, Sheba Medical Center, Tel Hashomer 52621, Israel.

Background: Cardiac arrest in the parturient is often fatal, but appropriate resuscitation in this special situation may save the lives of the mother and/or unborn baby. Concern has arisen as to application of recommended techniques for resuscitation in the obstetric patient. The Israel Board of Anesthesiology has incorporated simulation assessment into accreditation examinations. Read More