January-February 2008 Volume 27 Number 1. Case Study Peer Reviewed Perimortem cesarean section in the helicopter EMS setting: A case report

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1 January-February 2008 Volume 27 Number 1 Case Study Peer Reviewed Perimortem cesarean section in the helicopter EMS setting: A case report Ricky Kue, MD * [ LOOKUP] Cheryl Coyle, BSN, CCRN, CEN, CFRN, EMT-B [ LOOKUP] Eric Vaughan, MD [ LOOKUP] Marc Restuccia, MD, FACEP [ LOOKUP] Previous article in Issue Next article in Issue View print version (PDF) Drug links from Mosby's DrugConsult Genetic information from OMIM Sections Introduction Case report Discussion References Publishing and Reprint Information Articles with References to this Article Introduction Perimortem cesarean section in the out-of-hospital setting is a rare and emotionally taxing occurrence. As a leading cause of maternal death, trauma occurs in 5% of all pregnancies, over half of which are attributable to motor vehicle crashes. 1,2 The decision to perform perimortem cesarean section by emergency care providers can be difficult, especially in the limited out-of-hospital environment, given the time constraints, personnel training, comfort level, and available resources. This technique has only been reported twice in the medical literature, with relatively poor outcomes. 3,4 We report a case of perimortem cesarean section performed in the emergency department by a helicopter emergency medical services (EMS) crew on a motor vehicle crash victim after maternal assessment by emergency abdominal ultrasonography.

2 Case report Paramedics responding to a motor vehicle crash arrived to find a 21-year-old female driver, 36-weeks pregnant, in cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated, and the patient was transported to a local emergency department (ED). LifeFlight was dispatched to intercept for transport to a level 1 trauma center. On LifeFlight arrival at the ED, the patient was asystolic despite receiving 3 mg epinephrine and 3 mg atropine sulfate intravenously. Estimated time from EMS scene arrival to LifeFlight contact was 25 minutes. The patient had massive head trauma with an open skull fracture, and fixed and dilated pupils. No fetal heart tones were present. A focused abdominal sonography for trauma (FAST) performed by the flight physician on the mother showed no cardiac activity. Fetal cardiac activity, however, was evident, and a perimortem cesarean section was performed. A midline vertical incision was made after sterile preparation and a male infant was delivered. A nuchal cord was immediately relieved by cord clamping and cutting. The infant was warmed, dried, and suctioned but did not have spontaneous respiratory efforts or palpable pulses. CPR was initiated immediately. The infant was intubated and received a total of 0.3 mg epinephrine via endotracheal tube. After failed umbilical vein catheterization, intraosseous access was obtained, and 0.1 mg epinephrine, 0.3 mg sodium bicarbonate, and saline bolus were administered without effect. Blood glucose was 400 mg/dl. Cardiac ultrasonography of the infant showed no activity. APGAR scores were 0 at 1 and 5 minutes. Despite resuscitative efforts, the infant was pronounced dead 41 minutes after delivery (56 minutes after LifeFlight arrival). Despite additional epinephrine and atropine after delivery, CPR, and dopamine drip, the mother showed no clinical improvement and was pronounced dead 33 minutes after LifeFlight arrival. Discussion According to Greek mythology, the physician Asklepios was delivered by his father Apollo from the womb of the dead Koronis. The first documented case of perimortem cesarean section, however, occurred in 237 bc in relation to the birth of Scipio Africanus, the Roman general who defeated Hannibal. 5 Current medical literature reports multiple cases of perimortem cesarean sections 6 8 ; however, only two have been reported in an out-of-hospital setting. 3,4 Both cases occurred in the setting of a helicopter EMS service whose flight crews were configured with an emergency medicine physician (typically a senior resident). Although this case did not occur in an out-of-hospital setting, it represents only the third case of perimortem cesarean section performed by a helicopter EMS crew reported in the literature, with the most recent reported in this journal in Greatest likelihood of infant survival seems to occur if delivery can be performed within 4 minutes of maternal death. This recommendation was the result of an exhaustive literature review, a case report and experimental data review published by Katz et al 9 in In this review, 93% of surviving neonates (57 of 61) were born within 15 minutes of maternal death, and only two had neurologic deficits. Seventy percent of the survivors were delivered within 5 minutes. A 2005 review, again by Katz et al, 10 included literature from 1985 through Findings supported the recommendation of fetal delivery within 4 minutes of maternal cardiac arrest to maximize both maternal and neonatal survival. In late pregnancy, CPR is compromised because of aortocaval compression, with obstruction of the inferior vena cava limiting venous return to the heart. The stroke volume of a term pregnant woman lying supine is only 30% that of normal. Delivery of the fetus can assist to unload the compressive force on abdominal great vessels, improve the effectiveness of chest compression, increase maternal cardiac output, and result in return of spontaneous circulation for both mother and infant. 5 Indication for this procedure is most commonly on a previously healthy mother who has suffered an acute, life-threatening event or within 4 minutes of initiating maternal CPR. For the infant to survive, the gestation must have progressed to at least 24 to 26 weeks. 11 The decision to initiate perimortem cesarean section in the field can be especially difficult given the unique environmental conditions out-of-hospital providers face compared with the in-hospital setting. Few out-of-hospital providers are trained in this technique, and many emergency medicine physicians will have never seen or performed one in their career. In this case, the decision to perform cesarean section was made after the flight physician performed an abdominal ultrasound and confirmed fetal heart activity. Under the direction of the helicopter emergency medical services (HEMS) crew, ground EMS

3 initiated transport to a local ED for intercept with the aircraft, given the hospital's proximity to the scene. This would provide the best clinical conditions for the HEMS crew to initiate stabilization without further delay, because flight times to either the scene or local ED were nearly identical. Performing perimortem cesarean section should occur as soon as possible once the decision has been made. Although the focused abdominal ultrasonography for trauma (FAST examination) could be regarded as a delay to cesarean section, it did provide rapid information on fetal cardiopulmonary status in utero. Additionally, it was unlikely to have contributed to the final outcome of the fetus given the mother's prolonged down time before arrival. Given this length of maternal down time before LifeFlight arrival, a cesarean section in this case may not have been performed had there not been evidence of fetal heart activity. In both previously reported cases of out-of-hospital cesarean section, the average length of time of maternal death was over 30 minutes. 3,4 In our case, CPR was being performed for over 25 minutes before the patient encounter with the flight crew. All three cases highlight the inherent difficulty in performing a perimortem cesarean section within the recommended 4 minutes of maternal death, especially in the out-of-hospital setting. Despite fetal survival after perimortem cesarean section, the long-term outcome for one infant was poor, despite discharge from the neonatal intensive care unit. At 1 year of age, the infant was significantly handicapped, with cortical blindness and deafness. 4 In the three cases, perimortem cesarean section was performed by an emergency physician. 3,4 Thus, performing this procedure is difficult to apply to all helicopter EMS systems, given the relative infrequency of a physician-inclusive flight crew configuration in the United States. It also would be impractical to institute a transabdominal ultrasound protocol before perimortem cesarean section in the helicopter EMS setting, given the rarity of this clinical condition as well as potential time delays to definitive care. This case study highlights the unique scenario of having a flight physician with access to diagnostic tools such as ultrasonography to aid in the diagnosis of a potentially viable fetus despite a 25- minute arrest time in the mother. Cesarean section in fact may not have been performed by the flight physician had the ultrasound showed no evidence of fetal heart activity in the face of a prolonged maternal cardiac arrest time. In-hospital performance of perimortem cesarean section as an anticipatory measure to impending maternal death seems to provide the highest likelihood of fetal survival after delivery. The focus of basic cardiopulmonary resuscitation by the air medical team should be emphasized in the care of the severely traumatized pregnant patient. Basic resuscitative measures to ensure adequate perfusion and oxygenation of the mother are the cornerstones of ensuring fetal survival, because it would be extremely difficult to achieve the recommended time limits for perimortem cesarean section in the out-of-hospital setting. In conclusion, perimortem cesarean section is a rare procedure performed in the out-of-hospital environment. This case illustrates the difficulty in providing rapid definitive care despite the presence of trained personnel and advanced diagnostic equipment such as ultrasonography. Given the innate difficulty in providing this procedure within the recommended timelines, flight programs may want to consider focusing on basic maternal resuscitative measures, as well as facilitating means to ensure access to rapid cesarean section.

4 References 1. Connolly AM, Katz VL, Bash KL. Trauma in pregnancy. Am J Perinatol 1997;14: Mattox KL, Goetzl L. Trauma in pregnancy. Crit Care Med 2005;33:S385-S Bowers W, Wagner C. Field perimortem cesarean section. Air Med J 2001;20: FULL TEXT 4. Kupas DF, Harter SC, Vosk A. Out-of-hospital perimortem cesarean section. Prehosp Emerg Care 1998;2: Whitten M, Irvine L. Postmortem and perimortem cesarean section: what are the indications?. J R Soc Med 2000;93: Dezarnaulds G, Nada W. Perimortem cesarean section: a case report. Aust NZ Obstet Gynaecol 2004;44: Page-Rodriguez A, Gonzalez-Sanchez JA. Perimortem cesarean section of twin pregnancy: case report and review of the literature. Acad Emerg Med 1999;6: Tang G, Nada W, Gyaneshwar R, Crooke D. Perimortem cesarean section: two case reports and management protocol. Aust NZ J Obstet Gynaecol 2000;40: Katz VL, Dotter DJ, Droegemueller W. Perimortem cesarean delivery. Obstet Gynecol 1986;68: Katz VL, Balderston K, DeFreest M. Perimortem cesarean delivery: Were our assumptions correct?. Am J Obstet Gynecol 2005;192: ABSTRACT FULL TEXT 11. Stallard TC, Burns B. Emergency delivery and perimortem C-section. Emerg Med Clin North Am 2003;21: Publishing and Reprint Information University of Massachusetts Medical School, Department of Emergency Medicine, UMassMemorial LifeFlight * Address for correspondence: Ricky Kue, MD, MPH, Medical Director, Hopkins Lifeline Division of Special Operations, Johns Hopkins Medical Institutions, Department of Emergency Medicine, 5801 Smith Avenue, Davis Bldg. 3220, Baltimore, MD address: mdemtp@yahoo.com (Ricky Kue) Copyright 2008 doi: /j.amj

5 Articles with References to this Article This article is referenced by these articles: Letter to the Editors Air Medical Journal July-August 2008 Volume 27 Number 4 Karsten Knobloch FULL TEXT