Maternal cardiopulmonary arrest around the time of delivery happens infrequently. Dr. Judith Aronsohn, Department of Anesthesiology, North Shore/LIJ Health System, New Hyde Park, New York, and colleagues describe a 38-year-old, 131 kg, patient with longstanding chronic hypertension and nontoxic goiter with a presumptive diagnosis of preeclampsia without proteinuria who became agitated and hypoxic while being placed in the semirecumbent position to perform a chest radiograph. The patient subsequently became unresponsive, apneic, and pulseless while being transported to the operating room for urgent cesarean delivery. What happened next is described in the article titled “Perimortem Cesarean Delivery in a Pregnant Patient with Goiter, Preeclampsia, and Morbid Obesity,” published in the current issue of A&A Case Reports.
The patient received chest compressions, epinephrine 1mg IV, followed by vasopressin. Resuscitation was complicated by problems with tracheal intubation that initially necessitated use of an i-gel™ laryngeal mask airway. Five minutes after chest compressions were initiated, the baby was delivered on a hospital bed by cesarean section. After delivery, the patient’s heart rate and blood pressure returned. Oral tracheal intubation was eventually performed blindly. Transesophageal echocardiography revealed a hyperdynamic left ventricle with concentric remodeling. The right ventricle was normal. No thrombus was observed.
Following delivery the patient was brought to the ICU, where she remained intubated for 8 days (until she “self extubated”). She was discharged to a rehabilitation facility on postoperative day 15. She subsequently made a full recovery. Her infant was discharged on day 8 without apparent sequelae.
This story illustrates two points. First, rapid surgical delivery shortly after maternal cardiac arrest is important. Though 4 minutes is the recommended time for initiation of surgical delivery, the fact that she arrested during transport and the baby was delivered within 5 minutes is a tribute to the staff, their organization, and possibly even their footwear. Second, there is the issue of an enlarged thyroid during pregnancy, which likely was a reason for this patient’s deterioration. Thyroidectomy should be considered during the second trimester of pregnancy for those patients who are morbidly obese and have additional comorbidities.