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Three Part Question

In [a third trimester pregnant female in cardiac arrest] is [emergency caesarean section effective] at [improving outcome for mother or foetus]?

Clinical Scenario

A 35 year old pregnant woman is brought into the resuscitation room of the Emergency Department in established cardiac arrest of 3 minutes duration. Full basic life support has been present since arrest; initial application of advanced protocols has not re-established circulation. You wonder whether emergency caesarian section could be life saving for either foetus or mother.

Search Strategy

Medline 1966-04/02 using the OVID interface.
[{exp heart arrest OR exp cardiopulmonary resuscitation OR exp resuscitation OR cardiac arrest.mp OR resuscitation.mp OR perimortem.mp} AND {exp cesarean section OR cesarean.mp OR caesarean.mp OR cesarian.mp OR caesarean.mp OR pregnan$.mp OR gravid$.mp OR uterine.mp}] LIMIT to human AND English Language

Search Outcome

1210 articles were identified, 1 of which was a summary of case reports up to 1985, this is summarised in the table below. Thirteen were case reports after 1985. The remaining 1196 reports were excluded as they were either case reports pre 1985 or failed to answer the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Katz VL et al, 1986, USA	Reported cases of maternal deaths with peri-mortem caesarean section	Literature review	Foetal survival	188 foetal survivors from 269 sections	Maternal survival not documented Strong reporting bias

Comment(s)

Of the 15 cases reported after 1985 there were 6 maternal and 11 foetal survivors (including one set of twins), 4 of these cases had survival of both parties. Success rates appear high but reporting bias will be strongly influential in cases of this type, with only 2 of the 13 papers reporting loss of both mother and child in three cases. Although there is no quality evidence in this field, and the chance of controlled trials is somewhat remote, the currently available evidence suggests section can produce foetal and maternal survivors whereas logic dictates that no intervention is unlikely to benefit either party.

Clinical Bottom Line

Peri-mortem caesarean section can lead to foetal survival with an unknown frequency.

References

1. Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean delivery Obstetrics & Gynecology 1986;68(4):571-6.