List Archives

Mon Aug 28 15:42:48 BST 2006

Dr. Mauritz,

I have forwarded a .pdf of the AmJOG paper to you under separate cover; I think my hospital's on-line subscription would be voided if I sent the article to the balance of the List.  Sorry, everyone.

The paper lists a grand total of 8 traumas over 20 years, with an assortment of other causes, including an equal number of primary maternal cardiac arrests.  Given the relative paucity of primary cardiac arrest among pregnant women in the real world, and the admitted exclusion of "numerous reports of postmortem sections performed on trauma victims who were brought to emergency rooms at lengthy periods of time after injury," one is forced to agree with the authors that selection bias probably has an enormous impact on results: they themselves were cherry-picking.

Further, although I've not read the article thoroughly, I'd wager that these cases were largely (if not exclusively) in-hospital sections performed by thoroughly qualified surgeons with ample resources and support.  

This isn't the sort of literature that should inspire sharp turns in prehospital practice.

Respectfully and regretfully, I stand by my original comments.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Walter.Mauritz at auva.at
Sent: Monday, August 28, 2006 8:30 AM
To: trauma-list at trauma.org
Subject: RE: pre-hospital C-section

Pret,

what you wrote seems logical, but there is some evidence that perimortem caesarean delivery might be an option in at least in some cases of maternal cardiac arrest:

Am J Obstet Gynecol. 2005 Jun; 192(6):1916-20; discussion 1920-1. 
Perimortem cesarean delivery: were our assumptions correct? 
Katz V, Balderston K, DeFreest M. 
Department of Obstetrics/Gynecology, Sacred Heart Medical Center, Oregon Health Sciences University, Eugene, 97401, USA. vkatz at peacehealth.org

OBJECTIVE: The recommendation to perform a perimortem cesarean delivery within 4 minutes of maternal cardiac arrest was introduced in 1986. This recommendation was based on the assumptions that cardiopulmonary resuscitation is ineffective in the third trimester because of aortocaval compression, and that fetal and perhaps maternal outcomes would be optimized by timely delivery. Our objective was to review the outcomes of perimortem cesarean deliveries to attempt to validate those assumptions. STUDY DESIGN: Ovid MEDLINE searches using maternal mortality, cardiopulmonary resuscitation, perimortem cesarean delivery, heart attack, and cardiac arrest from 1985 until 2004. Citations from bibliographies of identified publications were perused and cross-referenced for other potential articles. Case reports were included for analysis when mothers had complete cardiopulmonary arrest, and cardiopulmonary resuscitation had been initiated before cesarean delivery. RESULTS: There were 38 cases of perimortem cesarean delivery identified; 34 infants survived (3 sets of twins, 1 set of triplets); 4 other infants survived initially, but died several days after the deliveries from complications of prematurity and anoxia. Of the 34 infants (25-42 weeks' gestation), time of delivery after maternal cardiac arrest was available for 25. Eleven infants were delivered within 5 minutes, 4 were delivered from 6 to 10 minutes, 2 were delivered from 11 to 15 minutes, and 7 were delivered more than 15 minutes. Of 20 perimortem cesarean deliveries with potentially resuscitatable causes, 13 mothers were resuscitated and discharged from the hospital in good condition. One other mother was successfully resuscitated after the delivery, but died within 24 hours from complications related to her amniotic fluid embolism. In 12 of 18 reports that documented hemodynamic status, cesarean delivery preceded return of maternal pulse and blood pressure, often in a dramatic fashion. Eight other cases noted improvement in maternal status. Importantly, in no case was there deterioration of the maternal condition with the cesarean delivery. We wish to emphasize the large selection bias in this data. CONCLUSION: Published reports from 20 years support, but fall far from proving, that perimortem cesarean delivery within 4 minutes of maternal cardiac arrest improves maternal and neonatal outcomes.

PMID: 15970850 [PubMed - indexed for MEDLINE]

I do not have access to that journal, and I have not read the full article. Thus, I don't know whether there were any trauma-related cases of maternal cardiac arrest (which I doubt). Still, this case series (the only one I found on medline) shows that perimortem caesarean delivery may be an option in some cases of maternal cardiac arrest (but very probably not in traumatic cardiac arrest).

Walter Mauritz MD PhD
Professor of Anesthesia and Critical Care Medicine
Trauma Hospital "Lorenz Boehler"
A - 1200 Vienna, AUSTRIA, EU
phone: ++43 1 33110 789
fax: ++43 1 33110 277
e-mail: walter.mauritz at auva.at

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Bjorn, Pret
Sent: Monday, August 28, 2006 2:15 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: pre-hospital C-section

The gravid uterus is the first organ sacrificed in the shock response cascade.  By the time mom is symptomatic, the fetus has been abandoned by her struggle for homeostasis: God and/or Darwin would rather she live to rejoin the herd than die for the sake of her unborn child.  All of which suggests that with regard to perimortem C-section, the mess-to-success ratio is stultifying.

Where mom is undeniably dead, you can at least claim to be doing no (physical) harm; but then you're stuck for an indication to justify her evisceration.  In all other cases, a proper retrospective review may rightly contend that you were treating the wrong patient without proper training or direction.  What kind of back-up employment do you have?

The goals are earnest and admirable, but nonetheless delusional.  Focus on mom's vital signs, make for a trauma center, and prepare for disappointment.

Sorry.  Heroic motives are no substitute for critical thinking.

Pret Bjorn, RN
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of David Sullivan
Sent: Sunday, August 27, 2006 3:18 PM
To: Trauma &amp, Critical Care mailing list
Subject: pre-hospital C-section

Hello List,

  I was sittting around the fire station at work, and one of my co-workers brought up an argument that we all had differing opinions on. Is there any reading out there about the pre-hospital c-section on a pregnant female that has injuries incompatable with life? ie decapitation, major trauma ect..has anyone on this list ever run into a situation like that or similar. i do this is far fetched, but it must have happened somewhere?

  dave sullivan BA NREMT-P

---------------------------------
Talk is cheap. Use Yahoo! Messenger to make PC-to-Phone calls.  Great rates starting at 1¢/min.
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html

List Archives

For your convenience, find the Trauma List Archive Below

pre-hospital C-section