(174) Do We Still Need to Perform Resuscitative Hysterotomy in the Era of eCPR? A Case Study

Introduction: Resuscitative hysterotomy (RH) is the standard of care for gravid patients sustaining cardiac arrest (CA), although associated with significant morbidity. Recently, the development of Extracorporeal Cardiopulmonary Resuscitation (eCPR) has revolutionized the management of patients, but the necessity of RH in the eCPR era is unknown. Our gravid patient was an exceedingly rare case in which both eCPR and RH were initiated for CA from massive pulmonary embolism. We explore the pros and cons of these therapies.

Description: Our case involves a healthy 50-year-old gravida 1 para 0 patient at 20 weeks gestation. After a minor car collision, she had a cardiac arrest, witnessed by Emergency Medical crew. Upon arrival at a quaternary academic center, the obstetric team attempted a resuscitative hysterotomy, which was complicated by thick abdominal adhesions. This was stopped and eCPR was initiated, with the patient achieving return of spontaneous circulation. Continued “oozing” from the incision led to transfusion of multiple blood products and ultimately a decompressive laparotomy a few hours later. The patient developed multiple complications, anoxic brain injury and unfortunately the family withdrew life support on hospital day 15.

Discussion: RH is a valuable tool that should be considered immediately in all cases of maternal CA greater than 20 weeks gestation. Evacuation of the uterus improves preload and cardiac output, alleviate aortocaval compression, divert blood flow away from the uterus, and improve maternal respiratory mechanics. RH can usually be completed in less than two minutes.
The use of eCPR and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides mechanical hemodynamic support, oxygen delivery, and carbon dioxide removal, with a similar function as RH in gravid patients. However, prompt initiation of ECMO can also be challenging and is contingent upon the proficiency of clinical teams and the accessibility of equipment. Further, VA-ECMO requires anticoagulation, significantly increases bleeding risk, as with our patient.
Therefore, when at an eCPR center, RH and its timing in comparison to ECMO cannulation should be considered in gravid patients in CA. More studies are needed to understand the risk and benefits of these modalities.