Description
This session focuses on two critical obstetric emergencies: Resuscitative Hysterotomy and Peripartum Cardiomyopathy. These rare but life-threatening conditions require timely recognition and swift multidisciplinary intervention to improve maternal and fetal outcomes. The discussion will cover clinical presentation, decision-making in high-pressure scenarios, and current best practices in emergency management. Real-life case insights and evidence-based protocols will be shared to enhance preparedness among healthcare providers. This webinar aims to strengthen clinical confidence in managing these high-risk situations effectively.
Summary Listen
- The presentation covers two critical obstetric emergencies: resuscitative hysterotomy (formerly post-mortem C-section) and peripartum cardiomyopathy with acute heart failure. The initial focus is on saving the mother's life, emphasizing that fetal survival depends on maternal resuscitation. In cases of maternal cardiac arrest, the prompt removal of the fetus is vital to reduce oxygen demand on the mother.
- Resuscitative hysterotomy should be considered after four minutes of unsuccessful maternal resuscitation. While earlier guidelines emphasized a strict 4-5 minute rule, newer data suggests successful maternal and neonatal outcomes even with longer delays, up to 30 and 47 minutes respectively. The procedure is indicated for pregnancies of 20 weeks or more, or when the uterine height is palpable at or above the umbilicus.
- Managing maternal cardiac arrest involves coordinating three distinct teams: one managing the medical cardiac arrest, another performing the hysterotomy, and a third dedicated to neonatal resuscitation. Emergency physicians should be prepared for this challenging and potentially rare situation with prepared checklists and debriefing protocols for the staff's well-being. Important differentials to consider include amniotic fluid embolism, anesthetic complications, uterine atony, cardiac disease, hypertensive disorders, placental abruption, bleeding disorders, and infections.
- Peripartum cardiomyopathy is defined by the development of heart failure in the last month of pregnancy or within the first five months postpartum, with an ejection fraction of less than 45% and no other identifiable cause. Predisposing factors include extremes of age, multi-parity, black ethnicity, smoking, alcohol, diabetes, vascular problems, and preeclampsia. Patients present with symptoms typical of heart failure, such as dyspnea, orthopnea, and peripheral edema.
- Diagnosis involves ECG, chest X-ray, and echocardiography. While ECG findings are non-specific, chest X-rays may show pulmonary edema. Echocardiography reveals poor contractility of the heart with or without LV dilation. Differential diagnosis should consider dilated cardiomyopathy, which is not exclusively related to pregnancy.
- Acute heart failure management during pregnancy requires a multidisciplinary team approach, including cardiologists, obstetricians, neonatologists, and emergency physicians. Prioritize fetal viability and lung maturity, considering steroid administration. In severe cases with low blood pressure, balance the use of inotropes and vasopressors to avoid uterine artery vasoconstriction. Delivery should be planned or emergent, based on maternal and fetal status.
- Treatment for peripartum cardiomyopathy includes bromocriptine, oral heart failure therapies (adjusted based on antipartum or postpartum status), anticoagulants, vasodilators, and diuretics. Approximately 50-60% of patients experience cardiac recovery, but some may require long-term management and advice regarding future pregnancies. An important mnemonic is BROADS (Bromocriptine, Oral HF therapies, Anticoagulants, Dilators, and Diuretics).
Sample Certificate
About the Speakers
Dr. Himanshu Mirani
Consultant Emergency Medicine, Sandwell & West Birmingham NHS Trust, England
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