Factors associated with non-survival from in-hospital maternal cardiac arrest: An analysis of Get With The Guidelines® (GWTG) data.

INTRODUCTION: Maternal mortality has risen in the United States during the 21st century. Factors influencing outcome of maternal cardiac arrest (MCA) remain largely unexplored. OBJECTIVE: We sought to further elucidate the factors affecting maternal death from in-hospital (IH) MCA. METHODS: Our query of the American Heart Association's GWTG®-Resuscitation voluntary registry from 2000-2017 revealed 561 index cases of IH MCA with complete outcome data. Logistic regression was performed using hospital death as the primary outcome and included variables with a p value = 0.1 or less based upon univariate analysis. Age, race, year of arrest, pre-existing conditions, first documented pulseless rhythm and location of arrest were used in the model. Sensitivity analyses and assessment of variable interaction were also performed to test model stability. Institutional review deemed this research exempt from ethical approval. RESULTS: Among 561 cases of MCA, 57.2% (321/561) did not survive to hospital discharge. IH death was not associated with maternal age, race and year of event. In the final model, IH death was significantly associated with pre-arrest hypotension/hypoperfusion (OR = 1.80 (95% CI, 1.16-2.79); p = 0.009). The occurrence of MCA outside of the delivery suite (referent group) or operating room was associated with a significantly higher risk of death: ICU/Post-Anesthesia Care Unit (PACU) (OR = 3.32 (95% CI, 2.00-5.52); p < 0.001) and ER/other (OR = 1.89 (95% CI, 1.15-3.11); p = 0.012). While MCA cases with a shockable vs. non-shockable first documented pulseless rhythm had similar outcomes, those with an indeterminate rhythm were less likely to die, (OR = 0.41(95% CI, 0.20-0.84); p = 0.014). In a sensitivity analysis, removal of the indeterminate group did not alter outcomes regarding first documented pulseless rhythm or arrest location. Area under the curve for the final model was 0.715 (95% CI 0.673-0.757). CONCLUSIONS: Our study identified several novel factors associated with IH death of our MCA cohort. More research is required to further understand the pathophysiologic dynamics affecting outcomes of IH MCA in this unique population.

Characteristics and outcomes of maternal cardiac arrest: A descriptive analysis of Get with the guidelines data.

BACKGROUND: Maternal mortality has risen in the United States in the twenty-first century, yet large cohort data of maternal cardiac arrest (MCA) are limited. OBJECTIVE: We sought to describe contemporary characteristics and outcomes of in-hospital MCA. METHODS: We queried the American Heart Association's Get with the Guidelines Resuscitation voluntary registry from 2000 to 2016 to identify cases of maternal cardiac arrest. All index cardiac arrests occurring in women aged 18-50 with a patient illness category designated as obstetric or location of arrest occurring in a delivery suite were included. Institutional review deemed that this research was exempt from ethical approval. RESULTS: A total of 462 index events met criteria for MCA, with a mean age of 31 ± 7 years and a racial distribution of: 49.4% White, 35.3% Black and 15.3% Other/Unknown. While 32% had no pre-existing conditions or physiologic disorders, respiratory insufficiency (36.1%) and hypotension/hypoperfusion (33.3%) were the most common antecedent conditions. In most cases, the first documented pulseless rhythm was non-shockable; pulseless electrical activity (50.8%) or asystole (25.6%). Only 11.7% presented with a shockable rhythm; ventricular fibrillation (6.5%) or pulseless ventricular tachycardia (5.2%) while the initial pulseless rhythm was unknown in 11.9% of cases. Return of spontaneous circulation occurred in 73.6% but 68 (14.7%) had more than one arrest. The rate of survival to discharge was 40.7% overall; 37.3% with non-shockable rhythms, 33% with shockable rhythms and 64.3% with unknown presenting rhythms. CONCLUSIONS: Maternal survival at hospital discharge in this cohort was less than 50%, lower than rates reported in other epidemiological datasets. More research is required in maternal resuscitation science and translational medicine to continue to improve outcomes and understand maternal mortality.

Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association.

This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.

Maternal cardiac arrest: a practical and comprehensive review.

Cardiac arrest during pregnancy is a dedicated chapter in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; however, a robust maternal cardiac arrest knowledge translation strategy and emergency response plan is not usually the focus of institutional emergency preparedness programs. Although maternal cardiac arrest is rare, the emergency department is a high-risk area for receiving pregnant women in either prearrest or full cardiac arrest. It is imperative that institutions review and update emergency response plans for a maternal arrest. This review highlights the most recent science, guidelines, and recommended implementation strategies related to a maternal arrest. The aim of this paper is to increase the understanding of the important physiological differences of, and management strategies for, a maternal cardiac arrest, as well as provide institutions with the most up-to-date literature on which they can build emergency preparedness programs for a maternal arrest.

Management of cardiac arrest in pregnancy: a systematic review.

OBJECTIVE: To describe the consensus on science pertaining to resuscitation of the pregnant patient. DESIGN: Systematic review. DATA SOURCES: EMBASE, Ovid MEDLINE, Evidence Based Reviews, American Heart Association library and bibliographies of selected articles. REVIEW METHODS: The following inclusion criteria were used: pregnancy and cardiac arrest out of hospital, pregnancy and cardiac arrest in hospital, cardiovascular, respiratory, fetal survival, and pharmacology as they relate to cardiac arrest and resuscitation. Non-English papers, case reports and reviews were excluded. Studies were selected through an independent review of titles, abstracts and full article. Two reviewers independently graded the methodological quality of selected articles. RESULTS: 1305 articles were identified and 5 were selected for further review. There were no randomized trials and overall the quality of the selected studies was good. Two studies examined chest compressions on a manikin in left lateral tilt from the horizontal and concluded that although feasible with increasing degrees of tilt forcefulness of the chest compressions decreases. The third study observed the transthoracic impedance was not altered during pregnancy. One case series and one retrospective cohort study reviewed perimortem cesarean section. Both reports concluded that perimortem cesarean section is rarely done within the recommended time frame of 5 min after the onset of maternal cardiac arrest. CONCLUSIONS: Usual defibrillation dosages are likely appropriate in pregnancy. Perimortem cesarean section is an intervention which is rarely done within 5 min to optimize maternal salvage from cardiac arrest. Chest compressions in left lateral tilt are less forceful compared to the supine position.