LETTER TO THE EDITOR

Perimortem cesarean section or perimortem cesareansupracervical hysterectomy?

Shigeki Matsubara • Rie Usui • Takashi Watanabe •

Mayumi Imayoshi • Masaru Ichida • Yoshihito Ando

Received: 13 June 2012 / Accepted: 31 July 2012 / Published online: 15 August 2012

� Springer-Verlag 2012

Dear Editor,

The pregnant uterus may prevent successful cardiopulmo-

nary resuscitation (CPR). In CPR for pregnant women, the

large gravid uterus decreases venous return from the infe-

rior vena cava, and obstructs blood flow through the

abdominal aorta. Delivery of the baby, cesarean section,

empties the uterus and relieves the aortocaval compression,

increasing the chance for successful CPR. Current recom-

mendations are that perimortem cesarean section (PCS)

should be performed to save not only the infant’s, but also

mother’s life [1, 2]. CS, really?

At 381/7 weeks, a 31-year-old primiparous woman with

controlled diabetes mellitus underwent labor induction

with oxytocin infusion without success, with the fetal

membranes remaining intact. One hour after stopping

oxytocin, an emergent call from the toilet of the delivery

room where she was found in cardiopulmonary arrest

(CPA). CPR was immediately started; however, sponta-

neous circulation did not return within 4 min. Thus, based

on The American Heart Association (AHA) 2010 Guide-

lines [2, 3], we decided to perform PCS. PCS was per-

formed, yielding a 2,754 g infant with an Apgar score of

2/4 (1/5 min), with cord arterial blood pH 6.64 and BE

-21.0 mEq/L. The infant was delivered 36 min after CPA.

We had no experience of CPA for pregnant women and

also had no system of ‘‘do PCS at the delivery room’’ at

that time [3]. Only central surgery unit, which located in

some distances from the delivery unit, was available for

PCS. That was the reason why 36 min was required for the

delivery of the infant. Because of the circulatory collapse,

blood sample was not obtained, and disseminated intra-

vascular coagulation (DIC) before PCS was not estimated.

After delivering the baby, cardiac contractions and

spontaneous respiration resumed with blood pressure (BP)

50/30 mmHg and heart rate (HR) 100 bpm. The uterus was

atonic; however, without bleeding possibly due to hypo-

tension. Brain computed tomography (CT) revealed no

remarkable findings at that time. Echocardiography

revealed normal cardiac structure and movement, rejecting

the possibility of pulmonary embolism or myocardial

infarction. Considering that the patient had shock with

subsequent DIC and uterine atony, amniotic fluid embolism

(AFE) should also be considered. Non-ruptured membranes

did not preclude AFE. Serum markers for AFE, sialyl Tn

and zinc-coproporphyrin [4], were not measured. AFE

could not be completely ruled out. The next day, CT

revealed a large brain stem infarction. Thus, we considered

that CPA was caused by brain stem infarction. CT soon

after the CPA did not reveal it, which may not preclude this

diagnosis: CT findings of brain infarction usually become

evident later.

After reestablishment of circulation (BP 110/50 mmHg,

HR 100 bpm), atonic bleeding (approximately 5,100 mL)

occurred and DIC manifested: hemoglobin 3.3 g/dL,

platelet 3.9 9 104 lL-1, fibrinogen 25 mg/dL, fibrin deg-

radation product 2,494 lg/mL, and D-dimer 1,006 lg/mL.

Due to an unresuscitatable cause, hysterectomy was not

performed. Uterine compression suture [5] or transarterial

S. Matsubara (&) � R. Usui � T. Watanabe � M. Imayoshi

Department of Obstetrics and Gynecology, Jichi Medical

University, 3311-1 Shimotsuke, Tochigi 329-0498, Japan

e-mail: matsushi@jichi.ac.jp

M. Ichida

Department of Cardiology, Jichi Medical University,

Tochigi, Japan

Y. Ando

Department of Neurology, Jichi Medical University,

Tochigi, Japan

123

Arch Gynecol Obstet (2013) 287:389–390

DOI 10.1007/s00404-012-2513-1

embolization [6] may have been useful for achieving

hemostasis; however, these were not employed also due to

an unresuscitatable cause. Instead, we employed ‘‘cervix

folding’’ technique [7] to reduce uterine hemorrhage of

which effectiveness was difficult to estimate in this case. A

total of 30 units of fresh frozen plasma, 30 units of plate-

lets, and 32 units of allogeneic blood were transfused. DIC

was gradually ameliorated. At 8 months after PCS, she

remained in an unconscious state and the baby suffered

cerebral palsy.

Considering that the culprit was brain stem infarction

severe enough to induce CPA, her intact survival chance is

low irrespective of treatment. If CPA was due to a resus-

citatable cause, atonic bleeding may have greatly worsened

the prognosis. We would have been obliged to perform

supracervical hysterectomy (SH) in the midst of DIC.

Supracervical hysterectomy, eliminating the bleeding

source, may be better than CS if the uterus was atonic even

without bleeding at laparotomy. Vencken et al. [8] reported

a PCS case: the operative field was initially bloodless;

however, followed by severe hemorrhage and DIC,

requiring gauze packing and relaparotomy. The situation

requiring CPA, regardless of its etiology, may lead to DIC.

Low systemic BP during PCS would prevent hemorrhage

from manifesting. However, DIC and BP rise after PCS

may manifest and accelerate atonic bleeding. SH requires a

couple of extra minutes, and may do no harm. No reports,

to our knowledge, touched on this issue.

No conclusion can be drawn from our single experience.

Quite a lot more study needs to be done to answer the

question ‘‘CS or SH?’’ Of course, it may depend on the sit-

uation: short-time CPR for drug anaphylaxis, for example,

may not cause severe DIC, in which PCS and not SH may

work well. We have no proposal regarding CS or SH in cases

without uterine atony discernable under laparotomy.

Supracervical hysterectomy precludes future fertility,

but may increase the survival chance in some cases and

thus it may be an option. Saving the life ‘‘now’’ outweighs

the fertility ‘‘future’’. Now, we started to make a system of

‘‘do PCS or peripartum SH’’ in the delivery room.

Patient anonymity Preserved.

Conflict of interest None.

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