Etiologies and Management of Maternal

Cardiac Arrest During Peripartum Anesthetic Care

A Study from the Multicenter Perioperative Outcomes Group Consortium

Michael J. Furdyna, MD

Critical Care Medicine | Obstetric Anesthesiology

Brigham and Women’s Hospital | Harvard Medical School

*No disclosures

Findings and Lessons Learned

Allison Mootz, MD | Shakthi Venkatachalam, MBBS

Michael Mathis, MD | Thomas Klumpner, MD

Kara Fields, MS | Jill Mhyre, MD

Brian Bateman, MD, MSc | Sharon Reale, MD

Background

Describe the frequency, risk factors, etiology,

and management of maternal cardiac arrest

during peripartum anesthetic care

Prior studies utilizing national hospitalization-level data to study maternal cardiac arrest

are limited in granular assessments

More detailed, contemporary studies are registry-based and rely on manual reporting

(NAP7, CAPS)

U.S. lacks studies assessing maternal cardiac arrest with this level of detail

Aims:

Mhyre Anesthesiology 2014 | Ford Ann Intern Med 2023 | Lucas Anaesthesia 2024 | Beckett BJOG 2017

Methods

Screening criteria:

• ICD/CPT codes

• ACLS medications

• MPOG electronic

record concepts/events

• Free-text notations

Inclusion criteria:

• All anesthetic records

for delivery + any

associated anesthetic

records within 7 days

• 2015-2022

• Ages 15-44

Manual review:

• Two anesthesiologists

independently

evaluated each case

• Granular data manually

abstracted from

anesthetic records

Patient Factors Odds Ratio (95% CI) Risk

Age 40+

2.13 (1.02, 4.5)

1:4,527

BMI 40+ 2.90 (1.61, 5.2) 1:4,477

Black Race 1.82 (1.08, 3.08) 1:5,843

Comorbidities Odds Ratio (95% CI) Risk

Pulmonary

Hypertension

60.4 (22.1, 165.0) 1:155

Placenta Accreta

Spectrum

35.9 (19.1, 67.7) 1:284

Chronic Ischemic

Heart Disease

27.0 (9.9, 73.6) 1:347

Results

11.2 per 100,000 deliveries

(95% CI 9.1, 13.8)

87 cardiac arrests during

anesthetic care

Overall risk 1:8,944

778,000 delivery

hospitalizations

21% of Arrests Before Delivery 62% of Arrests After Delivery

17% Indeterminate

Minutes from Delivery to Arrest

Etiology Median Onset

All Causes 26

Hemorrhage 102

Amniotic Fluid Embolism 6.5

Respiratory 61

Anesthesia Complication -5.5

Acute Cardiac Event 18

Unknown 13

Operating

Room

Labor Floor

Other

PACU

Arrest Location

Location and Timing

Delivery

Time

Etiology N (%)

ROSC

N (%)

30 Day Survival

N (%)

Median LOS

Among Survivors

(Days)

Trach/G-tube

Among Survivors

N(%)

All Causes* 87 67 (77.0) 60 (69.0) 6 3 (5.0)

Hemorrhage 35 (40.2) 23 (65.7) 22 (62.9) 8 1 (4.55)

Amniotic Fluid Embolism 27 (31.0) 23 (85.2) 20 (74.1) 8 3 (15.0)

Respiratory 12 (13.8) 9 (75.0) 6 (50.0) 4 1 (16.7)

Anesthesia Complication 10 (11.5) 10 (100.0) 9 (90.0) 4 -

Acute Cardiac Event 8 (9.2) 7 (87.5) 6 (75.0) 13.5 -

Trauma 3 (3.5) 0 (0.0) 0 (0.0) - -

Venous Thromboembolism 3 (3.5) 2 (66.7) 1 (33.3) 5 -

Air Embolism 1 (1.2) 0 (0.0) 0 (0.0) - -

Unknown 9 (10.3) 7 (77.8) 7 (77.8) 2 -

* Some cases had multiple etiologies

Etiologies and Outcomes

Interventions N (%) Adjuvant Medications N (%)

Advanced Airway

Epinephrine (1 milligram)

76 (87.4)

Pre-existing

45 (51.7)

Amiodarone

10 (11.5)

New 35 (40.2) Atropine

22 (25.3)

Arterial Access Sodium Bicarbonate

46 (52.9)

Pre-existing 22 (25.3) Calcium Chloride

40 (46.0)

New 40 (46.0) Vasopressor Infusions+

53 (60.9)

Central Venous Access Ino-chronotrope Infusions++

31 (35.6)

Pre-existing 5 (5.8) Pulmonary Vasodilators

6 (6.9)

New 26 (29.9) Blood Products

44 (50.6)

Transesophageal Echo 17 (19.5) Factor Concentrates

8 (9.2)

Transthoracic Echo 9 (10.3) Lipid Emulsion

1 (1.1)

ECMO (VA or VV) 14 (16.1)

Deviation from ACLS Guidelines 16 (18.4)

Management

+ Phenylephrine, norepinephrine, vasopressin

++ Epinephrine, milrinone, dopamine

Delayed resuscitative

hysterotomy

Epinephrine

Amiodarone

14 cases

11 survived case

8 survived to 30 days

Conclusions

Opportunities for improvement?

• Hemorrhage Outcomes

• ACLS

Risk of peripartum MCA during anesthetic care:

1:8,944

Highest risk comorbidities:

Pulmonary hypertension, placenta accreta spectrum,

chronic ischemic heart disease

Most common etiologies:

Hemorrhage and AFE

Outcomes after MCA:

77% ROSC, 69% 30-Day Survival

Lessons Learned: Needle in a Haystack

How do you screen for something exceedingly rare?

Multiple search criteria will increase sensitivity, but at the

expense of specificity

A preliminary ‘chart biopsy’ is essential to identify the right

screening criteria

Screening criteria:

• ICD/CPT codes

• ACLS medications

• MPOG electronic

record concepts/events

• Free-text notations

Lessons Learned: Needle in a Haystack

Limited temporal resolution

Screening criteria:

• ICD/CPT codes

• ACLS medications

• MPOG electronic

record concepts/events

• Free-text notations

Can’t screen by dose in Data Direct

Must be mapped correctly at sites

Requires manual review

Lessons Learned: “I know it when I see it”

Manual review can help extract inconsistently documented

parameters, or capture complex concepts

Share the load as much as you can, inversely with complexity

Be judicious – time commitment scales fast with manual review

detail and sample size

Lessons Learned: “I know it when I see it”

Manual review can help extract inconsistently documented

parameters, or capture complex concepts

Share the load as much as you can, inversely with complexity

Be judicious – time commitment scales fast with manual review

detail and sample size

You only want to do this once…

Cardiac Arrest?

Arrest Timing?

Location?

Airway?

Lines?

Echo?

Resuscitative

Hysterotomy?

Outcome?

Duration?

Rhythm?

Medications?

Etiology?

Thank you!

mfurdyna@bwh.harvard.edu