Enhancing maternal survival in traumatic cardiovascular collapse during pregnancy: A case series on resuscitative hysterotomy (RH) from a level 1 trauma center.

Background: Trauma during pregnancy presents multifaceted risks to both the developing fetus and the expectant mother due to pregnancy-induced physiological adaptations that affect the response to traumatic injuries. The infrequent occurrence of cardiac arrest during pregnancy necessitates interventions such as perimortem cesarean section (PMCS), now termed resuscitative hysterotomy. While early resuscitative hysterotomy focused primarily on fetal survival, more recent literature reports substantial maternal benefits. Resuscitative hysterotomy can lead to the restoration of maternal pulse and blood pressure within minutes and has shown potential to improve maternal outcomes. RH has been demonstrated to aid in fetal and maternal survival in hemodynamic unstable pregnant patients before cardiovascular collapse. The linguistic change from PMCS to resuscitative hysterotomy is a shift towards maternal-centric approaches and survival.

Objective: In this series, we evaluate the outcomes of resuscitative hysterotomy performed before or after cardiovascular collapse to maximize maternal survival while concurrently optimizing fetal outcomes.

Methods: We performed a retrospective case series review of 4 consecutive pregnant trauma patients who underwent RH due to hemodynamic instability. In addition, we conducted a descriptive analysis of all pregnant patients from 2013 to May 2024 who presented due to a traumatic injury but did not require a RH.

Results: The average age of patients undergoing RH was 26.5 ± 6.8 years. All patients were in the third trimester with a mean gestational age of 32.3 ± 0.5 weeks. Fifty percent (50 %) of patients were involved in motor vehicle accidents, one (25 %) pedestrian was hit by a vehicle, and one (25 %) had GSW to the head. The median time to RH was 14.5 min. The mean estimated blood loss (EBL) was 625 mL ±108.9 mL. The maternal survival rate was 50 %, with a fetal survival rate of 100 %. Three patients achieved hemodynamic stability; however, one of the patients progressed to death by neurological criteria. Therefore, we achieved 50 % of maternal survival. A resuscitative hysterotomy was performed due to early signs of maternal hemorrhagic shock and suggestive features of ongoing bleeding (persistent maternal tachycardia despite adequate analgesia and resuscitation, persistent maternal bradycardia, gradual decline of BP, and FHR abnormalities) in three patients. The remaining patient was found to have cardiac arrest at the scene with a brief return of spontaneous circulation and received resuscitative hysterotomy in the ED to restore cardiovascular function.

Conclusion: RH in pregnant patients with traumatic injury and impending hemorrhagic shock or cardiovascular collapse may provide maternal survival benefits by supporting circulatory function and promoting resuscitation with no additional risks to fetal outcomes. Quick decision-making is crucial to the implementation of this life-saving procedure. Further research with a more significant number of patients is needed to validate the efficacy of RH in maximizing maternal survival. This case series adds to the evolving literature on RH, shedding light on practical aspects and maternal outcomes to inform ongoing discussions and strategies for maternal cardiopulmonary resuscitation.