Recommended Citation
Elgamil A, Sadiq M, Rizkalla L. Intra-operative cardiac arrest during a caesarean section for twin pregnancy. Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Presentation Notes
Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Abstract
Introduction: Cardiac arrest during Caesarean section (CS) is a rare event, with an incidence of 1 in 9,200 [1]. We present a case of intraoperative cardiac arrest during an elective CS for a twin pregnancy. Case Presentation: A 40-year-old G4P3 female with dichorionic diamniotic twins and diet-controlled gestational diabetes was scheduled for an elective CS at 37 weeks of gestation. Combined spinal-epidural anesthesia was performed without complications. Intrathecal administration included 1.4 mL of 0.75% hyperbaric bupivacaine, 15 micrograms of fentanyl, and 150 micrograms of morphine, achieving a sensory block at the T4 level. Twin A was delivered without complications; however, the delivery of Twin B was difficult, requiring fundal pressure from the obstetric team. Immediately after Twin B’s delivery, the patient became unresponsive to verbal and tactile stimuli and exhibited vigorous shaking with continued flexion of both arms. This was followed by apnea, necessitating endotracheal intubation. She subsequently developed bradycardia, which did not respond to 0.4 mg of IV glycopyrrolate, progressing to asystole with absent carotid pulses. Cardiopulmonary resuscitation (CPR) was initiated and return of spontaneous circulation (ROSC) was achieved after one cycle of chest compressions without the need for epinephrine. The patient was extubated by the end of the surgery, and no neurological deficits were observed. In the PACU, the patient developed shortness of breath, with examination revealing new-onset bilateral expiratory wheezing. She showed some improvement after bronchodilator therapy and a magnesium infusion and was transferred to the SICU in stable condition on room air. CT imaging revealed segmental and subsegmental pulmonary emboli in the left upper lobe, prompting initiation of a heparin infusion. Postoperative laboratory findings were consistent with disseminated intravascular coagulation (DIC), including thrombocytopenia, prolonged prothrombin time, prolonged partial thromboplastin time, low fibrinogen, and low hemoglobin. Consequently, the heparin infusion was discontinued, and the patient received two units of packed red blood cells and two units of cryoprecipitate. She was discharged home on the third postoperative day. Conclusion: Potential causes of cardiac arrest during CS include hemorrhage, heart failure, amniotic fluid embolism (AFE), sepsis, anesthesia complications, aspiration pneumonitis, venous thromboembolism, and eclampsia [2]. The sudden onset of symptoms, bronchospasm, and development of DIC in this patient suggest AFE as the most likely etiology. AFE is a rare but life-threatening condition characterized by a profound systemic inflammatory response following the introduction of fetal cells into the maternal circulation, leading to consumptive coagulopathy and cardiovascular collapse. Risk factors in this patient included CS delivery, advanced maternal age, and twin pregnancy [3]. Diagnosis is primarily clinical. Rapid recognition of cardiac arrest and immediate initiation of CPR contributed to a favorable outcome. 1. Lucas, D. N. et al. (2024) Anaesthesia 79(5):514-523 2. Mhyre, J. et al. (2014) Anesthesiology 120(4):810-818 3. Metodiev, Y. et al. (2018) BJA Educ 18(8):234-238
Type
Oral/Podium Presentation
Affiliations
Advocate Illinois Masonic Medical Center