Carolyn M Zelop1, Richard E Shaw2, Dana P Edelson3, Steven S Lipman4, Jill M Mhyre5, Julie Arafeh6, Farida M Jeejeebhoy7, Sharon Einav8. 1. Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Valley Hospital, Ridgewood, NJ, USA; Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA. Electronic address: cmzelop@comcast.net. 2. Valley Health, Research and Statistical Consultant, The Valley Hospital, 223 N Van Dien Ave., Ridgewood, NJ, 07450, USA. Electronic address: shawres@aol.com. 3. Rescue Care and Resiliency, The University of Chicago, Department of Medicine, 5841 S. Maryland Ave., MC 5000, Chicago, IL, 60637, USA. Electronic address: dperes@bsd.uchicago.edu. 4. Anesthesia Medical Group of Santa Barbara, 514 W. Pueblo St, 2nd Floor, Santa Barbara, CA, 93105, USA; Adjunct Clinical Faculty of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: lipper1@cloud.com. 5. Department of Anesthesiology, University of Arkansas for Medical Sciences, USA. Electronic address: JMMhyre@uams.edu. 6. Center for Advanced Pediatric and Perinatal Education, Department of Pediatrics, Stanford University School of Medicine, USA. Electronic address: jarafeh@stanford.edu. 7. Division of Cardiology, Dept of Medicine, William Osler Health System, Brampton, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada. Electronic address: Farida.j@sympatico.ca. 8. Surgical Intensive Care, Shaare Zedek Medical Center, Samuel Byte 12, Jerusalem, 9103102, Israel; Hebrew University Faculty of Medicine, Jerusalem, Israel. Electronic address: einav_s@szmc.org.il.
Abstract
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.
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.