Cardiac Arrest Rate Rare During Delivery, Stable Over Time (printer-fr...

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CME/CE Information
CME/CE Released: 05/09/2014 ; Valid for credit through 05/09/2015

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1. Discuss trends in maternal morbidity in the United States.
2. Evaluate the potential causes of cardiac arrest during peripartum hospitalizations and the outcomes of these cases.

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Author(s)
Michael O'Riordan

Michael O'Riordan is a journalist for theheart.org. Before becoming a journalist for theheart.org, now part of the WebMD
Professional Network, he worked for WebMD Canada. Michael studied at Queen's University in Kingston and the University of
Toronto and has a master's degree in journalism from the University of British Columbia, where he specialized in medical
reporting. He can be contacted at MORiordan@webmd.net.
Disclosure: Michael O'Riordan has disclosed no relevant financial relationships.

Editor(s)
Nafeez Zawahir, MD

CME Clinical Director, Medscape, LLC

Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

CME Author(s)
Charles P. Vega, MD, FAAFP

Associate Professor and Residency Director, Department of Family Medicine, University of California-Irvine, Irvine
Disclosure: Charles P. Vega, MD, FAAFP, has disclosed no relevant financial relationships.

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Amy Bernard, MS, BSN, RN-BC

Lead Nurse Planner, Continuing Professional Education Department, Medscape, LLC

Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

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From Heartwire CME

Cardiac Arrest Rate Rare During Delivery, Stable Over Time CME/CE
News Author: Michael O'Riordan
CME Author: Charles P. Vega, MD, FAAFP
CME/CE Released: 05/09/2014 ; Valid for credit through 05/09/2015

Clinical Context
More women are now having children at older ages than in decades past, and this trend has led to a concomitant increase in
the risk for comorbid chronic illness complicating pregnancy and the peripartum period. Callaghan and colleagues examined
trends in severe complications at the time of delivery in a study published in the November 2012 issue of Obstetrics &
Gynecology. They found that severe morbidity affected 129 and 29 per 10,000 hospitalizations for delivery and postpartum
care, respectively, in 2008-2009. Compared with the rate of severe complications 10 years earlier, these figures represented
respective increases of 75% and 114%. The increase in complications was broad, encompassing diverse events such as
acute myocardial infarction, aneurysms, acute renal failure, and blood transfusions. This study also demonstrated an upward
trend in the risk for death at the peripartum period.
The current study by Mhyre and colleagues evaluates the prevalence of cardiac arrest during the peripartum period, its most
common causes, and its outcomes.

Study Synopsis and Perspective

Maternal cardiac arrest during childbirth remains a rare event, occurring in approximately one in 12 000 deliveries, according to
a new US analysis[1].
The frequency of cardiac arrest during childbirth does not appear to be increasing over time, either, report investigators,
despite the perception that it may be on the rise because of more and more women with congenital heart conditions now
having children.
"Whereas the frequency of arrest has been fairly stable over the past decade, survival has improved," write Dr Jill Mhyre
(University of Arkansas, Little Rock) and colleagues in the April 2014 issue of Anesthesiology. The survival rate was 58.9%,
which is nearly twice as high as in the general population, which the researchers say reflects the age and general health of the
childbearing mothers.
The analysis, taken from the Nationwide Inpatient Sample, the largest discharge database in the United States, includes
more than 56 million hospital deliveries between 1998 and 2011. Of these, there were 4843 cardiopulmonary arrests, or 8.5
arrests per 100 000 hospitalizations. The rate was stable over time.
Hemorrhagic conditions, such as antepartum and postpartum hemorrhage, caused 38% of the cardiac arrests. Other causes
included heart failure, amniotic-fluid embolism, sepsis, anesthesia complications, aspiration pneumonitis, venous
thromboembolism, and preeclampsia.
Although 59% of women survived to discharge, survival was dependent on the cause of the arrest. Those who had an aortic
dissection/rupture or trauma had the lowest survival, while those with an arrest caused by aspiration pneumonitis or
complications from the medication and/or anesthesia had higher survival rates. Survival rates also improved over time, note
the investigators.
References
1. Mhyre JM, Tsen LC, Einav S, et al. Cardiac arrest during hospitalization for delivery in the US, 19982011.
Anesthesiology 2014; 120: 810-818. Article

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Study Highlights
Study data were drawn from the Nationwide Inpatient Sample database, which represents approximately 20% of all
admissions to nonfederal hospitals in the United States annually. Approximately 1000 hospitals provide information to
the database each year.
The study period for the current research was 1998-2011. Cases were included if they included a diagnosis or
procedure code related to delivery, but cases of abnormal products of conception or abortion were excluded.
The primary study outcome was the prevalence of maternal cardiac arrest, as determined by diagnosis and procedure
codes. Researchers examined the demographic and disease variables associated with maternal cardiac arrest as well
as the outcomes of cardiac arrest.
A multivariable logistic regression analysis was used to evaluate potential risk factors and causes of maternal cardiac
arrest.
Among 56,900,512 hospitalizations for delivery between 1998 and 2011, there were 4843 cases of maternal cardiac
arrest. This equated to 8.5 cases of cardiac arrest per 100,000 deliveries.
The rate of cardiac arrest was stable throughout the study period.
Demographic variables associated with a higher risk for cardiac arrest included maternal age of 35 years or older,
black race, and funding through Medicaid vs private insurance.
Medical conditions most strongly associated with cardiac arrest included pulmonary hypertension, malignant disease,
cardiovascular disease, liver disease, and systemic lupus erythematosus.
Preeclampsia/eclampsia and placenta previa were associated with a higher risk for cardiac arrest.
Hemorrhagic conditions accounted for the highest proportion of cases (38.1%) of cardiac arrest. Heart failure, amniotic
fluid embolism, sepsis, anesthesia complications, aspiration pneumonitis, venous thromboembolism, and eclampsia
accounted for between 6% and 14% of cases each.
Amniotic fluid embolism carried the highest risk per cardiac arrest event among the conditions described above.
59.0% of women who experienced cardiac arrest survived to hospital discharge. Survival was most common after
cardiac arrest related to aspiration pneumonitis or medication-related complications, and was least likely after aortic
dissection or rupture.
There was a gradual improvement in the rate of survival after cardiac arrest during the study period. This rate improved
by an average of 7% per year.
74.0% of women with cardiac arrest had a contributory comorbid condition, but survival outcome after cardiac arrest
was unchanged by the presence of these comorbid conditions.
Hospitals with a large number of deliveries (> 1000/year) had higher proportions of cases of cardiac arrest compared
with lower-volume facilities, but full adjustment for patient risk factors rendered this result nonsignificant.

Clinical Implications
A previous study by Callaghan and colleagues found that the rate of severe complications during the peripartum period
exceeded 150 cases per 10,000 deliveries in 2008-2009. This represented a nearly twofold increase in the risk for
such complications during the previous 10 years, and the rates for multiple types of complications were increased.
In the current study by Mhyre and colleagues, cardiac arrest during hospitalization for delivery was rare and did not
increase during the study period from 1998-2011. Most cases of cardiac arrest were the result of hemorrhagic
conditions, but amniotic fluid embolism was the diagnosis with the highest risk ratio for cardiac arrest. The majority of
women with cardiac arrest survived.

CME Test
To receive AMA PRA Category 1 Credit, you must receive a minimum score of 75% on the post-test.

You are seeing a 40-year-old woman admitted to the hospital in active labor. She has a history of chronic

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hypertension and type 2 diabetes mellitus. According to the previous study by Callaghan and colleagues,
which of the following statements regarding complications during the peripartum period is most accurate?
Severe complications affect approximately 7% of pregnancies
The rate of severe complications has increased with time
Severe postpartum hemorrhage accounts for nearly all major peripartum complications
There has been no change in the rate of cardiac or renal complications in the peripartum period with
time
This patient undergoes a cesarean delivery but then quickly experiences complications and goes into
cardiac arrest. According to the current study by Mhyre and colleagues, which of the following statements
regarding cardiac arrest during hospitalization is most accurate?
There has been a gradual increase in the rate of cardiac arrest in the peripartum period
Most cases of cardiac arrest were related to hemorrhagic conditions
Anesthesia complications carried the highest risk ratio for cardiac arrest
The survival rate after cardiac arrest was 25%

This article is a CME/CE certified activity. To earn credit for this activity visit:
http://www.medscape.org/viewarticle/823177
Disclaimer
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Heartwire CME 2014 MedscapeCME

This article is a CME/CE certified activity. To earn credit for this activity visit:
http://www.medscape.org/viewarticle/823177

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