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Perimortem cesarean delivery 30 minutes after a laboring patient jumped from a fourth-floor window: Baby survives and is normal at age 4 years

      We describe the first case of a perimortem cesarean section on a patient who committed suicide during labor by jumping from the fourth-floor window of the labor ward. The cesarean section was performed 30 minutes after the death of the woman, and a child of 3037 g was born with an Apgar score of 0 at 1 minute. Today, 4 years later, the baby is well and has no apparent neurological problems.

      Key words

      Current recommendations are that perimortem cesarean section should be immediately performed to save the fetus’s life. We describe an extremely unusual case of a delayed perimortem cesarean section done on a patient who committed suicide during labor by jumping from the fourth-floor window of the labor ward.

      Case Report

      The fetus was born at 39 weeks of gestation by perimortem cesarean section following her mother’s suicide in February 2003. The mother, who was in labor at the time, jumped from a fourth-floor window to the ground below, a distance of 18 meters. The time lapse between verification of the death of the mother (absence of carotid pulse and heart rate on the electrocardiogram) and incision of the skin to perform cesarean section was 30 minutes. A female infant weighing 3037 g was born with an Apgar score of 0 at 1 minute (absence of cardiac activity). The infant was intubated and ventilated, and external chest compression was performed. Adrenaline 1:10,000 (0.02 mg/kg) was administered inside the tracheal tube. Five minutes after delivery, the newborn regained cardiac activity (less than 100 beats/minute), and an improvement in the skin color was observed. The baby was subsequently transferred to the neonatal intensive care unit (NICU). On admission to the NICU, the arterial blood gas analysis showed a pH of 6.79, pCO2 of 87.8 mm Hg, and pO2 50 mm Hg, with a base deficit of 19.6 mmol/L and bicarbonate 7.2 mEq/L.
      The newborn was ventilated with synchronous intermittent mandatory ventilation (SIMV) with pharmacologic hemodynamic support (dopamine 3 μg/kg per minute). Three hours after birth, cerebral ultrasound showed mild parenchymal edema and ultrasound of the abdomen was normal. Seizures were observed 4 hours after birth and anticonvulsant therapy with phenobarbital was initiated (20 mg/kg).
      Repeat arterial blood gas analysis at 9 hours of life was considerably improved with a pH of 7.37, pCO2 of 36.6 mm Hg, and pO2 of 50.7 mm Hg, with a base deficit of 3.4 mmol/L and bicarbonate 21 mEq/L.
      At 13 hours the cerebral ultrasound demonstrated a marked edema with diffused hyperechogenicity. The administration of an additional 5 mg/kg of phenobarbital was necessary because of the onset of a further convulsive episode with hypertonus.
      Her clinical condition improved steadily, and at around 32 hours, the newborn was extubated and mechanical ventilation was suspended.
      Reduced spontaneous movement, reduced muscular tone, generalized hyperreflexia, and an almost total absence of the archaic reflexes were also observed.
      At 10 days of life, after an initial phase of feeding by gavage, the baby was bottle fed with a consequential increase in growth.
      Before discharge, a neurology consultation confirmed an improvement in the baby’s neurological condition with the normalization of the electroencephalogram.
      The infant was discharged at 34 days of life. The follow-up examinations underlined a modest but constant improvement of the clinical condition and the neurological status.
      The child was assessed at 9 and 18 months using the revised (in 1997) Brunet-Lézine scale.
      • Brunet O.
      • Lézine I.
      Le développement psychologique de la petite enfance.
      • Josse D.
      Brunet-Lézine révisé: échelle de développement psychomoteur de la première enfance.
      The child was assessed at 3 and 4 years of age using the Revised Wechsler Preschool and Primary Scales of Intelligence (WPPSI-R; revised in 1995).
      • Wechsler D.
      Manual for the Wechsler Preschool and Primary Scale of Intelligence.
      • Wechsler D.
      Manuel: Echelle d’Intelligence de Wechsler pour la Période Préscolaire et Primarie.
      This scale assesses the intellectual development of children. Performance on both the Brunet-Lézine and the WPPSI-R scales is classified as follows: a score of 115 or greater indicates an accelerated performance, 85-114 indicates a performance within normal limits, 70-84 indicates a mildly delayed performance, and 69 or less indicates a significantly delayed performance. In our case, the results of the scales were 88, 90, 95, and 100, respectively, at 9 months, 18 months, 3 years, and 4 years of age. Thus, at 4 years of age, neurological development was normal.

      Comment

      The current recommendation for cardiopulmonary arrest during pregnancy is that the fetus should be extracted within 4 minutes to prevent death of the fetus or neurological consequences to the newborn.
      • Katz V.L.
      • Dotters D.J.
      • Drogemueller W.
      Perimortem cesarean delivery.
      Since 1986, the American Heart Association has taken into consideration the principle of the 4 minute rule when maternal cardiopulmonary resuscitation efforts are ineffective.
      American Heart Association in collaboration with the International Liaison Committee on Resuscitation
      Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care: International Consensus on Science, Part 3: Adul Basic Life Support.
      Therefore, in the case of maternal cardiac arrest, if pulsations are no longer observed, cesarean section should be immediately performed.
      • Katz V.
      • Balderston K.
      • DeFreest M.
      Perimortem cesarean delivery: were our assumptions correct?.
      Few cases have been reported in literature of newborns who have survived perimortem cesarean section. Kazandi et al
      • Kazandi M.
      • Mgoyi L.
      • Gundem G.
      • Hacivelioglu S.
      • Yucebilgin S.
      • Ozkinay E.
      Post-mortem caesarean section performed 30 minutes after maternal cardiopulmonary arrest.
      described the case of a woman who, after 35 weeks of pregnancy, had a perimortem cesarean section performed 30 minutes after a sudden maternal cardiopulmonary arrest. Her child was discharged from the hospital 17 days later, and the electroencephalograms taken on the fourth and seventh days of life were normal; however, the authors did not report a long-term follow-up of the child. Lopez-Zeno et al
      • Lopez-Zeno J.A.
      • Carlo W.A.
      • O’Grady J.P.
      • Fanaroff A.A.
      Infant survival following delayed postmortem cesarean delivery.
      reported the case of a 19-year-old woman who underwent perimortem cesarean section after sustaining 3 gunshot injuries (face, abdomen, and thorax); the cesarean section was performed 22 minutes after documented maternal cardiopulmonary arrest. By 18 months of age, the child was clinically normal except for persistent, mild hypotonia and recurrent otitis media. Dezarnaulds and Nada
      • Dezarnaulds G.
      • Nada W.
      Perimortem caesarean section: a case report.
      reported a perimortem cesarean section in a woman with sudden cardiopulmonary arrest because of aortic dissection starting at the proximal ascending aorta and extending through the thoracic and abdominal aorta (according to postmortem examination). The newborn was discharged at 3 weeks of life and appeared neurologically normal, but again no follow-up was reported.
      Yildirim et al
      • Yildirim C.
      • Goksu S.
      • Kocoglu H.
      • Gocmen A.
      • Akdogan M.
      • Gunay N.
      Perimortem cesarean delivery following severe maternal penetrating injury.
      performed perimortem cesarean section on a woman with a cardiopulmonary arrest after multiple knife injuries. She had 25 penetrating injuries and an extensive cardiopulmonary resuscitation for 45 minutes before undergoing a cesarean section. Six months later the baby was found to be completely normal.
      Our case report is unique because the cesarean section was performed on a patient who committed suicide by jumping from the window of the fourth floor of the labor ward. The cesarean section, which was performed about 30 minutes after the impact of the woman with the ground and her sudden death, demonstrates a remarkable ability of the baby to survive despite a long delay from cardiopulmonary arrest, and today the child shows no neurological damage. At the present time, the somatic, psychomotor, and intellectual development of the infant is within normal limits.
      Our case report is the perimortem cesarean section with the longest follow-up (4 years) of the child yet reported in literature. It is extremely difficult to explain from a scientific point of view how a fetus can survive for more than 30 minutes in the uterus after its mother’s death. Fully aware that this is only a case report, we nevertheless are quite impressed that the fetus has a such a remarkable capacity to survive in a such a case of acute asphyxia. Indeed, some early postpartum signs in infants, such as pH of 6.79 and base deficit of 19.6 mmol/L at arterial blood gas analysis, should not be considered definitive prognosticators of adverse sequelae. In fact, many infants with early signs of asphyxia go on to have minimal to no sequelae. This is clearly more true of a fetus who was previously in good condition and when the event is so sudden and acute.

      Acknowledgments

      The authors thank Professor Carol Watson, English teacher at Sassari University, who revised the English translation of the manuscript.

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