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\title{4 Minutes Rule in Perimortem Caesarean Delivery: Does it Still Relevant? Case Series}
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             \author[1]{Abdul Karim  Othman}

             \author[2]{Mohd Nazri  Ali}

             \author[3]{Mohd Habibullah  Zakaria}

             \author[4]{Wan Nasrudin Wan  Ismail}

             \author[5]{Nurul Aimi  Mustaffa}

             \affil[1]{  University Sultan Zainal Abidin}

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\date{\small \em Received: 11 December 2019 Accepted: 2 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


Objective: To highlight the importance of immediate initiation of perimortem caesarean delivery in maternal with sudden cardiac arrest. Case report: We reported the outcomes of three cases of perimortem caesarean delivery secondary to maternal cardiac arrest. A 28-year-old G3P2 at 36 weeks of gestation who developed severe hypoxaemia secondary to acute pulmonary oedema which was arise from pre-eclampsia related hypertensive crisis.The second case was a 29-year-old G1P0 at 38 weeks of gestation who developed severe hypoxaemia secondary to spinal anaesthesia complication (total spinal)and the third case was a 44-year-old G5P4 at 39 weeks of gestation who developed severe hypoxaemia secondary to failed intubation and ventilation during induction of anaesthesia. Observing the outcomes of the three maternal after post perimortem caesarean delivery, we are strongly agreed that the time from maternal cardiac arrest to the initiation of resuscitative hysterotomy should be shifted from 4 minute to immediately. Conclusion: Preparations for perimortem caesarean delivery should be made simultaneously with the initiation of maternal resuscitative efforts. Case report:We reported the outcomes of three cases of perimortem caesarean delivery secondary to maternal cardiac arrest. A 28-year-old G3P2 at 36 weeks of gestation who developed severe hypoxaemia secondary to acute pulmonary oedema which was arise from pre-eclampsia related hypertensive crisis.The second case was a 29-year-old G1P0 at 38 weeks of gestation who developed severe hypoxaemia secondary to spinal anaesthesia complication (total spinal)and the third case was a 44-yearold G5P4 at 39 weeks of gestation who developed severe hypoxaemia secondary to failed intubation and ventilation during induction of anaesthesia. Observing the outcomes of the three maternal after post perimortem caesarean delivery, we are strongly agreed that the time from maternal cardiac arrest to the initiation of resuscitative hysterotomy should be shifted from 4 minute to immediately. Conclusion:Preparations for perimortem caesarean delivery should be made simultaneously with the initiation of maternal resuscitative efforts.

\end{abstract}


\keywords{perimortem caesarean delivery, resuscitative hysterotomy, maternal cardiac arrest.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
erimortem caesarean delivery (PMCD), or so called resuscitative hysterotomy is a hysterotomy procedure performed to resuscitate a maternal in the middle or late period of gestations who has entered cardiac arrest for any reason. This procedure is recommended to be initiated for two important reasons that is to maximize the maternal response to resuscitation during cardiopulmonary resuscitation and to save the life of the viable foetus. The theory behind perimortem caesarean delivery procedure is that effective cardiopulmonary resuscitation is extremely difficult in maternal at middle to late period of gestations due to the gravid uterus. It was reported that the chest compression in a maternal with a gravid uterus will only leads in the best of circumstances to a cardiac output of 10\% of the normal cardiac output \hyperref[b0]{1} . Therefore, by emptying the gravid uterus early enough and with the support of high-quality cardiopulmonary resuscitation, we believe that the outcome of the arrested maternal and the viable foetus will be improved significantly and probably we can reduce the neurological damage to the survived maternal. 
\section[{II.}]{II.} 
\section[{Cases Case 1.}]{Cases Case 1.}\par
A 28 years old G3P2 at 36 weeks of gestation developed severe hypoxaemia secondary to acute pulmonary oedema which was arise from pre-eclampsia related hypertensive crisis. As the patient developed cardiac arrest, perimortem caesarean delivery was attempted after failed to regain the return of spontaneous circulation (ROSC) despite 10 minutes duration of high-quality cardiopulmonary resuscitation. The baby was discharged home at Day 3 of life with no neurological deficit. The mother was discharged home with no neurological deficit on the 25 th day of PMCD having an occipital lacunar infarct. 
\section[{Case 2.}]{Case 2.}\par
A 27 years old G1P0 at 39 weeks of gestation with maternal obesity (BMI of 32kg/m 2 ) developed severe hypoxaemia secondary to spinal anaesthesia complication (total spinal). As the patient developed cardiac arrest, perimortem caesarean delivery was attempted after failed to regain the return of spontaneous circulation (ROSC) despite 10 minutes duration of high-quality cardiopulmonary resuscitation. The baby was discharged home at Day 3 of life with no neurological deficit. However, the mother was discharged home on the 198 th day of PMCD with severe neurological deficit secondary to global hypoxic ischaemic brain injury. 
\section[{Case 3.}]{Case 3.}\par
A 42 years old G5P4 at 38 weeks of gestation with gestational diabetes and one previous caesarean delivery developed severe hypoxaemia secondary to failed ventilation and intubation during induction of anaesthesia. As the patient developed cardiac arrest, perimortem caesarean delivery was attempted after failed to regain the return of spontaneous circulation (ROSC) despite 3 minutes duration of high-quality cardiopulmonary resuscitation. The baby was discharged home with no neurological deficit. However, the mother was discharged home on the 44 th day of PMCD with a severe neurological deficit secondary to global hypoxic ischaemic brain injury.\par
In Table  {\ref 1we} describe the durations (in minutes) for each significant step from the time of maternal cardiac arrest to the initiation of perimortem caesarean delivery and duration for achieving the return of spontaneous circulation to the arrested maternal. 
\section[{Case1}]{Case1}\par
Case  
\section[{Discussion}]{Discussion}\par
4-minutes rule in perimortem caesarean delivery requested that the resuscitative hysterotomy procedure should be initiated within 4 minutes of maternal cardiopulmonary arrest if the resuscitative efforts were unsuccessful \hyperref[b1]{2} . This is due to the traditional believed that adults begin experiencing anoxic brain damage 4 to 6 minutes into a cardiac arrest. However, this assumption has raised an important immediate question especially in resuscitating pregnant women in the late period of gestations.\par
Pregnant women in the third trimester are actually not very comparable to "adults" in the physiology of resuscitation: high oxygen consumption with overall high metabolic rate, reduced oxygen reserve with faster tendency to develop hypercapnia and hypoxaemia, high percentage of cardiac output being directed to the uteroplacental circulation \hyperref[b2]{3} and these factors are further aggravated by a significant reduced efficacy of chest compressions during cardiopulmonary resuscitation and completely obstructed vena cava by the gravid uterus. Therefore, the four-minutes rule cut-off for anoxic brain injury may not be applicable to this population as it is applying to non-pregnant patients. We would expect that pregnant women with gravid uterus to be even more susceptible to oxygen deprivation than the non-pregnant adults who experienced ischemic brain injury in as early as 4 minutes. Furthermore, there is a major hemodynamic fluid shifts occur at birth including a significant increase in venous return following the relief of the vena cava compressions, and redirection of the circulating blood from the uterine to the systemic circulation \hyperref[b3]{4} .\par
Looking at the outcome of the maternal in our case series, we are strongly agreed with Rose et al which suggest that if the uterus is palpable at or above the umbilicus, preparations for delivery should be made simultaneously with the initiation of maternal resuscitative efforts; and if maternal condition is not rapidly reversible, resuscitative hysterotomy with delivery should be performed regardless of foetal viability or elapsed time since maternal cardiac arrest \hyperref[b4]{5} . In addition to this, it is important to note that of all the reversible causes cited for maternal cardiac arrest by the American Heart Association, many are absolute indications for prompt delivery of the fetal \hyperref[b5]{6} .\par
IV. 
\section[{Conclusion}]{Conclusion}\par
The decision to resuscitative hysterotomy should be made around the cardiac arrest, and it's should not be delayed, as both maternal and foetal chances of survival are expected to decline significantly with time and therefore, the time from maternal cardiac arrest to initiation of resuscitative hysterotomy should be shifted from 4 minute to immediately.		 		\backmatter   			 
\subsection[{Acknowledgements}]{Acknowledgements}\par
The authors would like to thank the Director General of Health Malaysia for his permission to publish this article. The authors would also like to acknowledge all the multidisciplinary members of the intensive care, anaesthetic teams and obstetric teams and paediatric teams for their dedications and support in managing these cases. 			  			  				\begin{bibitemlist}{1}
\bibitem[Jeejeebhoy et al. ()]{b5}\label{b5} 	 		‘Cardiac arrest in pregnancy: a scientific statement from the American Heart Association’.  		 			F M Jeejeebhoy 		,  		 			C M Zelop 		,  		 			S Lipman 		.  	 	 		\textit{Circulation}  		2015. 132 p. .  	 
\bibitem[Marx ()]{b0}\label{b0} 	 		‘Cardiopulmonary resuscitation of latepregnant women’.  		 			C F Marx 		.  	 	 		\textit{Anesthesiology}  		1982. 56 p. 156.  	 
\bibitem[Rose et al. ()]{b4}\label{b4} 	 		‘Challenging the 4-to 5 -minute rule: from perimortem caesareannot resuscitative hysterotomy’.  		 			C H Rose 		,  		 			A Faksh 		,  		 			K D Traynor 		,  		 			D Cabrera 		,  		 			K W Arendt 		,  		 			B C Brost 		.  	 	 		\textit{Am. J. Obstet. Gynecol}  		2015. 213 p. .  	 
\bibitem[Benson et al. ()]{b3}\label{b3} 	 		‘Maternal collapse: Challenging the four-minute rule’.  		 			M D Benson 		,  		 			A Padovano 		,  		 			G Bourjeily 		,  		 			Y Zhou 		.  	 	 		\textit{EBioMedicine}  		2016.  (6)  p. .  	 
\bibitem[Hegewald and Crapo ()]{b2}\label{b2} 	 		‘Respiratory physiology in pregnancy’.  		 			M J Hegewald 		,  		 			R O Crapo 		.  	 	 		\textit{Clin. Chest Med}  		2011. 32 p. .  	 
\bibitem[Sanders et al. ()]{b1}\label{b1} 	 		‘The physiology of cardiopulmonary resuscitation’.  		 			A B Sanders 		,  		 			H W Meislin 		,  		 			G A Ewy 		.  	 	 		\textit{JAMA}  		1984. 252 p. 328.  	 
\end{bibitemlist}
 			 		 	 
\end{document}
