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BackgroundOur objective was to review the latest evidence on resuscitation care for maternal cardiac arrest (MCA) and gain expert consensus on best practices to inform an evidence-based curriculum.MethodsWe convened a multidisciplinary panel of stakeholders in MCA to develop an evidence-based simulation training, Obstetric Life SupportTM (OBLS). To inform the learning objectives, we used a novel three-step process to achieve consensus on best practices for maternal resuscitation. First, we reaffirmed the evidence process on an existing MCA guideline using the Appraisal of Guidelines for Research and Evaluation (AGREE II). Next, via systematic review, we evaluated the latest evidence on MCA and identified emerging topics since the publication of the MCA guideline. Finally, we applied a modified Research and Development (RAND) technique to gain consensus on emerging topics to include as additional just-in-time best practices.ResultsThe AGREE II survey results demonstrated unanimous consensus on reaffirmation of the 2015 American Heart Association (AHA) MCA guideline for inclusion into the OBLS curriculum. A systematic review with deduplication resulted in 11,871 articles for review. After categorizing and synthesizing the relevant literature, we presented twelve additional best practices to the expert panel using a modified RAND technique. Upon completion, the 2015 AHA statement and nine additional just-in-time best practices were affirmed to inform the OBLS curriculum.ConclusionsA novel three-step process including reaffirmation of evidence process, systematic review, and a modified RAND technique resulted in unanimous consensus from experts in MCA resuscitation on existing and new just-in-time best practices to inform the learning objectives for an evidence-based curriculum.

Objective Maternal cardiac arrest is a rare and complex process requiring pregnancy-specific responses and techniques. The goals of this study were to (1) identify, evaluate, and determine the most current best practices to treat this patient population and (2) establish a standardized set of guidelines to serve as a foundation for a future educational simulation-based curriculum. Study design We used a three-step modified Delphi process to achieve consensus. Twenty-two healthcare experts from across North America agreed to participate in the expert panel. In round 1, 12 pregnancy-specific best practice statements were distributed to the expert panel. Panelists anonymously ranked these using a 7-point Likert scale and provided feedback. Round 2 consisted of a face-to-face consensus meeting where statements that had not already achieved consensus were discussed and then subsequently voted upon by the panelists. Results Through two rounds, we achieved consensus on nine evidence-based pregnancy-specific techniques to optimize response to maternal cardiac arrest. Round one resulted in one of the 12 best practice statements achieving consensus. Round two resulted in six of the remaining 12 gaining consensus. Best practice techniques involved use of point-of care ultrasound, resuscitative cesarean delivery, cardiopulmonary resuscitation techniques, and the use of extracorporeal cardiopulmonary resuscitation. Conclusion The results of this study provide the foundation to develop an optimal, long-term strategy to treat cardiac arrest in pregnancy. We propose these nine priorities for standard practice, curricula, and guidelines to treat maternal cardiac arrest and hope they serve as a foundation for a future educational curriculum.

Background: Pregnancies complicated by hypertensive disorders are at risk of fetal growth restriction, abruption, and stillbirth. These complications are likely mediated through endothelial vascular disease of the placenta. Case: A 34 year old female G3P0111 with a history of HELLP syndrome was referred for severe fetal growth restriction at 23 weeks and 3 days. She was normotensive with normal fetal anatomic survey, low risk cell free DNA screen, negative antiphospholipid antibody panel and no evidence of TORCH infections. She returned to the clinic two weeks later with new onset hypertension, suboptimal interval fetal growth and oligohydramnios. She was admitted, and delivered at 25 weeks and 5 days for preeclampsia with severe features. Her female infant weighted 340 grams, and was intubated and admitted to the NICU. The NICU stay was complicated by respiratory distress syndrome, cholestasis, pancreatic insufficiency, dyschezia, growth failure, hydronephrosis, and vesicoureteral reflux. Today she is 12 months old and thriving. Placental pathology showed accelerated villous maturation suggestive of placenta underperfusion, consistent with clinical history of preeclampsia. Discussion: Preeclampsia is a complication of pregnancy typically characterized by elevated blood pressure and damage of other organs, most commonly the liver or kidney. While the exact mechanisms that cause preeclampsia are not known, the resultant endothelial vascular disease affecting the placenta can lead to fetal growth restriction or abruption. Second trimester fetal growth restriction can result from fetal aneuploidy, viral infections, or maternal conditions that lead to uteroplacental insufficiency such as chronic hypertension or pre-gestational diabetes. Few cases describe fetal growth restriction preceding the onset of preeclampsia, although this is not uncommon in clinical practice. Conclusion: Pregnancies complicated by severe, preterm fetal growth restriction preceding the development of hypertensive disorder appear to have a common etiologic pathway, and the absence of hypertension does not exclude the possibility of underlying preeclampsia. Increased vigilance for signs and symptoms of preeclampsia in these pregnancies is warranted.

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