探讨对心脏骤停(CA)孕产妇采取本院产科快速反应团队(RRT)进行救治的效果。

选择2020年7月24日山东第一医科大学附属省立医院收治的1例30孕周时发生阵发性下腹痛，入院后发生CA孕产妇(孕产妇1)为研究对象。采取回顾性分析方法对孕产妇1临床病史、入院相关检查结果、诊治经过等临床资料进行分析。分别以"孕产妇""心脏骤停""pregnant woman""pregnancy""heart arrest""cardiac arrest"为中英文关键词，在中国知网、维普、万方数据知识服务平台及PubMed数据库中，检索CA孕产妇救治相关研究文献。其文献检索时间设定为各数据库建库至2022年12月。总结孕产妇1及文献涉及CA孕产妇相关研究的CA发生时间、原因及孕产妇预后等。本研究遵循的程序符合山东第一医科大学附属省立医院伦理委员会制定的伦理学标准，并得到该伦理委员会批准(审批文号为CXJL：ZQN-202209)。

①孕产妇1病史、入院相关检查结果、诊治经过：26岁，自然妊娠，本次入院检查结果提示，羊水偏多(羊水指数为27.4 cm)。2020年7月27日，对其实施超声引导下羊水减量术。7月29日14：45，发生胎膜早破，入产房待产；16：18，突发胸闷、憋气，紧急进行凝血功能、心肌酶学指标与N末端脑钠肽前体(NT-proBNP)水平检查结果显示，D-二聚体水平>5.93 mg/L，纤维蛋白原水平为8.46 g/L，超敏肌钙蛋白T(hs-TnT)水平为242.2 pg/mL，肌酸激酶同工酶(CKI)水平为16.83 ng/mL，肌红蛋白(Mb)水平为800.7 ng/mL，NT-proBNP水平为23 643 pg/mL，均较正常值异常增高；16：20，实施本院产科RRT救治方案；16：30，RRT初步诊断孕产妇1为急性心肌损伤、心功能衰竭、急性肺栓塞，羊水栓塞不能排除，建议做好全身麻醉下剖宫产术分娩准备；16：52，孕产妇1被转入手术室，突发CA，产科RRT立即启动猝死孕产妇急诊剖宫产术分娩预案，对其进行心肺复苏(CPR) 4 min后成功，立即于全身麻醉下进行紧急子宫下段剖宫产术分娩＋双侧子宫动脉上行支结扎术，手术顺利，术后转入重症医学科。娩出1例女活婴的出生体重为1 900 g，生后1-5-10 min Apgar评分为1-3-4分，转入本院新生儿科治疗。7月31日，孕产妇1心脏超声结果提示，围产期心肌病(PPCM)，左心室射血分数(LVEF)为46%(较正常值降低)，左心室内径(LV)为52.3 mm(较正常值增高)。对其采取维持生命体征平稳及水、电解质平衡，控制静脉液体输入量及速率，密切监测心功能相关指标、体温及炎性指标变化，并注意脏器保护及营养支持等治疗方案。8月7日，孕产妇1顺利出院，其分娩新生儿于生后第14天(8月12日)自动出院后，失访。②文献复习结果：根据本研究设定的文献检索策略，检索到CA孕产妇救治相关研究的国内外相关文献共计52篇，纳入158例CA孕产妇，加上孕产妇1，共计159例CA孕产妇。这159例孕产妇中，CA发生于产前、产时、产后者分别为57例(35.8%)、42例(26.5%)与60例(37.7%)；对其产科CA均进行初级CPR，120例(75.5%)成功，39例(24.5%)失败；孕产妇CA原因主要为失血性休克(34例)、羊水栓塞(25例)、心脏疾病(19例)、感染性休克(13例)、重度子痫前期/子痫(12例)、麻醉相关并发症(8例)及其他(26例)；报道预后情况的124例孕产妇中，CA所致孕产妇死亡率为37.1%(46/124)；报道新生儿预后情况的112例新生儿中，新生儿死亡率为49.1%(55/112)。

本研究中，通过早期预警、一键呼叫及产科RRT快速反应，成功挽救了CA孕产妇生命。孕产妇CA的救治依赖于产科RRT成员准确判断、快速反应及协同合作。

To investigate the effect of obstetrics rapid response team (RRT) in treating pregnant women with cardiac arrest (CA).

A pregnant woman with paroxysmal lower abdominal pain (pregnant woman 1) at 30 gestational weeks admitted to the Shandong Provincial Hospital Affiliated to Shandong First Medical University on July 24, 2020 was selected as study subject. The clinical data of pregnant woman 1 such as clinical history, admission-related examination results, and diagnosis and treatment processes was retrospectively analyzed. Medical literature related to pregnant women with CA was reviewed with keywords " pregnant women", " pregnancy" " heart arrest" and " cardiac arrest" both in Chinese and English as keywords in CNKI, VIP, Wanfang Data service platform and PubMed database. The literature search time was set from the establishment of each database to December 2022. Pregnant woman 1 and the occurrence time, causes and prognosis of CA in pregnant women and related studies were summarized. The procedures followed in this study were in line with the ethical standards set by the Ethics Committee of Shandong Provincial Hospital Affiliated to Shandong First Medical University and were approved by the Ethics Committee (Approval No. CXJL: ZQN-202209).

①Medical history, admission-related examination results, diagnosis and treatment of pregnant woman 1: 26 years old, spontaneous pregnancy, polyhydramnios (amniotic fluid index of 27.4 cm) at admission. On July 27, 2020, she was performed with amniotic fluid reduction under ultrasound guidance. At 14: 45 on July 29, she had premature rupture of membranes and was admitted to the delivery room for delivery. At 16: 18, chest tightness and suffocation suddenly appeared, urgent examination of coagulation function, myocardial enzyme index and N-terminal pro-brain natriuretic peptide (NT-proBNP) level showed: D-dimer level was > 5.93 mg/L, fibrinogen level was 8.46 g/L, hypersensitive troponin T (hs-TnT) level was 242.2 pg/mL, creatine kinase isoenzyme (CKI) level was 16.83 ng/mL, myoglobin level (Mb) was 800.7 ng/mL, NT-proBNP level was 23 643 pg/mL, all of which were significantly higher than normal value. At 16: 20, the RRT treatment plan of obstetrics department in our hospital was implemented. At 16: 30, preliminary diagnosis of RRT was that pregnant woman 1 was acute myocardial injury and heart failure, the possibility of acute pulmonary embolism and amniotic fluid embolism, RRT recommended preparation for cesarean section delivery under general anesthesia. At 16: 52, pregnant woman 1 was transferred to the operating room, CA occurred, obstetric RRT immediately initiated emergency cesarean section delivery plan for sudden death pregnant women, successful cardio-pulmonary resuscitation (CPR) was achieved for 4 minutes, then emergency lower uterine cesarean delivery and bilateral ascending branch ligation of uterine artery were performed immediately under general anesthesia. The operation was successful, and pregnant woman 1 was transferred to intensive care department after operation. A female live neonate was delivered with a birth weight of 1 900 g and a 1-5-10 min Apgar score of 1-3-4. The neonate was transferred to the neonatology department of our hospital for treatment. On July 31, the results of cardiac ultrasound in pregnant women 1 suggest peripartum cardiomyopathy (PPCM), left ventricular ejection fraction (LVEF) of 46% (lower than normal value), and left ventricular diameter (LV) of 52.3 mm (higher than normal value). Pregnant woman 1 was treated by measures to maintain stable vital signs and balance electrolytes, control the volume and rate of intravenous fluid infusion, closely monitor cardiac function-related indicators, temperature, and inflammatory marker changes, and pay attention to organ protection and nutritional support. On August 7th, she was discharged and her newborn was automatically discharged 14 days after birth (August 12), with the loss to follow-up. ② Literature review results: according to the literature search strategy set in this study, 52 pieces of domestic and foreign literature related to CA pregnant women treatment were retrieved, involving 158 cases of CA pregnant women. Including pregnant woman 1, a total of 159 cases of CA pregnant women were reviewed. Among them, CA occurred in 57 cases (35.8%) before delivery, 42 cases (26.5%) during delivery, and 60 cases (37.7%) after delivery. Primary CPR was performed successfully in 120 cases (75.5%) and failed in 39 cases (24.5%). The main causes of CA in pregnant women were hemorrhagic shock (34 cases), amniotic fluid embolism (25 cases), heart disease (19 cases), septic shock (13 cases), severe preeclampsia/eclampsia (12 cases), anesthesia-related complications (8 cases) and others (26 cases). Among the 124 pregnant women with reported prognosis, the maternal mortality rate due to CA was 37.1% (46/124) and among 112 neonates with reported prognosis, the neonatal mortality rate was 49.1% (55/112).

In this study, the CA pregnant woman is successfully rescued through early warning, one-click call and rapid response of obstetric RRT. The treatment of maternal CA depends on accurate judgment, rapid response, and the cooperation of obstetrics RRT.