title: Emergent transesophageal echocardiography in hemodynamically unstable obstetric patients.
abstract: BACKGROUND
  The obstetric population has an increasing incidence of comorbid conditions. These, coupled with the possibility of acute embolic events involving air, amniotic fluid, and thrombus, increase the likelihood of hemodynamic instability. Although the utility of transesophageal echocardiography to guide management in cardiac and high-risk, non-cardiac surgical populations has been well established, the emergent use in critically-ill parturients has not been comprehensively evaluated.
  
  
  METHODS
  Using our departmental transesophageal echocardiography database of 28 293 examinations, parturients were identified who underwent emergent transesophageal echocardiography for evaluation of hemodynamic instability, including cardiac arrest, between January 1999 and March 2014. Transesophageal echocardiography findings and their impact on patient management were analyzed.
  
  
  RESULTS
  Ten peripartum patients were evaluated. Six patients became unstable during dilation and evacuation procedures; one after a forceps delivery; one during and one after cesarean delivery; and one during a postpartum laparotomy. Six patients proceeded to cardiac arrest; however, all women survived their initial operation and resuscitation. Transesophageal echocardiography was instrumental in determining the etiology and guiding resuscitation in all 10 patients including emergent cardiac surgical intervention with cardiopulmonary bypass (n=2). Seven patients survived to hospital discharge, but three died after experiencing neurologic complications.
  
  
  CONCLUSIONS
  Severe hemodynamic instability and cardiac arrest can occur in previously healthy parturients in pregnancy. Our data suggest that emergent transesophageal echocardiography is a valuable tool in determining the etiology and directing therapy of refractory hypotension or cardiac arrest in obstetric patients.
authors: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: P S
authors: PS
authors: Burrage
authors: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: S K
authors: SK
authors: Shernan
authors: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: L C
authors: LC
authors: Tsen
authors: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: J A
authors: JA
authors: Fox
authors: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: K
authors: K
authors: Wilusz
authors: Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, CO, USA.
authors: H K
authors: HK
authors: Eltzschig
authors: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology and Critical Care Medicine, Eberhard Karls University, Tübingen, Germany. Electronic address: jhilberath@partners.org.
authors: J N
authors: JN
authors: Hilberath
mesh_terms: D000293:Adolescent; D000328:Adult; D016887:Cardiopulmonary Resuscitation; D002318:Cardiovascular Diseases / Q000175:diagnosis* / Q000628:therapy; D016638:Critical Illness; D017548:Echocardiography, Transesophageal / Q000379:methods*; D005260:Female; D006323:Heart Arrest / Q000175:diagnosis / Q000628:therapy; D006439:Hemodynamics; D006801:Humans; D007022:Hypotension / Q000175:diagnosis; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000175:diagnosis* / Q000628:therapy; D062606:Tertiary Care Centers; D055815:Young Adult
keywords: Cardiac arrest; Emergency; Hemodynamic instability; Peripartum; Transesophageal echocardiography