Resuscitative Hysterotomy and Maternal and Neonatal Mortality in Maternal Cardiac Arrest Patients---A Systematic
Gunaseelan Rajendran1, Sasikumar Mahalingam2, Anitha Ramkumar3
1Department of Trauma and Emergency Medicine, All India Institute of Medical Sciences, Madurai, Tamilnadu, India.
Background:
Resuscitative hysterotomy (RH) is a critical intervention during maternal cardiac arrest and is traditionally recommended to be performed within 5 minutes to optimize maternal and neonatal outcomes. This systematic review and meta-analysis aimed to evaluate the associations between the timing of RH and survival outcomes.
Methods:
The PubMed, Scopus, and Embase databases were searched through April 2025 for studies reporting maternal and/or neonatal outcomes based on timing of RH after maternal cardiac arrest. Data on patient characteristics, the timing of intervention, and survival outcomes were extracted. A meta-analysis was conducted to assess the relationship between the time to RH and survival.
Results:
Of the 762 records identified, 12 studies (n = 507) met the inclusion criteria. Studies included 4 retrospective cohorts, 2 prospective cohorts, 3 case series, and 1 survey; 8 studies (n = 176) contributed data to the meta-analysis. Maternal survivors underwent RH at a mean time of 12.55 ± 4.85 minutes, which was significantly shorter than that of nonsurvivors (P = 0.023; I2 = 71%). Neonatal survival was more likely when the procedure was performed at a mean time of 10.25 ± 5.5 minutes (P = 0.034; I2 = 85%), with a high I2 indicating substantial between-study heterogeneity.
Conclusions:
RH performed up to 10-12 minutes after maternal cardiac arrest may be associated with favorable survival outcomes. These findings raise the question of the optimal timing for RH and suggest that meaningful maternal and neonatal survival can occur beyond the traditionally recommended 5-minute window, particularly when high-quality resuscitative efforts are ongoing. Because the certainty of the evidence is very low and the included studies are observational and heterogeneous, our findings do not support an immediate change to guideline timing. They highlight a critical area for future research, preferably using targeted trial emulation methods, registry analyses, or prospective observational cohorts with standardized timing and outcome definitions, because randomized trials in this emergency setting are unlikely to be ethical.
Registration:
PROSPERO CRD42024522666.
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