ABSTRACT A case report of a primigravida, who was admitted with severe pregnancy induced hypertension (BP 160/122 mmHg) and twin pregnancy, is presented here. Antihypertensive therapy was initiated. Elective LSCS under general anaesthesia was planned. After the birth of both the babies, intramyometrial injections of Carboprost and Pitocin were administered. Immediately, she suffered cardiac arrest. Cardio pulmonary resucitation (CPR) was started and within 3 minutes, she was successfully resuscitated. The patient initially showed peculiar psychological changes and with passage of time, certain psycho-behavioural patterns emerged which could be attributed to near death experiences, as described in this case report.

1. MY MEMORABLE CASE!

2. AN UNANTICIPATED CARDIAC
ARREST
&
UNUSUAL POST-RESUSCITATION
PSYCHO-BEHAVIOURAL PHENOMENA
& NEAR DEATH EXPERIENCE (NDE)
IN A PATIENT WITH
PREGNANACY INDUCED HYPERTENSION (PIH)
AND TWIN PREGNANCY
POSTED FOR ELECTIVE
LOWER SEGMENT CAESARIAN SECTION
(LSCS):
A CASE REPORT

3. DR. MRIDUL M. PANDITRAO
CONSULTANT
Department Of Anesthesiology
&
Intensive Care
Public Hospital Authority‟s
RAND MEMORIAL HOSPITAL
Freeport, Grand Bahama
Commonwealth of the Bahamas

4. FORMERLY:
PROFESSOR, HEAD,IN-CHARGE OF ICU
DEAN OF FACULTY OF MEDICINE
DEPTT. OF ANAESTHESIOLOGY & CRITICAL CARE
PAD. Dr. D.Y.PATIL MEDICAL COLLEGE
PIMPRI, PUNE
INDIA

5. INTRODUCTION
 PERI-PARTUM MORBIDITY & MORTALITY
 VARIED AETIOLOGIES of CARDIAC ARREST
 SUCCESSFUL RESUSCITATION?
 AFTER THAT????
A CASE OF POST CARDIAC ARREST
RESUSCITATION (CPR) UNDERGOING ELECTIVE
LSCS FOR PIH AND TWINS!
 INTERESTING, UNEXPLANABLE PHENOMENA IN
POST-OP PERIOD!

6. CASE REPORT
 24 Yrs. Old primi-gravida near term
 B.P. 160/122 mm Hg.
 Twins
 Anti-hypertensive /other Therapy
 Development of S/S of impending Eclampsia
 Planned Elective L.S.C.S.

7. ANAESTHETIC MANAGEMENT
 Standard Balanced G.A.
 At birth of both Babies : infusion of Pitocin
 Obstetricians: Intramyometrial Injections
Carbiprost x 3 injections
Pitocin 10 I.U.
 “SUDDEN CARDIAC ARREST!”
 CPR Started
 Revived successfully in 3.5 – 4 minutes

8. ANAESTHETIC MANAGEMENT(CONTD.)
 Surgery was allowed to commence.
 B.P. on Higher range 150-160/100-110 mm
Hg.
 At the end of surgery, patient was making
spontaneous respiratory efforts.
 Reversal was given and patient was
extubated when she was fully conscious and
responding to verbal commands.
 Patient was shifted to ICU after 30 min.

9. IN ICU
IMMEDIATE POST-OPERATIVELY
 Patient had no recollection of intra-operative events
 Did not recognize her relatives.
 Patient Was drowsy but awake
 Anticerebral oedema therapy was given.

10. NEXT 24 HOURS– 1 WEEK
 Patient became oriented gradually, but had amnesia
 Vitals and physiological functions were normal
 Had difficulty with speech initially which later improved
 Patient was discharged after 1 week

11. JUST BEFORE DISCHARGE
 Recollection of immediate pre-operative period
 Anterograde amnesia after that
 Remembrance of “travelling through dark terrain with a
distant bright light at the end of it”
 Seemed to have heard “She‟s no more/ She is dead!”

12. REVIEW AT 6 MONTHS
 Till 3 months „unusual experiences‟
 In Mirror, seeing her own image !
 “Out Of Body” experiences
 Hearing again that “ She is No More!”
 Establishment of normal relationship with
own newborns, spouse and other family members

13. DISCUSSION
 The “Near Death Experiences” – NDES
 Have been described in detail in literature*
 Neither discussed amongst medical fraternity nor
taught in syllabi and curricula and left in the realm
of the ambiguity**.
•Greyson B, Stevenson I. Phenomenology of Near death experience. Am J Psychiatry 1980; 137:1193 – 6.
•Gabbard GO, Twemlove SW, Jones FC. Do „Near-death experiences‟ occur only near death? J. Nerv Ment.dis. 1981; 169:374 – 7
• Kircher PM. Love is the Link: A Hospice Doctor shares her experiences of Near Death & Dying, New York 1995, Larson Publications
•Blackmore, SJ. Near-death experiences in India: They have tunnels too. Journal of Near-Death Studies 1993 11(4) ;205-11
•Parnia S, Waller DG, Yeates R, Fenwick P. A qualitative and quantitative study of the incidence, features and etiology of near death
experiences
in cardiac arrest survivors. Resuscitation 2001;48:149 - 56

14. “NEAR DEATH EXPERIENCES” – NDES
 Especially Post cardiac Arrest & return after CPR
 Unexplainable phenomenon
 Cultural variations
 But commonly reported through out the world
 Never given importance by Medical fraternity
•French CC. Near-death experiences in cardiac arrest survivors. Prog. Brain Res.2005;150:351 - 67
•James D. What emergency Department staff need to know about Near Death experiences. Topics in Emergency Medicine 2004; 26:29 - 34.

15.  Peri partum morbidity and even mortality is again a well
documented phenomenon*
 Especially where surgical intervention has been required
 Morbidity and mortality might be due to various etio-
pathological processes involved
 Treatment modalities logically may be varied with their final
outcome.
•Say L, Pattison R C, GulazogluA M: WHO systematic review of maternal morbidity and mortality, the prevalence of severe acute maternal morbidity (near
miss), Reproductive Health,2004,1 (1), 3
•Minauskiene M, Nadasauskiene R, Padaiga Z, Makari S: Systematic review on the incidence and prevalence of severe maternal morbidity; Medicina (Kaunas)
2004, 40 (4): 299-

16.  Exact cause of the Catastrophe?
 Cause of cardiac arrest is still a dilemma
 “Delivery of babies?” or Intra-myometrial injections of
Carbiprost / Oxytocin
 Post-CPR psychological Phenomena?
 “O-O-B” experiences, “Dark Tunnel” have been
reported.

17.  Carboprost tromethamine (Hemabate)®,
 Methylated analogue of Prostaglandin F2 α (PGF2 α)
 In clinical practice for fairly sometime
 Many obstetrician use it*
to stimulate myometrial contractility,
increase the tone,
decrease the bleeding and reduce the incidence of PPH.
 Routinely given by many Obstetricians intra-myometrially
•Brancazio LR, Stizel RE Uterine Simulates & Relaxants. In: Craig CR., Stitzel RE, editors. Modern Pharmacology with Clinical Applications. 6th ed, Philadelphia:
Lippincott Williams & Wilkins; 2003, p. 719-721
•Singh N, Singh U. Methylergometrine and carboprost tromethamine prophylaxis for post partum hemorrhage; J Obstet Gynecol of India 2005 ,55: 325-8

18.  Oxytocin, although nowadays rare.
 Carboprost, Misoprostol and other uterine
stimulants causing cardiac arrest has been
documented*.
•Adverse event in female receiving Hemabate (Carboprost). Reported by a physician from United States on 2007-03-09. Patient: female ...
www.druglib.com/adverse-reactions_side-effects/hemabate/seriousness_serious /

19.  Successful revival of the patient suggests
 Whatever was the cause of the event, was acute, transient and not
related to any organic lesion.
 Further confirmed by the fact that she did not require any support or
any further sustained pharmacological intervention
 The experiences that our patient had can be included under the realm
of NDEs, as per the Greyson‟s NDE Scale (of more than 7 )
•French CC. Near-death experiences in cardiac arrest survivors. Prog. Brain Res.2005;150:351 - 67
•James D. What emergency Department staff need to know about Near Death experiences. Topics in Emergency Medicine 2004; 26:29 - 34.

20.  Various psychological phenomena in post-CPR period
 But our patient‟s few more peculiar psycho-behavioural
experiences are not explainable to us.
 Discussion with psychiatrists has not been very
conclusive.
 Till date, this has been an enigma to us.

21. CONCLUSION
 PIH Patient for elective LSCS, under GA
 Suffered C-P Arrest,
 Following delivery of babies and
 Intra-myometrial Injections of a prostaglandin and Oxytocin.
 Post CPR „peculiar‟ psycho-behavioral phenomena, which were self-limiting.
 Can be cofirmed as NDEs
 Patient is now living “peaceful” life.

22. CONCLSION
 Complicated Obstetrics can be very challenging and put us
through unusual situations
 Intra-myometrial use of uterine stimulants can be very
risky and should be avoided as far as possible
 Making all healthcare givers, well acquainted with the
knowledge of “Out of Body”/ NDEs in post CPR period
must be part of our curriculum
 In addition to already reported behavioral changes, new
experiences could be added to the existing list.

23. It is our fervent wish and earnest effort
to make all aware that:
Post CPR NDEs might be difficult
to explain but are a real
phenomena
Clinicians must be, less sceptic &
more considerate about their
existence !!

24. ALREADY PUBLISHED AS A CASE REPORT:
Indian J Anaesth. 2010 Sep-Oct; 54(5): 467–469.
doi: 10.4103/0019-5049.71035
PMCID: PMC2991660
An unanticipated cardiac arrest and unusual post-
resuscitation psycho-behavioural
phenomena/near death experience in a patient
with pregnancy induced hypertension and twin
pregnancy undergoing elective lower segment
caesarean section
Mridul M Panditrao, Chanchal Singh,1 and Minnu M
Panditrao