A case report details an unexpected cardiac arrest occurring during an elective cesarean section in a 24-year-old pregnant patient with pregnancy-induced hypertension and twins. The patient, after successful resuscitation, exhibited unusual post-resuscitation psycho-behavioral phenomena, including amnesia and near-death experiences (NDEs), which were not initially recognized by the healthcare team. The case emphasizes the need for medical education regarding NDEs and the risks associated with intra-myometrial use of uterine stimulants.

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