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The Delicate Balance of the Maternal-Fetal Dyad in an Emergency

September 29, 2023

In a Maternal Fetal Case Studies published in the September issue of NeoReviews entitled, Maternal Atrial Fibrillation and Neonatal Complications, Dr. Victor N. Oboli and colleagues discuss the case of a pregnant woman at term who develops atrial fibrillation with rapid ventricular response and becomes subsequently hemodynamically unstable. The obstetricians and cardiologists provide immediate assessment and clinical treatment with the primary goal of maternal stabilization. She receives intravenous antiarrythmics to which her atrial fibrillation is refractory; subsequently, electrocardioversion is performed with appropriate clinical response. Subsequent assessment of the fetus following maternal electrocardioversion demonstrates fetal bradycardia requiring urgent cesarean. Fortunately, both the maternal and neonatal patient have reassuring outcomes. It’s important to note that the outcome perhaps would have been different if the clinicians involved had not recognized the need to stabilize the maternal cardiac emergency.

In obstetrics, we consider the maternal-fetal dyad as a 2-patient model that has a unique relationship with medical, ethical, and legal implications.1 This case specifically focuses on the necessary importance of stabilizing maternal status, and in many urgent situations during pregnancy, particularly at a viable gestational age, the fetal status can be assessed and evaluated while supporting the maternal status.2,3,4 Such scenarios may include an acute illness or flare of a chronic medical condition, such as diabetic ketoacidosis or hypertensive urgency. 

However, in cases similar to the one described in Oboli et al, emergent clinical situations may occur in which the fetal assessment must be deferred until immediately after the maternal status is stabilized. These situations may include acute trauma, acute seizure, or a cardiac emergency.2 In this case, the adult multidisciplinary care team correctly made the necessary choice to prioritize and focus only on the maternal status. Taking an unstable maternal patient to an immediate operative delivery may lead to further destabilization, and—in certain situations—catastrophic maternal outcomes.

In an emergent clinical scenario involving a pregnant patient, treatment should never be withheld or delayed due to gravid status.2,3,4 Typically, emergencies involving pregnant patients should operate under the same algorithms as non-pregnant patients, with the goal of urgent maternal stabilization. In some scenarios, well-intentioned emergency providers may feel conflicted over possible effects to the fetus based on maternal treatment. This feeling is understandable given medical providers’ strong sense of benevolent obligation to care for both maternal and fetal statuses, thus making this case important for readers as it describes such a scenario when the delicate maternal-fetal dyad must be prioritized only for the maternal patient.

Ultimately, in such clinical emergencies, a shared model for multidisciplinary providers regarding the prioritization of maternal care is critical. Either way, care providers should be unified behind the premise that stable maternal status is essential to optimize fetal status. 

References:

  1. Mattingly SS. The Maternal-Fetal Dyad: Exploring the Two-Patient Obstetric Model. The Hastings Center Report. 1992;22(1):13-18
  2. American College of Obstetricians and Gynecologists' Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease. Obstet Gynecol. 2019;133(5):e320-e35656
  3. ACOG Practice Bulletin No. 211: Critical Care in Pregnancy. Obstet Gynecol. 2019;133(5):e303-e319
  4. ACOG Committee Opinion No 775 : Nonobstetric Surgery During Pregnancy. Obstet Gynecol. 2019;133(4):e285-e286
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