Authors: Madruga C et al.
Source: Cureus, September 2025, DOI 10.7759/cureus.92688
Summary:
This case report describes a sudden maternal cardiac arrest occurring minutes after spinal anesthesia for an urgent 39-week cesarean section. The patient, with chronic hypertension, type 2 diabetes and obesity, had undergone a prolonged labor induction. Spinal anesthesia was placed with standard doses of hyperbaric bupivacaine, sufentanil, and morphine. Despite co-loading with only 500 mL of crystalloid, she rapidly developed severe hypotension unresponsive to ephedrine, followed by bradycardia and asystole.
Resuscitation began immediately, including chest compressions, left uterine displacement and 1 mg IV epinephrine, with return of spontaneous circulation after four minutes. An emergent cesarean section under general anesthesia delivered a viable neonate. The mother recovered fully, with transient myocardial stunning that normalized over time. No obstetric, structural cardiac, hemorrhagic, or anaphylactic cause was found.
The clinical picture and timing strongly support activation of the Bezold-Jarisch reflex—an abrupt vagal-mediated cardioinhibitory reflex triggered by sudden decreases in venous return and sympathetic tone. Prolonged induction, limited fluid administration before the block, aortocaval compression, and rapid sympathectomy likely combined to precipitate severe bradycardia and arrest. The case reinforces that even stable parturients may be vulnerable to reflex cardiovascular collapse immediately after spinal anesthesia.
What You Should Know:
• Sudden cardiac arrest after spinal anesthesia, though rare, can occur even in otherwise stable obstetric patients.
• A rapid drop in preload combined with sympathetic blockade can trigger the Bezold-Jarisch reflex, producing profound bradycardia and asystole.
• Limited preloading (500 mL) and prolonged hospitalization may increase susceptibility.
• High-quality CPR, left uterine displacement and early epinephrine are essential for maternal survival.
• Emergent cesarean delivery should proceed promptly once maternal cardiac arrest occurs.
• Post-arrest myocardial injury may occur but usually resolves with supportive care.
• Maintaining adequate intravascular volume and early vasopressor support can reduce the risk of catastrophic reflex-mediated collapse.
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