Advanced Maternal–Fetal Resuscitation After Obstetric Cardiac Arrest: A Systematic Review of Resuscitative Hysterotomy, Extracorporeal Cardiopulmonary Resuscitation, Venoarterial Extracorporeal Membrane Oxygenation, Resuscitative Endovascular Balloon Occlusion of the Aorta, and Damage-Control Hemostatic Resuscitation

Obstetric cardiac arrest is uncommon; however, when it occurs, the consequences are immediate and often devastating for both the mother and fetus. Management has evolved considerably over the past two decades, although the relevant evidence remains scattered across several disciplines and is rarely considered as a single continuum of care. This systematic review was undertaken to examine the current evidence supporting advanced maternal–fetal resuscitation strategies after obstetric cardiac arrest, with particular attention to resuscitative hysterotomy, extracorporeal cardiopulmonary resuscitation (ECPR)/venoarterial extracorporeal membrane oxygenation (VA-ECMO), resuscitative endovascular balloon occlusion of the aorta (REBOA), and damage-control hemostatic resuscitation. A structured search of major electronic databases was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 recommendations. From 978 records initially identified, 31 studies met the predefined eligibility criteria and were included in the final synthesis. The literature consistently supports rapid pregnancy-specific cardiopulmonary resuscitation and timely resuscitative hysterotomy as core interventions during maternal cardiac arrest. Beyond these measures, emerging evidence indicates a growing role for ECPR/VA-ECMO in selected cases of refractory arrest and for REBOA in severe obstetric hemorrhage accompanied by hemodynamic collapse. Studies evaluating tranexamic acid, fibrinogen replacement, viscoelastic-guided coagulation management, and massive transfusion protocols suggest that early hemostatic optimization may substantially influence survival in hemorrhagic etiologies. At the same time, much of the available evidence is derived from observational studies, small cohorts, and case-based reports, which limits direct comparisons between interventions.