///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-05:00

An Abnormal Presentation of Amniotic Fluid Embolism

Abstract Number: 29
Abstract Type: Case Report/Case Series

Carrie E. Bastin M.D.1 ; Grace Shih M.D.2

Intro:

Amniotic fluid embolism (AFE) is a rare complication of pregnancy with acute and dramatic presentation. Onset is characterized by hypoxia and cardiovascular collapse; often not survived. We present the case of an abnormal presentation of AFE where prompt recognition and treatment resulted in maternal survival.

Case:

A 34 y/o G3P1 at 23 5/7 weeks found down at home. This pregnancy had been complicated by a twin gestation with loss of one twin at 12 weeks. She had been on bed rest for known placenta previa. Upon arrival to ER, she was in PEA with ongoing CPR. On physical exam, she was found to be tachycardic, hypotensive, unresponsive with decorticate posturing, and had active bleeding from both oral and vaginal cavities. She was intubated and ventilated, placed on maximal pressor support, and resuscitated with IVF, PRBCs, FFP, cryoprecipitate and factor VII. Upon stabilization of hemodynamics, she was transferred to the ICU. With recurrent hemorrhage (1500ml over 30 min), she underwent emergent c/s in the ICU. After delivery of a non-viable infant, post-partum hemorrhage was not controlled with methergine, hemabate, oxytocin or uterine artery ligation. Ultimately a hysterectomy was required. She was eventually weaned from all supportive measures and on POD 9 was discharged to a rehab facility with residual right sided neurologic deficits. The consensus among OBs is that the abnormal placental surface from the fetal demise allowed amniotic fluid to enter the maternal circulation.

Discussion:

AFE continues to be a feared and devastating complication of pregnancy. Its diagnosis is one of exclusion based on clinical presentation. Although the pathophysiology is poorly understood, current data suggest that an initiating event triggers a process more similar to anaphylaxis or complement activation than to embolism. Progression usually occurs in 2 phases, with phase 1 characterized by hypoxia and cardiopulmonary arrest. If this is survived, phase 2 is characterized by massive hemorrhage with uterine atony and DIC. Maternal mortality is near 61%, and those who do survive usually have permanent neurologic impairment. No definitive diagnostic test exists, but the following 4 criteria should be considered in making the diagnosis: 1) acute hypotension or cardiac arrest, 2) acute hypoxia, 3) coagulopathy or severe hemorrhage, 4) presence of these during labor, c-section, dilation and evacuation, or within 30 minutes postpartum with no other explanation of findings. Treatment is supportive with CPR, aggressive resuscitation, treatment of coagulopathy and delivery of infant in pts unresponsive to resuscitation.

Conclusion:

AFE is a rare obstetric emergency that is unpredictable, unpreventable, and with an unknown cause. Management of this condition mandates prompt recognition and aggressive resuscitation efforts. The 3 main goals of treatment are oxygenation, maintaining cardiac output, and correcting coagulopathy.

SOAP 2009