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///2010 Abstract Details
2010 Abstract Details2019-08-03T15:49:10-05:00

Possible Amniotic Fluid Embolism: A case report

Abstract Number: 209
Abstract Type: Case Report/Case Series

Liane Germond MD1 ; Deborah Stein MD2; Matthew Hirschfeld MD3

A 37 y/o, G1P0 at 37 weeks, was admitted for induction due to GDM and a fetus with an enlarging pelvic cyst. Upon patient request, a CSE was placed, at a cervical dilatation of 1, and an epidural infusion started. The patient remained comfortable until 6 hours later, when she complained of difficulty breathing. Her saturation was found to be 70-80% and there was a fetal bradycardia to 50 bpm. She was transported to the OR for an emergent cesarean section.

On arrival to the OR, the patient was awake and conversive with a saturation of 89%, but there was difficulty obtaining a maternal blood pressure. The FHR was 60 bpm, a rapid sequence induction was performed with ketamine and succinylcholine, and the patients trachea easily intubated. A female neonate was delivered in 3 minutes, with APGARS of 4,7,9. During the procedure, the patient became hypotensive (70/40) and a phenylephrine infusion was started. An intraoperative HCT was 28% (starting HCT: 38.7), and a transfusion was started with 1 U PRBCs. Following closure of the abdomen, expression of the uterus revealed 1 L blood loss. The presumptive diagnosis of amniotic fluid embolus was made, and the patient was transferred intubated to the ICU for treatment of DIC.

On admission to the ICU, vital signs were: HR=97, RR=12, SpO2=100%, BP=101/74, and the patient remained on phenylephrine. Transfusions were continued to treat the DIC, and further pressor support was initiated with norepinephrine. Subsequent labs showed a declining HCT to 23% and later 20%. Approximately three hours after arrival in the ICU, the patient was brought back to the OR for re-exploration and a possible hysterectomy.

The patient remained on pressors in the OR, while anesthesia was maintained with isoflurane. Thirty minutes into the surgery, as the surgeon retracted the uterus, the blood pressure dropped to 50/25 and sine waves were noted on the monitor. With the presumptive diagnosis of hyperkalemia, calcium, insulin, dextrose, and bicarbonate were given with resolution of the dysrhythmia. Throughout the operation, the surgeons had difficulty maintaining hemostasis, with an estimated blood loss of 2L. Intraoperatively 11 U PRBCs, 9 U FFP, and 1U plts were given. Prior to transfer back to the ICU, there was evidence of pulmonary edema with pink frothy material in the ETT, which was treated with suctioning and furosemide.

Upon return to the ICU, vital signs were: BP=135/85, HR=113, SpO2=97%, RR=15, T= 97F. The patient continued to demonstrate evidence of DIC with oozing from her incision, and received an additional 12 U PRBCs, 14 U FFP, 2 U plts, and 1 mg rf VII in the next 24 hours. Chest x-ray was indicative of ARDS. Due to elevated troponins, a TTE was performed showing an EF=10%. The patient was given a diagnosis of stress induced cardiomyopathy. She was eventually weaned from all pressor support and extubated on postop day #11. On postop day #13 the patient and neonate were discharged home.

SOAP 2010