Amniotic Fluid Embolism Managed with Prothrombin Complex Concentrate: Case Report
Abstract Number: F-61
Abstract Type: Case Report/Case Series
Amniotic fluid embolism (AFE) is the fourth leading cause of maternal death and a main cause of morbidity, causing neurological sequelae, thrombotic events and kidney failure. It is defined by the hypoxia, hypotension or cardiac arrest and coagulopathy triad during labor, birth or C-section. We report the case of a patient developing coagulopathy after AFE during birth.
Patient G1P0, 21 years old, in labor with epidural. During expulsive labor, patient presents vomit, unconsciousness, cyanosis, shallow breathing, bradycardia and hypotension. Ventilatory support initiated with face mask, 2mg etilefrine and IV fluids; quick regain of consciousness, vital signs stabilized, no neurological deficit. Fetus extracted with terminal forceps; good Apgar score.
Third-stage management with good uterine contraction; second degree perineal tear. Despite all this, and despite the absence of lesions in the birth canal, abundant and non-coagulating bleeding begins in the uterus and the previously sutured tear. After ruling out other causes, coagulopathy from AFE is confirmed; tranexamic acid administered; frozen fresh plasma (FFP) and cryoprecipitated transfused. After four hours, vulvar hematoma is evident with active bleeding and Hb 4.7 g/dL; ultrasound does not reveal free fluid in the abdomen, but it does in the endometrial cavity. Uterus and birth canal explored under general anesthesia. Large hemorrhage with few clots is present; 3000UI IV (50UI/Kg) prothrombin complex concentrate (PCC) initiated, followed by carbetocin IV and rectal prostaglandin. Bleeding recedes 5-10 min after prothrombin complex is administered; patient receives 4 RBC units transfusion; early extubation possible; quick ICU recovery and discharge on the third day after correcting coagulopathy.
AFE is still an exclusion diagnosis with mortality above 20%; there is no way to predict or prevent it.
Its physiopathology implies immunological mechanisms triggered by AF vasoactive and procoagulant substances that enter maternal circulation, and cause a systemic inflammatory state and disseminated intravascular coagulation.
During initial management, cardiopulmonary resuscitation procedures, ventilator and hemodynamic support, as well as C-section within five minutes in case of non-responsive cardiac arrest, are all fundamental. In case of coagulopathy, initiate antifibrinolytic agents and blood products (RBC, FFP, platelets and cryoprecipitated). Currently, PCC is available, which increases factors II, VII, IX and X without volume overload, reduction in HCT or platelet count, with quick availability for application.
PCC may be a good option for managing coagulopathy from AFE
1.Tanaka KA and Szlam F. Treatment of massive bleeding with prothrombin complex concentrate: argument for. J Thromb Haemost 2010; 8:2589–2591