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Management of Cardiac Arrest Following Amniotic Fluid Embolism and Placenta Increta during Cesarean Section and Resulting Sheehan Syndrome: A Case Report.
Abstract Number: T-48
Abstract Type: Case Report/Case Series
Introduction: Amniotic fluid embolus (AFE) is the second leading cause of maternal death in the US with a case fatality rate of 21-27%.(1,2) Here we describe the management of cardiovascular collapse and massive blood loss in the setting of AFE and placenta increta during a cesarean section (C/S).
Case: A 26 year old G3P2, at 39 2/7 weeks presented for her third C/S. Prior C/Ss were complicated by postpartum hemorrhage due to uterine atony, necessitating uterine artery embolization. PMH included hepatitis C, asthma, and cocaine/heroin abuse. Two 18G IVs were placed prior to spinal anesthesia and blood was available in the OR. Following hysterotomy and rupture of membranes, she became asystolic and ACLS was initiated. A baby girl was delivered with Apgars of 8, 9. A 9F introducer and CVP/arterial catheters were inserted. Surgeons noted uncontrolled bleeding with placenta accreta, massive transfusion was started, and hysterectomy performed. An epinephrine infusion (+boluses) was needed and chest compressions were required 7 different times. With extensive microvascular bleeding (no macrovascular source), AFE was suspected and hydrocortisone added. The aorta was occluded and TEE used to assist resuscitation. The abdomen was packed to allow time for correction of coagulopathy, and she was transferred to the ICU. Despite massive transfusion, diffuse bleeding continued and recombinant FVII (90mcg/kg) was given twice. Over 8 hours (OR x2) operative fluids were U/O 2L, 7.8L crystalloid, 75U cryo, 36U FFP, 60U plt, and 63U PRBCs. Our patient stabilized and was extubated on POD #6. A subsequent work up for hypoglycemia, including MRI evidence of pituitary infarction, led to the diagnosis of Sheehan’s syndrome, requiring hydrocortisone and levothyroxine. Although blood volume was replaced x6, labs supported the diagnosis of AFE (C3↓, C4↓, zinc coproporphyrin↑). Additionally, pathology confirmed placenta increta.
Discussion: The combination of cardiac arrest with AFE, DIC, and placenta increta presented a unique challenge. Our transfusion goal of PRBC:FFP of 1:1 utilized multiple resources including extra personnel, a rapid infusion system, and constant communication.(1) Administration of recombinant FVII after adequate resuscitation appeared to be useful in this case of AFE.(1) Collaboration among our teams (anesthesia, OB/GYN, trauma surgery, blood bank) resulted in a positive outcome.
(1) Anesthesiology 2011;115:1201-8
(2) Anesth Analg 2009;108:1599-602