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Faces of Amniotic Fluid Embolism
Abstract Number: F-27
Abstract Type: Case Report/Case Series
Introduction: Amniotic fluid embolism (AFE) is a rare unpredictable and unpreventable catastrophe during pregnancy or delivery. Amniotic fluid (AF) enters maternal circulation through endocervical veins, placental insertion site or areas of uterine trauma. AFE is characterized by sudden and devastating onset of hypotension, hypoxemia and disseminated intravascular coagulation (DIC). We present four cases to highlight various presentations of this syndrome.
Case #1 – 30 year old G4P3003 40 weeks admitted for induction of labor with vaginal prostaglandin. At 0600 fetal bradycardia for 4min, BP 97/55, O2 sat 100%. Enroute to OR at 0606, she became unresponsive and cyanotic. Upon intubation, O2 sat 75%, EtCO2 16. Within 2 mins of ACLS: BP from 50 to 150, O2 sat 90. Baby by C/S at 0614 Apgars 2, 6 and 7. In OR: 8 PRBC, 6 FFP, 20 cryo, 1 platelets, 8 L LR, EBL 4500, urine 1100. Discharged 10 days later.
Case #2: 36 year old G7P3033 induction for postdates and polyhydramnios with prostaglandins. BP 125/83, P121, R20, Hct 34 platelets 172 WBC 8.1. Five hours later, painful contractions, headache and tingling of left arm. SROM followed by profuse vaginal bleeding. She grunted, became unarousable and developed seizures. O2, MgSO4, lorazepam and phenytoin. Labs: hct 40, platelets 66K, PT 60 PTT 113 INR 5.7. Baby by C/S with Apgars 4 and 7. Hysterectomy for intractable hemorrhage. Fluids: crystalloids 7K, PRBC 15, FFP 9, platelets 6, cryo 7. Cryptogenic embolic stroke was due to paradoxical embolism confirmed by positive “bubble test”. Mother and baby well, patient back to work.
Case #3: 33 year old G6P5005, 40 weeks gestation underwent amniotomy for induction of labor. Sudden cardiopulmonary arrest from which the patient never recovered. A healthy baby was delivered by postmortem C/S.
Case #4: 36 year old G3P2002 stopped talking, became unresponsive and cyanotic during C/S. O2 sat 60%, BP 70/45, P42. The patient coughed, opened her eyes and started breathing spontaneously, HR rose from 40 to 90, BP 100/50, O2 sat 95%. She had no memory of what happened.
Discussion: AFE can occur like a bolt of lightning on a clear day. Severity may depend on size of embolic material. High index of suspicion can lead to prompt initiation of supportive care before irreparable damage occurs.