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A Rare and Unique Presentation of Amniotic Fluid Embolism during Dilation and Evacuation of a Missed Abortion at 15 weeks of Gestation in a Healthy Pregnant Patient
Abstract Number: F-63
Abstract Type: Case Report/Case Series
Amniotic fluid embolism (AFE) is a rare and catastrophic event with a reported incidence of 1.9 to 6.1 per 100,000. It is the number one cause of cardiovascular collapse and death in pregnant patient. Most reported cases are presented between 2 hours before and 4 hours after delivery. It is exceedingly rare for an AFE to occur in the second trimester. We present a rare case of AFE during routine dilatation and evacuation for intrauterine fetal demise (IUFD) at 15 weeks of gestation.
A 28 year old G2P0 female presented for D&E for IUFD at 15 weeks of gestation. The patient had a past medical history of polysubtance abuse with a negative drug screen on day of surgery. The procedure started under GA and proceeded uneventfully for 35 minutes with stable vital signs; the products of conception with all fetal bony parts were removed. At this point, patient suddenly became hypoxic and hypotensive and did not respond to phenylephrine and 20mcg of epinephrine and proceeded to PEA cardiac arrest. ACLS was started and resuscitation continued for 20 minutes. The patient survived the initial insult and was taken to the ICU, where she developed acute DIC with PT >100, INR 8.9 and Fibrinogen <10. The CT chest image showed extensive bilateral segmental pulmonary emboli compatible with pulmonary hypertension and ground glass opacity in the lung bases. The patient is still in critical condition in ICU (27days) after the event. We believe that the patient suffered a massive amniotic fluid embolus, which caused cardiovascular collapse and PEA cardiac arrest, leading to DIC and ischemic brain injury.
Although mortality has declined in recent decades, AFE still proves fatal in 40% to 60% of cases. Disruption of the maternal-fetal barrier and fetal tissue entering the maternal circulation is hypothesized to be the inciting event for signs and symptoms of AFE. Diagnosis of AFE is one of the exclusions after clinical observation and in many cases during autopsy. Usually AFE occurs in parturients during labor, cesarean section, or in the immediate post-partum period. The case that is presented here with the classical signs and symptoms of AFE at 15 weeks of gestation during D&E is exceedingly rare.
McDonnell NJ, Percival V, Paech MJ. “Amniotic fluid embolism: a leading cause of maternal death yet still a medical conundrum”. Int J Obstet Anesth. 2013 Nov; 22(4):329-36