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Atypical AFE- Truly a Diagnosis of Exclusion
Abstract Number: S-83
Abstract Type: Case Report/Case Series
Introduction: Amniotic fluid embolism (AFE) is a rare, but highly fatal, complication unique to pregnancy. It has an incidence of 1 in 8,000 to 1 in 80,000 deliveries in the United States. The proposed pathophysiology involves entry of amniotic fluid into the maternal circulation, release of endogenous mediators, such as histamine, bradykinin, leukotriene and endothelin, and ultimately an inflammatory and anaphylactoid reaction. AFE will commonly present after ROM, during C/S or within thirty minutes of delivery. Despite numerous types of presentations, it most commonly presents with cardiovascular collapse and respiratory distress initially, and then disseminated intravascular coagulopathy (DIC). Cardiovascular effects usually occur in a biphasic manner with; phase I characterized by pulmonary vasoconstriction and right heart failure and phase II by left heart failure. AFE is a challenging condition to manage and is a diagnosis of exclusion. This is a case report of a young woman who had an atypical presentation of a presumed AFE.
Case Report: An 18 year old G1P0 in active labor at 36 weeks and 1 day gestation underwent an uncomplicated C/S for breech presentation under CSE. The baby was born with fetal anomalies not compatible with life. About two hours post C/S, the patient had one episode of hypotension that was treated with ephedrine and thought to be secondary to postural change. A second IV was placed, blood tests and coagulation studies sent and oxygen administered, all as precautionary measures. The patient returned to her baseline status. Three and a half hours post C/S, the patient was found to be mildly hypotensive and with decreased saturation. In just minutes, she further declined in both saturation and mental status. She was then emergently intubated and immediately taken back to the OR. An ultrasound suggested no signs of hemorrhage though there was concern. However, the previously sent coagulation studies depicted a DIC pattern. Resuscitation was started with crystalloid and blood. Vascular access was obtained with peripheral IVs, a rapid infusion catheter and a right internal jugular central line. A radial arterial line was inserted. The patient received pRBCs, FFP, cryoprecipitate, platelets and recombinant Factor VII. A diagnostic TEE showed intracardiac volume depletion and no signs of right or left sided heart failure. The patient was hemodynamically stabilized, coagulation abnormalities corrected, diffuse bleeding from DIC controlled and then transported to the ICU where she was further treated for AFE, DIC, ARDS and AKI.
Discussion: Though unusual, AFE can have an initial presentation of DIC. As a serious peripartum complication with difficult management and high morbidity and mortality, it is of utmost importance to have an early suspicion or diagnosis of AFE. This patient’s survival and limited morbidity can be attributed to the quick recognition, management and multi-disciplinary approach to her care.