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Non-fatal Amniotic Fluid Embolism
Abstract Number: SU-87
Abstract Type: Case Report/Case Series
Background: Amniotic Fluid Embolism (AFE) may be the most feared complication in obstetric anesthesiology. Traditional teaching suggested mortality of 60-80%, with near universal neurologic compromise among survivors. More recent population data has suggested that most women (4/5) actually survive. Similarly, cardiopulmonary resuscitation and coagulopathy requiring cryoprecipitate may be required in fewer than half of cases. It is thus very much worthwhile to present and study these cases to facilitate early recognition and effective treatment. The most consistent risk factors are advanced maternal age and induction of labor, though fetal distress and cesarean section also appear frequently. Prostaglandin use may confer a 6-fold increase in risk. Presentation often involves shortness of breath, respiratory failure, and hypotension. The mechanism is poorly understood, but is thought to involve a reaction to amniotic fluid or fetal tissue in maternal circulation. This is thought to precipitate a cascade of immunologic or anaphylactoid events precipitating pulmonary hypertension and cardiovascular collapse, often followed by severe coagulopathy in survivors.
Case Description: A 37 week gravida 3 para 2 was brought to the OR for emergent cesarean section for profound late fetal decelerations during induction of labor for gestational hypertension. Induction of general anesthetic was uneventful and baby delivered with APGAR’s of 8 & 9. Immediately thereafter, there was a sudden drop in ETCO2 to 10 mm Hg, accompanied by profound hypotension and mild bronchospasm. Carotid pulse was barely palpable. Manual bag ventilation was easily done with slightly lowered compliance. There was no response to phenylephrine and ephedrine, so epinephrine was aggressively administered. A norepinephrine drip was required to achieve systolic pressures of 90. The table was tilted sharply left and head down. Two units of packed red cells were transfused for uterine artery bleeding. The patient was brought to intensive care intubated, but weaned off pressors and extubated that evening. She was discharged a week later without any further complications.
Discussion: This case illustrates the more recent understanding that AFE’s may present a spectrum of severity that may indeed be treatable. Although this patient became acutely unstable, she ended up not requiring CPR. Although her D-dimer was sharply elevated and fibrinogen low, she also did not progress to frank coagulopathy.
References: Fitzpatrick, KE et al, Incidence, risk factors, management and outcomes of amniotic fluid embolism: a population-based cohort and nested case-control study, BJOG (2015) 123:1
McDonnell, N et al, Amniotic fluid embolism: an Australian-New Zealand population-based study, BMC Pregnancy and Childbirth (2015) 15:352