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ROTEM-Guided Resuscitation of Suspected Amniotic Fluid Embolism During Dilation and Evacuation for Fetal Anomalies
Abstract Number: T-19
Abstract Type: Case Report/Case Series
Amniotic fluid embolism (AFE) is a rare and enigmatic obstetric complication associated with hypoxia, hemodynamic instability, and coagulopathy. Rotational thromboelastometry (ROTEM) is a point-of-care test that assesses multiple pathways of hemostasis including the intrinsic and extrinsic coagulation systems, fibrinogen function, and fibrinolysis. We report a case of suspected AFE in which ROTEM facilitated rapid diagnosis and correction of severe coagulopathy.
A 31 year-old gravida 3, para 1 patient at 16 weeks gestation was scheduled for an elective dilation and evacuation (D&E) for fetal anomalies, performed under moderate sedation and a paracervical nerve block. Shortly after amniotic membrane rupture, the patient developed cyanosis, agitation, and oxygen desaturation followed by tachycardia and hypotension. She was intubated for airway protection and became pulseless. Cardiopulmonary resuscitation and epinephrine administration resulted in prompt return of spontaneous circulation. Oozing was noted from her existing peripheral intravenous line as well as from rapidly obtained arterial and central venous access sites. The first laboratory evidence of coagulopathy was obtained from ROTEM which demonstrated no measurable clotting time or maximal clot formation from the intrinsic (INTEM) and extrinsic (EXTEM) systems; fibrinogen function (FIBTEM) was immeasurable and hyperfibrinolysis (APTEM) was noted (Figure). Subsequently reported laboratory results were significant for PT 39.8 s, PTT 108.5 s, INR 4.3, platelet 185x10^9/L (previously 297x10^9/L), and fibrinogen <38 mg/dL. Continuation of the D&E was completed approximately one hour later, after the patient underwent partial correction of the coagulopathy, guided by serial ROTEM analyses, with cryoprecipitate, fresh frozen plasma, and tranexamic acid. No significant hemorrhage occurred. The patient was extubated on post-operative day one with significant short-term memory impairment that subsequently improved by discharge on hospital day six.
AFE complicates 1/10,000 – 1/100,000 pregnancies with a mortality rate approaching 50% or higher. One of the major sequelae of AFE is the development of a rapid and profound consumptive coagulopathy, often leading to post-partum hemorrhage. ROTEM is a point-of-care test that can quickly diagnose and guide management of coagulopathy.