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Case Report : Survival From Amniotic Fluid Embolism (AFE) Complicated by Right Heart Thrombus Requiring Cardiopulmonary Bypass (CPB) for Removal
Abstract Number: F1C-2
Abstract Type: Case Report/Case Series
AFE is a rare, deadly complication of pregnancy which occurs when amniotic fluid (AF) enters the maternal pulmonary circulation. AF contains vasoactive, procoagulant products which may cause an anaphylactoid process leading to cardiovascular collapse. We present a case of AFE complicated by a large right heart/IVC thrombus requiring CPB for removal.
A 29-y/o G1P0 female presented at term for IOL. After SROM, late FHR decelerations were noted. She became unresponsive and cyanotic. SaO2 and BP were unobtainable, EKG revealed sinus tachycardia at 100 bpm. She was intubated and a male infant was delivered 2 min later via C/S with APGARs 1, 3, 3. Maternal PEA arrest followed and CPR/ACLS began while a multidisciplinary team arrived. ECMO cannulation was unsuccessful but ROSC was achieved after 30 min. A TEE demonstrated fibrinous material in the RV with RV failure. Labs showed profound coagulopathy (unreportable aPTT/PT/INR, fibrinogen < 35mg/dL, Hgb 9.8g/dL, platelets 6,000/µL) and she was given 16 units PRBC, 18 units FFP, 8 units cryoprecipitate, 7 units platelets, 15 L crystalloid, factor IX conc., tranexamic acid (TXA), and aminocaproic acid. Inhaled epoprostenol followed by nitric oxide became necessary. Repeat TEE demonstrated progression to LV failure and an extensive clot from the IVC to the RA. [Fig 1] CPB via median sternotomy was required for removal. Both mother and baby are without neurologic deficit.
A rapidly assembled multidisciplinary team, high quality CPR and immediate C/S are paramount to achieve ROSC in an AFE arrest. Real time TEE and bedside POC testing allow diagnosis and tailored treatment. CPB and ECMO have been used to treat cardiac compromise, but after improving perfusion and reluctance to anticoagulate a bleeding patient, we abandoned ECMO. Both epoprostenol and inhaled nitric oxide have been used as well (1), but not simultaneously. It is unclear if dual therapy has synergistic effects. AFE coagulopathy has been described as DIC, a hypercoagulable state with secondary hyperfibrinolysis. Some suggest coagulopathy may start as hyperfibrinolysis (2) and tx is with lysine analogues. Unfortunately, administration of TXA, factor IX and aminocaproic acid may have contributed to the growing cardiac thrombus. Evidence of a clot warrants caution when using antifibrinolytics in the setting of AFE + DIC without testing for hyperfibrinolysis.
1. IJOA 2007;16:269-73. 2. IJOA 2013;22:71-6.