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Surprised by Sextuplets: Diagnostic Dilemmas in Perimortem Caesarean Section
Abstract Number: F4C-3
Abstract Type: Case Report/Case Series
We report a case of a 37-year old Nigerian parturient at 23 weeks’ gestation who presented to our emergency department in cardiac arrest after collapsing on an aircraft at London Heathrow. She was en route to the United States for further antenatal care of an IVF pregnancy, presumed to be triplets based on ultrasound findings. Perimortem Caesarean section (PMCS) had commenced within 6 minutes of arrival to facilitate resuscitation. Unexpectedly, a total of 6 fetuses were delivered who, at less than 24 weeks, were non-viable and not resuscitated. Return of maternal spontaneous circulation was achieved 2 minutes after delivery of the last fetus, but she remained profoundly hypotensive. Key findings from arterial blood gas analysis were pH 6.79, PaO2 13.8kPa (FiO2 1.0), haemoglobin 65 g L-1 and lactate 13.8mmol L-1. Although venous thromboembolism (VTE) was deemed a likely cause of collapse, findings of malodorous liquor and a boggy uterus at PMCS suggested sepsis was also a factor. Thrombolysis was not instituted in view of the perceived potential for uncontrollable haemorrhage following PMCS, especially with the risk of disseminated intravascular coagulation related to sepsis. Despite intravenous fluids, antibiotics, inotropic support, transfusion of blood products and uterotonics, there was no clinical improvement and the patient died within an hour of admission to the intensive care unit.
This case highlights the diagnostic challenges of maternal arrest in complex obstetric patients travelling from abroad, where background information is scarce. Whilst strong clinical suspicion of VTE existed, there was no conclusive evidence in the acute resuscitative period to support the diagnosis. This was compounded by limited access to echocardiography out of hours. There are no previous reports on thrombolysis in the context of PMCS; related case report evidence suggests that thrombolysis may be conducted with good outcome following Caesarean delivery (1), but others caution against its use (2). With inadequate evidence to guide management, we felt it was unjustified to institute thrombolysis in this case, where the clinical picture was multifactorial.
With increasing global communication, there are likely to be more instances of antenatal care being transferred internationally. Additionally, the rising prevalence of IVF, for which practicalities and legalities vary globally, may generate more complex pregnancies that necessitate a mother to go abroad for specialist care. A possible solution to help manage these patients could be the use of an international maternity passport with standardised documentation that could aid decision-making in challenging circumstances.
1. Ayad et al. Massive pulmonary embolism in a patient undergoing Cesarean delivery. J Clin Anaesth. 2012
2. Akazawa et al. Thrombolysis with intravenous recombinant tissue plasminogen activator during early postpartum period: a review of the literature. Acta Obstet Gynecol Scand. 2017.