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“Rescue TEE” for real-time management of cardiac arrest in a parturient with AFE during Cesarean Delivery
Abstract Number: S3C-2
Abstract Type: Case Report/Case Series
Amniotic fluid embolism (AFE) is a rare, potentially fatal obstetric emergency. The true incidence of AFE-related morbidity and mortality is uncertain given the lack of consensus diagnostic criteria. (1)
A 35-year-old G2P1 black woman with complete anterior placenta previa presented for repeat cesarean delivery. She had a BMI of 34 kg/m2 and gestational diabetes. Antenatal ultrasound did not suggest placenta accreta.
After application of standard monitors, a CSE was placed. Although stable at the time of delivery, she became unresponsive on extraction of the placenta. CPR was immediately initiated for PEA arrest with tracheal intubation. The differential diagnosis included acute hypovolemia, embolic event and myocardial infarction. A departmental "rescue echo" team (including ECMO back-up) arrived within 15 minutes. Transesophageal echocardiogram (TEE) revealed a dilated, diffusely hypokinetic RV, preserved LV function consistent with AFE; no air or clot was visualized. Coagulopathy, visible on the surgical field, was confirmed with fibrinogen=81 mg/dl, PTT>150 sec. Management included three parallel, urgent pathways: surgical control of bleeding (hysterectomy), TEE guided treatment of RV failure and medical management of coagulopathy.
With TEE guidance, RV dysfunction was treated with epinephrine, milrinone and inhaled nitric oxide. Femoral ECMO catheters were placed but not employed. The patient received early cryoprecipitate replacement, 1:1 PRBC & FFP replacement (15 U each), 6 doses of platelets and tranexamic acid. Over the next 24 hours, she was off vasopressors and extubated in the ICU. She was discharged home, without deficits, with her baby 5 days later.
The pathophysiology of AFE involves abnormal activation of maternal proinflammatory mediators with severe systemic inflammatory immunologic and/or "anaphylactoid" response to fetal antigens (2), pulmonary hypertension and RV failure. Untreated RV failure can lead to LV failure and cardiac collapse. Our patient had several (AFE) risk factors (operative delivery, anterior placenta previa). (1, 2) Her demographic risk factors included age and ethnic minority group. This case illustrates the importance of early interdisciplinary teamwork, ECMO availability, prompt echo-guided optimization of RV contractility, fluid resuscitation and aggressive reversal of coagulopathy.
1. SMFM. Am J Obstet Gynecol 2016: B16-24
2. Knight M. Obstet Gynecol 2010. 115 (5): 910-7