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Atypical Presentation of Anaphylactoid Syndrome of Pregnancy with Isolated Coagulopathy
Abstract Number: S5C-8
Abstract Type: Case Report/Case Series
Introduction: Anaphylactoid Syndrome of Pregnancy (ASP) is a rare and life-threatening complication of pregnancy. Reported incidence is from 1 in 8,000 to 1 in 80,000 pregnancies (1). Typical ASP consists of a triad of acute hypoxia, hypotension, and coagulopathy around the time of labor and delivery (1). Over the last few decades, there have been increasing reports of atypical presentations of ASP. We describe a patient with atypical ASP, presenting with isolated coagulopathy.
Case: A healthy 23 year-old G1P0 presented at 39w3d for induction of labor. A labor epidural was placed in anticipation of artificial rupture of membranes. Later the patient complained of shivering with a temperature of 38°C. Acetaminophen, Ampicillin, and Gentamicin were given for presumed chorioamnionitis. Subsequently, the patient developed hematuria and severe bleeding from the epidural site. Labs drawn (fibrinogen <40, INR 3.1, PTT 62, platelets 137) were consistent with disseminated intravascular coagulation (DIC). The patient was hemodynamically stable. Hematology was consulted and massive transfusion was initiated. Arterial line and additional large bore peripheral access were placed. The patient also reported significant bilateral lower extremity weakness. Neurosurgery was consulted for concern of possible epidural hematoma. Given the patient’s condition and a non-compatible epidural catheter, MRI was deferred. Attempted forceps delivery in the OR failed due to lack of fetal descent. Emergent cesarean delivery under general anesthesia was performed. Uterine atony and postpartum hemorrhage further complicated delivery. The patient received 5FFP, 3Cryo, 6PRBCs, and 2 platelets. The patient remained hemodynamically stable with normal oxygenation. She was awakened briefly for neurological exam, which was improved, and transported intubated to the ICU. The patient had a full recovery.
Discussion: The pathophysiology of ASP is poorly understood. It is postulated that amniotic fluid and fetal debris enter maternal pulmonary circulation, causing anaphylaxis and cardiopulmonary collapse (1). DIC develops in 83% of patients, and has been attributed to the transfer of vasoactive and procoagulant products (platelet-activating factor, thromboxane, leukotrienes) into maternal circulation (1). In some cases, the maternal immune system may not mount a response to amniotic debris, resulting in isolated coagulopathy from the direct procoagulant property of amniotic fluid (1). This would explain our patient’s atypical presentation. The patient’s survival is attributed to prompt identification of DIC, coordination of multiple care teams, and availability of resources including rapid lab analysis and blood products. Case reports of atypical ASP are needed to further characterize presentation and management of this rare process.
(1) Kaur et al. J of Anaesthesiology, Clin Pharm 2016: 153–159.