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ROTEM Informs Care in Case of Amniotic Fluid Embolism
Abstract Number: T1C-6
Abstract Type: Case Report/Case Series
29 year old G3P1 with history of asthma and obesity presented for planned cesarean section for total placenta previa at 36 weeks gestation. A lumbar epidural was placed and surgery proceeded followed by delivery of a healthy infant and intact placenta. Uterine tone was poor, so patient was treated with oxytocin infusion, methylergonovine, and Bakri balloon. Minor microvascular bleeding was suspected, but uterine tone was satisfactory. Abdominal wall closure continued uneventfully. During this time, a second large bore IV was placed and Rotational ThromboElastoMetry (ROTEM) was drawn to rule out coagulation abnormality. Later in PACU, the patient became acutely hypoxic, hypotensive, and increased vaginal bleeding was noted. Simultaneously, the ROTEM results returned and indicated a critically low fibrinogen level (FIBTEM A10 = 8 mm). Other factors and CBC were within appropriate ranges. Given this constellation of symptoms of hypotension, hypoxia, and coagulopathy, Amniotic Fluid Embolism (AFE) was suspected. Patient was brought back to the OR and further diagnostic and supportive measures were initiated: supplemental oxygen applied, blood pressure responded to phenylephrine pushes, and 3 g of fibrinogen concentrate were given. Meanwhile, arterial line was placed, uterine atony was ruled out, transthoracic echocardiogram showed preserved ventricular function, and chest x-ray showed no abnormalities. Subsequently, her blood pressure, oxygenation and vaginal bleeding improved, follow-up ROTEM normalized, and no additional blood products were given. Once stable for transport, chest CT demonstrated multiple pulmonary emboli, the contents of which were not distinguishable from thrombus. Patient recovered well in the ICU and was discharged home several days later.
Amniotic Fluid Embolism is a rare condition that occurs in up to 1/8000 pregnant women. Mortality is up to 60% and accounts for approximately 6% of maternal deaths in the United States. Diagnosis of AFE is clinical, with cardinal symptoms of hypotension, respiratory distress, coagulopathy, and occasional seizures in a peripartum patient. Pathophysiology of AFE involves mechanical obstruction of pulmonary blood flow in addition to inflammatory mediators causing pulmonary vasospasm leading to V/Q missmatch, biventricular heart failure, and coagulopathy. Treatment is supportive and requires swift diagnosis, and thus a fast, accurate point of care test such as ROTEM can help in the differential diagnosis and in targeted administration of blood product. In this case, ROTEM helped diagnose critically low hypofibrinogenemia, which has been shown to be the primary coagulopathy in AFE. Other cases have also demonstrated the utility of ROTEM in aiding diagnosis of AFE as well as guiding precise, targeted coagulation therapy which may have reduced the need for additional blood products and their associated complication and cost.