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Early diagnosis and treatment of Anaphylactoid Reaction of Pregnancy (formerly known as Amniotic Fluid Embolism) using Rotational Thromboelastometry (ROTEM)
Abstract Number: FCB-154
Abstract Type: Case Report Case Series
Anaphylactoid reaction of pregnancy (ARP) is an extremely rare, often fatal complication of pregnancy occurring only in 20-40,000 parturients. This reaction can lead to severe and sudden respiratory and cardiovascular collapse and is often associated with early and profound disseminated intravascular coagulation (DIC). (1) We present a case which was diagnosed and successfully treated with the early use of rotational thromboelastometry (ROTEM).
A 32 y.o G1P0 presented for a scheduled cesarean delivery for known complete placenta previa. Spinal anesthesia was performed. Shortly after uterine incision, the patient became unresponsive and cyanotic. EKG revealed severe bradycardia with profound hypotension (Figure 1A). She was intubated as baby was delivered. Volume resuscitation and pressor support were initiated. Intra-op Trans Esophageal Echocardiogram revealed dilated right ventricle and atrium, moderate tricuspid regurgitation and pulmonary artery dilation, all consistent with pulmonary emboli (PE). With fundal pressure, 1L BRB was expelled. Coagulation profile and a blood sample for ROTEM analysis were sent given increased intra-operative bleeding. Blood products given can be seen in Figure 1B. ROTEM results confirmed DIC with hyperfibrinolysis and a consumption of coagulation factors (Figure 1C). Fibrinogen concentrate was used as a bridge to treat hypofibrinogenemia while awaiting cryoprecipitate. A follow up ROTEM revealed improvement of coagulation (Figure 1D,E). A head CT was negative for stroke, and the patient was extubated hours later in SICU. On POD 1 patient, had full neurological recovery and was discharged after 3 days.
ARP is a rare obstetric emergency with diagnosis made only after exclusion of other causes. In this case, factors supportive of ARP included complete previa, sudden and reversible hypoxemia and an early coagulopathy observed on ROTEM. ROTEM is a viscoelastomeric method of testing whole blood which can be visualized in real time. (2) Its unique ability to visualize hyperfibrinolysis enabled us to appropriately diagnose ARP over PE or cardiomyopathy, and guided blood factor replacement and use of tranexamic acid. Hyperfibrinolysis may be a contributor to coagulopathy associated with ARP, but infrequently reported due to traditional coagulation tests. Fibrinogen concentrate should be considered while awaiting cryoprecipitate in these cases.
1. Anaesthesia 2015; 70 78-86. e27-8.
2. Int J Obstet Anesth 2013;22:71-6.