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Amniotic Fluid Embolism: A Management Conundrum
Abstract Number: FCB-214
Abstract Type: Case Report Case Series
Amniotic fluid embolism (AFE) is a rare but serious complication of pregnancy, presenting as sudden onset hypotension or cardiac arrest during labor, CS or within 30 minutes of delivery, with associated severe hypoxia and coagulopathy. Mortality rates as high as 80% have been reported (1,2). The pathophysiology is likely an anaphylactoid reaction to fetal antigens leading to intense pulmonary vasospasm and acute right heart failure, as well as activation of the coagulation cascade and DIC.
We present a 35yo P1001 healthy female at 37w gestation with complete placenta previa for scheduled primary CS. A spinal anesthetic (12mg hyperbaric bupivacaine + 20 mcg fentanyl + 0.1 mg morphine) was placed with stable hemodynamics. During delivery, she developed profound bradycardia and became unresponsive with no palpable pulse and PEA. We initiated ACLS: CPR, intubation, epinephrine; and obtained arterial and central venous access. SpO2 <80% on 100% O2; TEE showed a massively dilated right heart with significantly depressed RV function. ROSC was obtained after 10 minutes. We suspected AFE, initiated inhaled nitric oxide and consulted CT surgery for emergent ECMO. MTP was ordered. About 30 minutes after the event, the hypoxia acutely worsened. TEE revealed a large RA thrombus. tPA 50 mg IV caused immediate improvement. ECMO initiated. Massive hemorrhage noted from upper abdomen with apparent uterine hemostasis and normalized TEG. Trauma surgery attempted to occlude the aorta by endovascular balloon but eventually cross clamped open. Multiple lacerations of the liver and spleen required splenectomy and left hepatectomy.
The patient was transferred to interventional radiology with an open abdomen for embolization, but active bleeding from the remaining liver could not be controlled. Upon transfer to CV ICU, ECMO circuit flow fell rapidly with multiple clots noted in the circuit; CPR was reinitiated and circuit thrombectomy attempted unsuccessfully. After 20 minutes, CPR was discontinued and the patient expired.
Untreatable liver lacerations contributed to this poor outcome. Significantly more common in pregnant women than the nonpregnant population (43% vs 2%)(3), hand placement and angle of compression should be carefully considered.
This case highlights several unique challenges for the anesthesiologist. There is no perfect method for management of these complex and contradictory patient issues, with very little data to support any particular strategy given the extreme rarity of AFE. This helps to explain why outcomes are still poor even with incredible resources at our disposal.
1. Gist RS, et al. Anesth Analg. 2009 May;108(5):1599-602.
2. Nagarsheth NP, et al. Anesth Analg. 2008 Sep;107(3):962-4.
3. Cox TR, et al. Resuscitation. 2018 Jan;122:121-125.