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Rapid Respiratory Decompensation, Altered Mental Status and Atony: A Case of Suspected Atypical Amniotic Fluid Embolism
Abstract Number: RF7B10-96
Abstract Type: Case Report Case Series
An estimated 5–15% of all maternal deaths in Western countries are due to amniotic fluid embolism (AFE) . We present a case of severe respiratory compromise, altered mental status, and hemorrhage during emergency cesarean delivery (CD) in a parturient with prolonged labor and chorioamnionitis thought to be atypical AFE.
A healthy 23 year old primigravida at 40w6d presented in active labor with spontaneous rupture of membranes (SROM). Her medical history was uncomplicated and labs were normal. One hour after arrival, a lumbar epidural was placed for labor analgesia using standard sterile technique. Pitocin was initiated for labor augmentation. At 8 hours post arrival, patient was noted to be tachycardic to 120 with low grade fever to 100.4°F. Ampicillin and gentamicin were initiated for suspected intra-amniotic infection and 2.5L of intravenous fluid (IVF) was given. At 14 hours post arrival, patient reported a singular episode of shortness of breath, with desaturation to low 90’s. Patient placed on non-rebreather with good response. EKG showed sinus tachycardia. At 26 hours post- arrival, decision was made to proceed to CD for arrest of dilation.In the OR, the epidural was loaded with 20cc of lidocaine 2% + epinephrine to a T4 level. Delivery was uneventful. Upon externalization of the uterus, atony was noted. Patient began to exhibit mental status changes and confusion. Patient then became hypertensive and tachycardic to the 180s. Desaturation to the low 80s was noted. Uterotonics were administered and help was called. The patient became more altered and continued to desaturate to the 60’s even with supplemental O2. There was concern for ongoing hemorrhage. Massive transfusion protocol (MTP) was activated. The patient was intubated with video laryngoscope and lung protective ventilation strategy was employed. Additional large bore IV access and arterial line were placed. Initial labs demonstrated a lactic acidosis and coagulopathy (Lactate 3.4 INR: 1.9. fibrinogen 393). Blood loss was significant for 2500mL. Patient received 3L crystalloid, 2U prbcs and 2 units FFP. Urine output was 750mL. The patient was transferred to the ICU and was extubated late on POD#1. Chest XR showed bilateral pulmonary infiltrates and CT was inconclusive for pulmonary embolism. She was continued on her antibiotic regimen and was able to go home on POD#3. Mother and baby have continued to do well.
This case highlights the rapid respiratory deterioration that can occur in parturients. Atypical amniotic fluid embolism (AFE) was highest on the differential for this patient. The timing of the decompensation coupled with the atony, hemorrhage and coagulopathy place AFE high on the list. There are no consistent clinical predictors of AFE, although chorioamionitis is clinically associated with its occurrence . Pulmonary edema and pulmonary embolism were also considered. Regardless of the etiology, prompt recognition and treatment resulted in a positive outcome.