P025: AMNIOTIC FLUID EMBOLISM IN OBSTETRIC PATIENT UNDERGOING REPEAT C-SECTION FOR PLACENTA PREVIA
Justin Alfonso, MD, Bradley Ullman, MD, Richard Tennant, DO, Giuseppe Giuratrabocchetta, MD; UF Health Jacksonville
Introduction: In the United States, the incidence of Amniotic Fluid Embolism (AFE) is 4 to 6 per 100,000 live births. AFE is characterized by acute and rapid collapse of mother and/or baby as a result of an allergic-like reaction to amniotic fluid entering the maternal circulation. AFE is a diagnosis of exclusion that is often assigned only after autopsy. AFE remains an unpredictable and often-fatal complication of pregnancy. AFE consists of a two-phase response. The first phase is characterized by rapid respiratory failure and cardiovascular collapse. The second phase is known as the hemorrhagic phase: the mother begins to bleed profusely at the wound site, and disseminated intravascular coagulopathy (DIC) develops, which prevents coagulation.
Case description: Patient is a 33 year old female, ex-smoker, G2P1001, with a history of a previous C-section, admitted at 35 weeks 1 day of gestational age with complaints of vaginal bleeding. She had no abdominal pain/contractions. Positive fetal movement, no loss of fluid. On ultrasound she presented with a complete placenta previa. The fetus was transverse, back down with a reassuring fetal heart rate in the 130s, moderate variability, no decelerations. Given her complete placenta previa with an episode of bleeding, a repeat C-section was planned. A Combined Spinal Epidural was performed with Bupivacaine, Fentanyl and PF Morphine. Upon baby delivery and uterus eversion, there was an episode of bradycardia with heart rate (HR) in the 40s associated with severe hypotension. Surgical team was asked to stop manipulating the uterus with no effect on HR. IV fluids and Ephedrine were given. HR in the 30s. Atropine was given. Despite interventions, HR in the 20s. Patient became unconscious. Additional Ephedrine was given, and HR eventually responded to resuscitating maneuvers. ST elevation and ventricular bigemini were noted on ECG monitor, and FiO2 100% was administered. ST went back to baseline, and the patient regained consciousness. A likely diagnosis of AFE was made. Laboratory results indicated likely DIC, and patient started bleeding profusely from the incision site. Patient was admitted to ICU, and received a total of 3 units of packed red blood cells, 2 units of fresh frozen plasma and 2 units of cryoprecipitate.
Discussion: AFE remains a diagnosis of exclusion, where all other possible clinical explanations for the symptoms have to be ruled out. In patients with suspected AFE prompt recognition and institution of resuscitative measures may influence maternal and fetal outcome. Most patients require intubation and mechanical ventilation. Prompt support of oxygenation and circulation may decrease the severity of neurologic sequelae. Early recognition and communication with the blood bank are necessary to facilitate the provision of the large quantities of blood products required during resuscitation. This case highlights the importance of a multidisciplinary approach to critically ill patients. With the cooperation of the obstetrical team, PACU nurses, ICU staff and careful coordination with the blood bank, a successful plan was created which ended up with a positive patient outcome.
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