Page 8 - Jcog-October 2017
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Hanson et al.

           J o u r n a l   o f   C a s e s   i n
           Obs tetrics & G ynecology

        pine 0.8 mg and compressions were initiated.  Return    for an AFE [2,4]. The proposed descriptive symptoms in-            plications  and their associated risk factors, because even   ate patients for suspected AFE. This ongoing development
        of spontaneous  circulation  occurred  at  0812 and a cen-  clude sudden onset of restlessness, tachypnea, new audible     with high suspicion, there may not be any warning signs.  of evidence based medicine and collection of data and re-
        tral  venous catheter  was placed.  There  was an increase   wheeze, altered level of consciousness, and fetal compro-     AFE is dangerous but a manageable  rarity  in delivering   search will further improve the obstetric care of these wom-
        of bleeding noted  from the vagina  at  0900 refractory   mise such as fetal bradycardia [3,5]. Because of the rapid       mothers. High suspicion and prompt recognition of AFE can   en as well as a strong and supportive multidisciplinary team.
        to fundal massage, Cytotec  per rectum,  Hebamate  250   onset and severity of symptoms, a high level of suspicion         improve morbidity and mortality.  It is important to consid-
        mg IM, and Methergine 0.2 mg IM were administered.      for  AFE should be maintained  in order to preempt and             er AFE with sudden changes such as restlessness, new on-
        An infusion of normal saline with Pitocin was started.  compensate for its sequelae. Commonly cited risk factors           set wheezing, respiratory changes, uncontrolled postpartum   Acknowledgement
        Laboratory  values drawn at 0930 were concerning  for   include age greater than 35, placenta previa, cesarean sec-        bleeding, and hemodynamic changes in the fetus. There is   None
        DIC: Hgb: 8.2, Hct: 24.6, PLT: 79, INR: 2.0, PTT: 66.9,   tion, multiple pregnancies and induction of labor [1,3,4,6].     no definite tool that can be used to predict the onset of AFE,   Declaration of Interest
        DDimer: >500, Fibrin degrade products : >40. Given the   There has been some research with regards to diagnostic           thus the importance of high clinical suspicion. There are   None
        profound blood loss and anemia,  the  patient  was trans-  markers  used to  assess severity  of  AFE. Since  approx-      developing diagnostic tool that may be able to help evalu-
        fused with six units of packed red blood cells, four units   imately  50% of women  with  an AFE will  develop  DIC
        fresh frozen plasma, and two units cryoprecipitate.  A   [1], diagnostic markers to identify DIC- CBC, fibrinogen,
        Bakrey balloon  was also placed.  A transthoracic  echo-  fibrinogen-  fibrin  split  products,  PTT  and  INR-  are  rec-
        cardiogram revealed increased pulmonary artery pres-    ommended [6]. While marked decreases of C3/C4 levels
        sure  >35, indicative  of moderate  to severe  pulmonary   have been demonstrated to have 100% specificity and 88%
        hypertension  with  decreased  right  ventricular  function.   sensitivity for an AFE [8], use is limited due to availabil-
        At this point, the patient required a higher level of care than   ity  and turn- around time.  C1 esterase  inhibitor, a more
        available, and arrangements were made for transfer to ter-  recently  identified  marker,  inhibits  c1  esterase,  factor
        tiary care center. Prior to helicopter transfer, the patient was   XIIa and Kallikrein [3]. Low levels of C1 esterase inhib-
        given a Factor VII infusion. Studies performed at the tertiary   itor, it is theorized, can be found prior to the onset of ma-
        center reflected that the most likely cause of the symptoms   jor symptoms of an AFE, but further research is needed.      References
        were an AFE resulting in DIC and cardiac arrest. She was   Treatment of AFE should begin with basic lifesaving care,
        discharged home after a week stay in the hospital and her   including, when indicated,  intubation, volume replace-
        lab values were as follows: INR: 1.02, Hgb: 10.9, Plt:223.  ment, early use of pressers, and correction of coagulopa-      1. Shen F, Wang L, Yang W, Chen Y. From appearance   Obstetrics.  Obstetrics  and  Gynecology:  Clin-  11. Nakagami H, Kajihara  T, Kamei  Y, Ishihara O,
                                                                thies [2,5]. It is important to assess fibrin levels promptly      to essence: 10 years review of atypical amniotic fluid   ical Expert Series 2015; 126 (5):  999- 1011.  Kayano H, Sasaki A, et al. Amniotic components
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                                                                                                                                                                                                             in the uterine vasculature and their role in am-
                                                                                                                                   embolism. Arch Gynecol Obstet 2015; 293(2):329-34.
        Discussion                                              as DIC can progress quickly. It was found that the fibrino-        2.  Rath  W, Hofer S, Sinicina I. Amniotic Fluid Em-  otic Fluid Embolism Pathophysiology Suggest   niotic fluid embolism.  The Journal of Obstetrics
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                                                                                                                                                                                                             intravascular coagulopathy. The Journal of Maternal-
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        enter the maternal blood stream [3]. It usually requires   layed  transfusion results in an increase  in mortality  rate   for management. Journal of Obstetrics and   er PA, Terao T. Immunologic studies in presumed amni-  Fetal and Neonatal Medicine 2011; 24 (11): 1411-15.
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                                                                                                                                                                        9. Phillips LE, McLintock C, Pollock  W, Gatt S,
        occur. The fetal material then accumulates in vessels and   dispensable to help control the DIC [3]. There have been       Incidence, risk factors, management and outcomes   Popham P, Jankelowitz G, et al. Recombinant acti-  lism: 10 year retrospective study in a level III maternity
        the resultant pulmonary vasoconstriction leads to pulmo-  some instances  where recombinant  factor  VIIa has been         of ambiotic- fluid embolism: a population- based co-  vated  factor VII in  obstetric hemorrhagic  experienc-  hospital. European Journal of Obstetrics & Gynecol-
                                                                                                                                                                        es from the Australian and New Zealand Haemo-
                                                                                                                                   hort and nested case- control study. British Journal
                                                                                                                                                                                                             ogy and Reproductive Biology 2013; 169: 189-192.
        nary hypertension [1,2,3].  There is, consequentially, an   used to successfully manage DIC in patients with AFE [1].      of Obstetrics and Gynecology 2015; 123 (1): 100-9.  stasis Registry. Anesth Analg; 109 (6): 1908-1915.  14. Eskandari N, Feldman N, Greenspoon J. Factor
        increase  in right ventricular pressure and subsequently   These women were noted to have a decrease in tissue fac-        5.  Kulshrestha A, Mathur M.  Amniotic flu-  10.  Yoneyama K, Sekiguchi A, Matsushima  T,   VII Deficiency in Pregnancy  Treated with Recom-
        right congestive heart failure.  This can lead to cardiopul-  tor concentration, increased uterine atony, uterine rupture   id embolism: A diagnostic dilemma. Anesthe-  Kawase R, Nakai A, Asakura H, et al. Clinical char-  binant Factor  VIIa.  The American College of Ob-
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        monary collapse as reflected by sudden hypoxia, increased   or abnormal  placenta  [9].  However,  recombinant  factor     6.  Cunningham  FG,  Nelson  D.  Disseminat-  perience  of  29  years.  The  Journal  of  Obstetrics
        work of breathing, respiratory distress and finally cardiac   VII is not well established, and should only be considered   ed  Intravascular  Coagulation  Syndromes  in  and Gynecology Research 2014; 40 (7): 1862-70.
        arrest  [3,4]. The  cells  may  also invade  the  uterine  tissue   with women who are  refractive  to traditional  treatment.
        locally [3]. This causes an anaphylactoid-like reaction and   In our case, there were no symptoms suggesting an AFE
        can  ultimately  result  in DIC or uncontrollable  postpar-  prior to the cardiac arrest. However, high suspicion was
        tum hemorrhage secondary to an atonic uterus. Typically,   warranted  in  this  case  given her  maternal  age,  place-
        evidence  of an amniotic  embolism  and subsequent com-  ment  of the placenta,  and method  of delivery. Complet-
        plications arise within thirty minutes of initial insult [1].  ing  the caesarean  section  in the  larger  operating  room
        A diagnosis of amniotic  embolism  is a diagnosis of ex-  allowed  for a larger, multidisciplinary  team  to help  with
        clusion, as there is no uniform clinical diagnostic criteria   resuscitation  and  provide  more  efficient  care.  This  case
                                                                reflects  the  importance  of  considering  all  potential  com-
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                                                                      October 2017            Journal of Cases in Obstetrics & Gynecology
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