Page 9 - Jcog-October 2017

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
7. Busardo F, Frati P, Zaami S, Fineschi V. Amni-
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
gen levels would decline to <100 mg/dL (nm 200-400 mg/ bolism: an interdisciplinary challenge. Deutch- the New Diagnostic Armamentarium: B- Trypt- and Gynecology Research 2015; 41 (6): 870-75.
12. Liao WC, Jaw FS. A noninvasive evaluation anal-
es Arzteblatt International 2014; 111 (8): 126-32.
ase and Complement Fraction C3-C4 are the
An AFE typically ensues when amniotic fluid/ fetal cells dL) within two hours of physical signs of DIC. [3]. De- 3. Kanayama N, Tamura N. Amniotic fluid em- Indespensable Working Tools 2015; 16: 6557-70. ysis of amniotic fluid embolism and disseminated
intravascular coagulopathy. The Journal of Maternal-
strategies
8. Benson MD, Kobayashi H, Silver RK, Oi H, Greenberg-
bolism:
Pathophysiology
and
new
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.
cells to enter the circulation in order for an embolism to and early transfusion with fresh frozen plasma can be in- Gynecology Research 2014; 40 (6): 1507-17. otic fluid ambolism. Obstet Gynecol 2001; 97: 510-14. 13. Guillaume A, Sananes N, Akladios C, Boudier E,
Diemunsch P, Averous G, et al. Amniotic fluid embo-
4. Fitzpatrick KE, Tuffnell D, Kurinczuk JJ, Knight M.
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
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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
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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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