Amniotic Fluid Embolism: A Rare Cause of Maternal Collapse: A Case Report
Sarita Sitaula1, Dipti Das1, Subhas Sitaula2, Manisha Chhetry1
1 B.P. Koirala institute of Health Sciences Dharan, Nepal
2 Critical Care Unit, Singing River Health System, Mississippi USA
Corresponding author
Dr Sarita Sitaula
Assistant Professor, BPKIHS, Dharan, Nepal
Email: dr.sarita.sitaula@gmail.com, sarita.sitaula@bpkihs.edu
ORCID iD : https://orcid.org/0000-0001-5312-4590
Contact number: +977-9842052514
Abstract
We present a case of postpartum women who collapsed immediately after delivery with probable diagnosis of amniotic fluid embolism. This is a rare but fatal condition and was managed with supportive measures. Suspicion of amniotic fluid embolism should be considered in any postpartum collapse if no obvious cause is known.
Keywords:
Amniotic fluid embolism, Maternal mortality/ collapse, Postpartum collapse, Coagulopathy
Key clinical message
High index of suspicion of amniotic fluid embolism should be considered in any intrapartum or postpartum collapse where obvious cause of collapse is not identified.
Introduction:
Amniotic fluid embolism (AFE) is a rare complication of pregnancy, associated with significant morbidity and mortality, occurring in 2-8 per 100,000 pregnancies[1]. They usually present with sudden and unexplained cardiorespiratory collapse and disseminated intravascular coagulopathy [2]. This is one of the cause for sudden death in obstetrics with high mortality rate, ranging from 20 to 60% [3]. Early recognition and prompt resuscitation are the key components for the management of AFE.
Case presentation
A 30 year old, unbooked, primigravida at 39 weeks 6 days of period of gestation (POG) presented to obstetric emergency of BPKIHS, Nepal, referred from private hospital with diagnosis of intrauterine fetal death (IUFD) with obstetric cholestasis.
She had stopped perceiving fetal movements for 2 days. She gave history of itching of the whole body, which had started at 35 weeks of gestation. Her liver function showed increased in liver enzymes( SGPT/SGOT-224/204IU/L respectively) and diagnosis of obstetric cholestasis was made clinically as bile acid concentration measurement was not available. She was started with tablet Ursodeoxycholic acid 300 mg BD for 1 week and then she stopped the medication on her own.
Her 1st and 2nd trimester was uneventful and no other significant past and family history was present.
She is a non-smoker and non-alcoholic.
On examination at admission:
She was well oriented to time, place and person. Her vitals were within normal limits, with systolic blood pressure of 110 mmHg and diastolic 70 mmHg. Abdominal examination showed term size fetus in cephalic presentation without cardiac activity and patient was not in labor (BISHOP score-3).
Her investigation reports at admission were all normal except increased liver enzymes value.
She was induced with 50 mcg of misoprostol, which was kept per-vaginum 4 hourly on 2nd day of admission. She had progressed after 3rd dose of misoprostol and delivered a macerated female weighing 2.9 kg after 12 hours of induction. Labor and delivery were uneventful.
Around half an hour of the delivery, she had started having symptoms of hypoxia like: irritability, sweating, anxiety. On examination, she was tachycardic and tachypneic with pulse rate 170 beats per minute and respiratory rate 24 breaths per minute respectively. Oxygen saturation was up to 92% on room air. There was drop in the blood pressure and became not recordable within a few minutes. Patient was conscious throughout with GCS of 15/15. Abdominal and local examination were normal and there was no evidence of postpartum hemorrhage or on going blood loss. Resuscitation was started immediately with intravenous fluid and oxygen supplementation. Repeat blood investigations were sent, blood products were arranged and patient was shifted to ICU. After 1500 ml of fluid resuscitation blood pressure was recorded up to 80/40 mmHg but there was no urine output. Arterial blood gas analysis showed lactic acidosis with metabolic alkalosis. Patient was started with noradrenaline as she was not maintaining blood pressure which was continued for 36 hours and stopped gradually. Patient had started bleeding and soakage from episiotomy site hence, adrenaline packing was also done. Investigation reports were collected which was suggestive of DIC. She was transfused with IV unit of fresh frozen plasma, IV units of fresh blood and I unit of whole blood over 48 hours. Her renal function was deranged and creatinine values worsened in the first three days. However, as she had started passing urine after 8 hours of resuscitative measure, she didn’t require hemodialysis. She was also started with broad spectrum antibiotics and low molecular heparin which was continued for 10 days.
Patient developed tachypnea on 4th postpartum day. Chest x-ray was done and was suggestive of pleural effusion. Diagnostic pleural fluid tapping was performed, which was suggestive of transudative effusion. Echocardiography, D- dimer and APTT was normal whereas electrocardiogram showed sinus tachycardia.
Multidisciplinary management of the patient was done in the maternal ICU for 8 days. She was then transferred to ward on 8thday as she was improving clinically and was discharged from hospital on 14th day. Patient was doing fine at 3rd week follow up after discharge.