Acute Episode Of Itching And Possible Amniotic Embolism With Circulatory Collapse In A Full Term Pregnant Patient
Amniotic fluid embolism (AFE) is a rare but serious obstetric condition. Its presentation includes a variety of signs and symptoms, most commonly hypoxia, hypotension, cardiac arrest, disseminated intravascular coagulopathy (DIC) and severe bleeding. A 28-year-old G1P0 full-term patient was admitted for an acute severe itching episode. After ruling out cholestasis, induction of labor and epidural analgesia was started. No significant progress of labor was seen in the next several hours. Blood was seen soaking the epidural catheter site. This was thought of as possibly an early sign of DIC. The decision was made to perform an urgent cesarean section. The patient bled profusely in the operating room and her hemodynamic condition deteriorated. Aggressive resuscitation was performed. We hypothesized that the itching on admission was a possible indicator of early AFE.
AFE is a rare but potentially fatal obstetric condition. In the United States, it is one of the leading causes of obstetric deaths that cannot be predicted. Some of the signs include hypotension, shortness of breath, cyanosis, unconsciousness, cardiopulmonary collapse and bleeding diathesis. However, the exact definition is noted to be, “presence of acute hypoxia, acute hypotension/cardiac arrest and DIC/severe hemorrhage during delivery or within 30 minutes postpartum and for which there is no alternative explanation.”
A 28-yrs-old G1P0 white, full-term patient with a past medical history of hemochromatosis was admitted for induction of labor for acute severe itching all over her body including palms but predominantly on the abdomen. After ruling out cholestasis, labor epidural analgesia was started. Misoprostol and oxytocin were used to induce labor. The patient had a spontaneous rupture of membranes but only minimal cervical dilation after 20 h of labor. Bloody fluid was seen through the indwelling epidural catheter’s dressing. The healthcare team suspected it to be an early onset sign of DIC.
The clinical decision was made to perform an immediate cesarean section prior to laboratory confirmation for suspected DIC and epidural anesthesia was used for the procedure. Fresh frozen plasma (FFP), cryoprecipitate and albumin were immediately given. The patient became acutely hypotensive shortly after delivering a healthy baby. Later, the patient became dyspneic. The patient was intubated and packed red blood cells (PRBCs) transfusion was started and a left radial arterial line was placed. A large amount of blood was seen between the patient's legs. The blood pressure fell to a nadir of 54/20 mm Hg.
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