RESUMEN
Resumen La embolia de líquido amniótico es una condición catastrófica propia del embarazo que ocurre típicamente durante el parto o justo posterior a este, cuyo sustrato fisiopatológico no ha sido aclarado por completo. Se ha estimado, según cifras de los Estados Unidos, que su incidencia rondaría 1 por cada 12.953 partos, y en el Reino Unido 1 por cada 50.000 partos; sin embargo, estas cifras pueden ser imprecisas debido a que no existen una referencia ni un consenso respecto a los criterios diagnósticos, además de que el cuadro clínico se puede confundir con otras emergencias obstétricas. Se presenta el caso de una paciente sin antecedentes mórbidos que presenta un cuadro de embolia de líquido amniótico no fatal, caracterizado por un estado fetal no tranquilizador durante la inducción del trabajo de parto, seguido de un paro cardiorrespiratorio durante la cesárea de urgencia y la rápida y catastrófica aparición de signos clínicos de una coagulopatía de consumo grave. Se describen además las complicaciones posoperatorias y su manejo, entre ellas un síndrome de Sheehan y la aparición de convulsiones tónico-clónicas generalizadas con alteración de neuroimágenes.
Abstract Amniotic fluid embolism is a catastrophic pregnancy condition that typically occurs during or inmediately after delivery, and whose pathophysiological background has not been fully clarified. According to US records the incidence of amniotic fluid embolism could been around 1 for every 12,953 births and in the United Kingdom 1 for every 50,000 births, however these numbers may be imprecise because there is no gold standard as well as no consensus regarding the diagnostic criteria, in addition that the clinical presentation can be misdiagnosis with other obstetric emergencies. We present the clinical case of a patient without a morbid history who presents with a non-fatal amniotic fluid embolism, characterized by an non-reassuring fetal status during labor induction, followed by cardiorespiratory arrest during emergency cesarean section and the rapid and catastrophic appearance of clinical signs of a severe consumptive coagulopathy. Postoperative complications and their management are also described, including Sheehans syndrome and the appearance of generalized tonic-clonic seizures with impaired neuroimaging.
Asunto(s)
Humanos , Femenino , Embarazo , Adulto , Embolia de Líquido Amniótico/cirugía , Paro Cardíaco/etiología , Hipopituitarismo/etiología , Cesárea , Reanimación Cardiopulmonar , Coagulación Intravascular Diseminada , Urgencias Médicas , Paro Cardíaco/terapia , Hipopituitarismo/terapiaRESUMEN
Two types of amniotic fluid embolism (AFE) have been described : cardiopulmonary collapse type and disseminated intravascular coagulation (DIC) type, with the latter proposed as uterine type. This report describes a healthy 28-year-old woman who developed AFE during a cesarean section. Because of a previous cesarean section, the patient underwent an elective cesarean section, under combined spinal-epidural anesthesia, at 38 weeks of pregnancy. She began coughing 5 minutes after delivery of the fetus, subsequently becoming unconscious and developing glossoptosis and bradycardia. Her blood pressure decreased to 76/43 mmHg, and AFE was suspected. Her uterus was atonic, and she experienced persistent noncoagulant bleeding, with a final blood loss of 6300 ml. Considerable blood transfusion was required. The patient survived, and she and her baby were discharged without any sequelae on the eighth postoperative day. This patient met the Japanese criteria for clinical AFE, with an obstetrical DIC score of 21 meeting the criteria for obstetrical DIC. Early diagnosis and treatment likely resulted in patient survival. J. Med. Invest. 67 : 207-210, February, 2020.
Asunto(s)
Cesárea/efectos adversos , Coagulación Intravascular Diseminada/cirugía , Embolia de Líquido Amniótico/diagnóstico , Adulto , Diagnóstico Precoz , Embolia de Líquido Amniótico/cirugía , Femenino , Humanos , EmbarazoRESUMEN
Over the past 30 years, maternal mortality has increased in the United States to 18 deaths per 100,000 live births. Obstetric emergencies, including hemorrhage, hypertensive disorders in pregnancy, HELLP syndrome, and amniotic fluid embolism, and anesthesia complications, including high neuraxial blockade, local anesthetic systemic toxicity, and the difficult obstetric airway, contribute to maternal cardiac arrest and maternal and fetal morbidity and mortality. Expeditious intervention by the obstetric anesthesiologist is critical in these emergent scenarios, and knowledge of best practices is essential to improve maternal and fetal outcomes.
Asunto(s)
Anestesia/métodos , Complicaciones del Embarazo/cirugía , Manejo de la Vía Aérea/efectos adversos , Anestesia/efectos adversos , Embolia de Líquido Amniótico/cirugía , Femenino , Síndrome HELLP/diagnóstico , Síndrome HELLP/terapia , Paro Cardíaco/etiología , Paro Cardíaco/terapia , Humanos , Mortalidad Materna , EmbarazoAsunto(s)
Embolia de Líquido Amniótico/cirugía , Hemoptisis/etiología , Complicaciones Posoperatorias/cirugía , Trastornos Puerperales/cirugía , Embolia Pulmonar/cirugía , Cesárea , Embolia de Líquido Amniótico/diagnóstico por imagen , Femenino , Humanos , Complicaciones Posoperatorias/diagnóstico por imagen , Embarazo , Trastornos Puerperales/diagnóstico por imagen , Embolia Pulmonar/complicaciones , Embolia Pulmonar/diagnóstico por imagen , Radiografía , Adulto JovenRESUMEN
BACKGROUND: Patients with amniotic fluid embolism (AFE) (major cardiac and pulmonary symptoms plus consumptive coagulopathy) have high circulating tissue factor concentrations. Recombinant factor VIIa (rVIIa) has been used to treat hemorrhage in AFE patients even though rVIIa can combine with circulating tissue factor and form intravascular clots. A systematic review was done of case reports from 2003 to 2009 of AFE patients with massive hemorrhage who were and were not treated with rVIIa to assess the thrombotic complication risk. METHODS: MEDLINE was searched for case reports of AFE patients receiving rVIIa (rVIIa cases) and of AFE patients who received surgery to control bleeding but no rVIIa (cohorts who did not receive rVIIa). Additional AFE case reports were obtained from the Food and Drug Administration, the Australian and New Zealand Haemostasis Registry, and scientific meeting abstracts. The risk of a negative outcome (permanent disability or death) in rVIIa cases versus cohorts who did not receive rVIIa was calculated using risk ratio and 95% confidence interval. RESULTS: Sixteen rVIIa cases and 28 cohorts were identified who did not receive rVIIa. All patients had surgery to control bleeding. Death, permanent disability, and full recovery occurred in 8, 6, and 2 rVIIa cases and 7, 4, and 17 cohorts who did not receive rVIIa (risk ratio 2.2, 95% CI 1.4-3.7 for death or permanent disability vs. full recovery). CONCLUSION: Recombinant factor VIIa cases had significantly worse outcomes than cohorts who did not receive rVIIa. It is recommended that rVIIa be used in AFE patients only when the hemorrhage cannot be stopped by massive blood component replacement.
Asunto(s)
Coagulantes/uso terapéutico , Embolia de Líquido Amniótico/tratamiento farmacológico , Factor VIIa/uso terapéutico , Adulto , Australia , Coagulantes/efectos adversos , Estudios de Cohortes , Embolia de Líquido Amniótico/cirugía , Factor VIIa/efectos adversos , Femenino , Mortalidad Hospitalaria , Humanos , Nueva Zelanda , Oportunidad Relativa , Embarazo , Proteínas Recombinantes/efectos adversos , Proteínas Recombinantes/uso terapéutico , Resultado del Tratamiento , Estados Unidos , Adulto JovenRESUMEN
Amniotic fluid embolism is a rare but devastating condition associated with a very high rate of morbidity and mortality. The treatment has traditionally been aggressive supportive care. We report a case of a term pregnant woman with complete cardiovascular collapse secondary to a paradoxical amniotic fluid embolism. The embolism was seen on transesophageal echocardiogram during an emergency Cesarean section as a free-floating interatrial clot through a patent foramen ovale. She was subsequently and successfully treated with immediate cardiopulmonary bypass, thromboembolectomy, and closure of the patent foramen ovale.
Asunto(s)
Embolia de Líquido Amniótico/cirugía , Choque/etiología , Adulto , Puente Cardiopulmonar , Ecocardiografía Transesofágica , Femenino , Foramen Oval Permeable/cirugía , Humanos , EmbarazoRESUMEN
Amniotic fluid embolism (AFE) is a rare, but often catastrophic, complication of pregnancy and associated with severe coagulopathy. We present an algorithm-based approach in managing coagulopathy and hemorrhage in a fatal case of histopathologically proven AFE. Thrombelastometry was used for rapid evaluation of the coagulation status. Stop of extensive hyperfibrinolysis with tranexamic acid, stabilization of initial clot formation with high-dose fibrinogen and platelet transfusions, and use of prothrombin complex concentrate together with a 1: 1 transfusion regimen of red packed cells and fresh frozen plasma was successful to control diffuse bleeding and restore clot firmness after hysterectomy. Stable clotting situation was maintained despite further clinical deterioration and development of multiple organ failure in this patient.
Asunto(s)
Algoritmos , Manejo de Caso , Embolia de Líquido Amniótico/terapia , Acidosis/etiología , Adulto , Factores de Coagulación Sanguínea/uso terapéutico , Transfusión de Componentes Sanguíneos , Fármacos Cardiovasculares/uso terapéutico , Enfermedad Catastrófica , Terapia Combinada , Diagnóstico Diferencial , Quimioterapia Combinada , Embolia de Líquido Amniótico/sangre , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/tratamiento farmacológico , Embolia de Líquido Amniótico/cirugía , Resultado Fatal , Femenino , Fibrinógeno/uso terapéutico , Humanos , Hipotensión/etiología , Histerectomía , Recién Nacido , Masculino , Insuficiencia Multiorgánica/etiología , Retención de la Placenta/diagnóstico , Hemorragia Posparto/tratamiento farmacológico , Hemorragia Posparto/etiología , Hemorragia Posparto/cirugía , Embarazo , Inyecciones de Esperma Intracitoplasmáticas , Tromboelastografía , Ácido Tranexámico/uso terapéuticoRESUMEN
Amniotic fluid embolism is a rare syndrome with potentially lethal outcomes. Complications include cardiorespiratory failure, disseminated intra-vascular coagulation, seizures, neurological deficits, and death. A 34-year-old woman had amniotic fluid embolism complicated by paradoxical embolism and disseminated intravascular coagulation. Emergency cesarean section followed by cardiopulmonary bypass with removal of the clot from the atria and closure of the patent foramen ovale was performed, resulting in a good outcome for both the mother and the baby. Subsequent treatment with anticoagulants for 6 months was recommended. A literature review revealed that this clinical scenario is rare but can be successfully managed by cardiopulmonary bypass and thromboembolectomy. Data on guidelines for the use of anticoagulation in this situation are limited.
Asunto(s)
Embolia de Líquido Amniótico/cirugía , Embolia Paradójica/cirugía , Foramen Oval Permeable/cirugía , Adulto , Puente Cardiopulmonar , Cesárea , Embolia Paradójica/complicaciones , Femenino , Foramen Oval Permeable/complicaciones , Humanos , EmbarazoRESUMEN
Amniotic fluid embolism (AFE), also referred to as anaphylactoid syndrome of pregnancy, is a rare obstetric emergency that may manifest itself at any time during pregnancy. AFE is believed to occur when the constituents of amniotic fluid enter the maternal circulation, leading to varying degrees of multiorgan compromise. AFE was first described in 1926, gaining widespread recognition in 1941. This article describes the pathogenesis of AFE, including theories of its immunological mediation available in the literature. The most current diagnostic and treatment modalities are discussed, including several novel therapies. A case report of a 40-year-old parturient who suffered probable AFE following amniotomy, with the development of cardiopulmonary compromise, neurologic involvement, fetal distress, and coagulopathy, is outlined. The patient survived emergency cesarean delivery and hysterectomy with no residual physiologic deficits.
Asunto(s)
Amnios/cirugía , Trabajo de Parto Inducido/efectos adversos , Adulto , Anestesia Obstétrica/métodos , Anestesia Obstétrica/enfermería , Trastornos de la Coagulación Sanguínea/etiología , Cesárea , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/etiología , Embolia de Líquido Amniótico/cirugía , Urgencias Médicas , Femenino , Sufrimiento Fetal/etiología , Humanos , Histerectomía , Trabajo de Parto Inducido/métodos , Enfermeras Anestesistas , Embarazo , Embarazo Prolongado/terapia , Enfermedades Raras , Factores de RiesgoRESUMEN
BACKGROUND: Amniotic fluid embolism is a life-threatening complication of pregnancy accompanied by a high mortality rate. The common clinical presentation is sudden onset of dyspnea, hypotension inappropriate to the volume of blood loss, and hypoxia, followed by cardiopulmonary arrest. Recently, cases of amniotic fluid embolism with isolated coagulopathy as an atypical presentation have been reported. CASE: A 27-year-old multigravida presented with continuous postpartum oozing after an uneventful vaginal delivery at 38 weeks of gestation. Laboratory evidence revealed disseminated intravascular coagulopathy. Despite good uterine contractions and massive blood component therapy, vaginal bleeding continued and finally led to emergency laparotomy. Histopathologic examination showed a deep cervical laceration in the endocervix, and multiple areas of amniotic fluid debris were demonstrated in the laceration site vasculature of the endocervix. After hysterectomy, the patient recovered fully, without sequelae. CONCLUSION: This case represents atypical symptoms and signs: clinical hemorrhage in the initial presentation rather than the classical pattern of cardiopulmonary collapse. In cases of suspected amniotic fluid embolism with an atypical presentation, a thorough histologic examination of the uterus, including the cervix, is critical to making the diagnosis of amniotic fluid embolism.
Asunto(s)
Cuello del Útero , Coagulación Intravascular Diseminada/etiología , Embolia de Líquido Amniótico/diagnóstico , Hemorragia Posparto/etiología , Adulto , Diagnóstico Diferencial , Embolia de Líquido Amniótico/patología , Embolia de Líquido Amniótico/cirugía , Femenino , Humanos , Histerectomía , EmbarazoRESUMEN
We report two cases of amniotic fluid embolism, confirmed by histological examination. Both patients had an immediate post-partum haemorrhage that required an haemostatic hysterectomy. A typical symptomatology of amniotic fluid embolism revelated the first case. The patient survived without any sequelae. In the second case, amniotic fluid embolism occurred immediately after the delivery. The patient developed an acute respiratory distress with a shock syndrome. Despite haemostatic hysterectomy and resuscitative efforts, she died 6 days later.
Asunto(s)
Embolia de Líquido Amniótico/diagnóstico , Histerectomía , Hemorragia Posparto/etiología , Adulto , Embolia de Líquido Amniótico/cirugía , Resultado Fatal , Femenino , Humanos , Hemorragia Posparto/cirugía , Embarazo , Resultado del Embarazo , Resultado del TratamientoRESUMEN
BACKGROUND: Amniotic fluid embolism is a rare yet often lethal peripartum complication resulting from rapid cardiovascular collapse. Progress toward a better understanding of this entity has failed to identify either the underlying hemodynamic pathophysiology or an effective evidence-based treatment. CASE: A 45-year-old woman with a documented placenta previa experienced an amniotic fluid embolism during scheduled cesarean delivery. Transesophageal echocardiogram examination revealed catastrophic pulmonary vasoconstriction. The use of cardiopulmonary bypass, heparin, epinephrine, and high-dose steroids resulted in a successful outcome. CONCLUSION: Timely placement of transesophageal echocardiogram revealed catastrophic pulmonary vasoconstriction as the cause of circulatory collapse in a patient with amniotic fluid embolism, supporting the use of cardiopulmonary bypass as an effective intervention.
Asunto(s)
Puente Cardiopulmonar/métodos , Ecocardiografía Transesofágica/métodos , Embolia de Líquido Amniótico/diagnóstico por imagen , Embolia de Líquido Amniótico/cirugía , Pulmón/irrigación sanguínea , Cesárea , Terapia Combinada , Constricción Patológica/complicaciones , Constricción Patológica/diagnóstico por imagen , Constricción Patológica/cirugía , Embolia de Líquido Amniótico/complicaciones , Femenino , Estudios de Seguimiento , Edad Gestacional , Humanos , Pulmón/diagnóstico por imagen , Pulmón/cirugía , Persona de Mediana Edad , Embarazo , Resultado del Embarazo , Medición de Riesgo , Choque/complicaciones , Choque/diagnóstico por imagen , Choque/cirugía , Resultado del TratamientoRESUMEN
Amniotic fluid (AF) embolism is a rare but catastrophic complication of pregnancy. We present the first case where the debris was seen in the maternal uterine veins at the time of cesarean section. During a cesarean delivery performed for deteriorating fetal status and in conjunction with massive hydramnios; air bubbles and vernix were observed in the left uterine vein and in an area of Couvelaire appearance of the uterine fundus. As the patient was clinically stable and desired retained fertility, a decision was made to attempt to contain the debris in the uterine vasculature. The infundibulopelvic ligament and uterine arteries were ligated and the area of Couvelaire uterus was oversewn. With the exception of a mild laboratory coagulopathy, which required no specific treatment, the patient did well. The area of Couvelaire uterus is the likely portal for the debris seen in this patient's vasculature. Containment appears to have averted the AF embolism syndrome.
Asunto(s)
Cesárea , Embolia de Líquido Amniótico/cirugía , Complicaciones Intraoperatorias , Manejo de Atención al Paciente , Adulto , Femenino , Humanos , EmbarazoRESUMEN
Amiotic fluid embolism is still a significant cause of maternal mortality. It must be suspected in all cases of sudden maternal collapse. For successful resuscitation, surgical delivery should be performed without delay.
Asunto(s)
Embolia de Líquido Amniótico/mortalidad , Mortalidad Materna , Adulto , Reanimación Cardiopulmonar , Causas de Muerte , Cesárea , Diagnóstico Diferencial , Embolia de Líquido Amniótico/cirugía , Femenino , Humanos , EmbarazoAsunto(s)
Puente Cardiopulmonar , Embolia de Líquido Amniótico/complicaciones , Trastornos Puerperales/etiología , Embolia Pulmonar/etiología , Choque/etiología , Embolia de Líquido Amniótico/cirugía , Femenino , Humanos , Embarazo , Trastornos Puerperales/cirugía , Embolia Pulmonar/cirugía , Choque/cirugíaRESUMEN
We report the successful treatment of a moribund patient as a result of amniotic fluid embolism with cardiopulmonary bypass and open pulmonary artery thromboembolectomy. Review of the literature indicates that this is the first reported case of treatment of amniotic fluid embolism with cardiopulmonary bypass and pulmonary thromboembolectomy.