RESUMEN
RATIONALE: Amniotic fluid embolism (AFE) is a fatal obstetric condition that often rapidly leads to severe respiratory and circulatory failure. It is complicated by obstetric disseminated intravascular coagulation (DIC) with bleeding tendency; therefore, the introduction of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is challenging. We report the case of a patient with AFE requiring massive blood transfusion, rescued using VA-ECMO without initial anticoagulation. PATIENTS CONCERNS: A 39-year-old pregnant patient was admitted with a complaint of abdominal pain. An emergency cesarean section was performed because a sudden decrease in fetal heart rate was detected in addition to DIC with hyperfibrinolysis. Intra- and post-operatively, the patient had a bleeding tendency and required massive blood transfusions. After surgery, the patient developed lethal respiratory and circulatory failure, and VA-ECMO was introduced. DIAGNOSIS: Based on the course of the illness and imaging findings, the patient was diagnosed with AFE. INTERVENTIONS: By controlling the bleeding tendency with a massive transfusion and tranexamic acid administration, using an antithrombotic ECMO circuit, and delaying the initiation of anticoagulation and anti-DIC medication until the bleeding tendency settled, the patient was managed safely on ECMO without complications. OUTCOMES: By day 5, both respiration and circulation were stable, and the patient was weaned off VA-ECMO. Mechanical ventilation was discontinued on day 6. Finally, she was discharged home without sequelae. LESSONS: VA-ECMO may be effective to save the lives of patients who have AFE with lethal circulatory and respiratory failure. For safe management without bleeding complications, it is important to start VA-ECMO without initial anticoagulants and to administer anticoagulants and anti-DIC drugs after the bleeding tendency has resolved.
Asunto(s)
Embolia de Líquido Amniótico , Oxigenación por Membrana Extracorpórea , Humanos , Femenino , Embolia de Líquido Amniótico/terapia , Embolia de Líquido Amniótico/diagnóstico , Oxigenación por Membrana Extracorpórea/métodos , Adulto , Embarazo , Cesárea/efectos adversos , Transfusión Sanguínea/métodos , Ácido Tranexámico/uso terapéutico , Ácido Tranexámico/administración & dosificación , Coagulación Intravascular Diseminada/etiología , Coagulación Intravascular Diseminada/terapia , Anticoagulantes/uso terapéutico , Anticoagulantes/efectos adversos , Anticoagulantes/administración & dosificaciónRESUMEN
PURPOSE OF REVIEW: The worldwide leading cause of maternal death is severe maternal hemorrhage. Maternal hemorrhage can be profound leading to an entire loss of blood volume. In the past two decades, Patient Blood Management has evolved to improve patient's care and safety. In surgeries with increased blood loss exceeding 500âml, the use of cell salvage is strongly recommended in order to preserve the patient's own blood volume and to minimize the need for allogeneic red blood cell (RBC) transfusion. In this review, recent evidence and controversies of the use of cell salvage in obstetrics are discussed. RECENT FINDINGS: Numerous medical societies as well as national and international guidelines recommend the use of cell salvage during maternal hemorrhage. SUMMARY: Intraoperative cell salvage is a strategy to maintain the patient's own blood volume and decrease the need for allogeneic RBC transfusion. Historically, cell salvage has been avoided in the obstetric population due to concerns of iatrogenic amniotic fluid embolism (AFE) or induction of maternal alloimmunization. However, no definite case of AFE has been reported so far. Cell salvage is strongly recommended and cost-effective in patients with predictably high rates of blood loss and RBC transfusion, such as women with placenta accreta spectrum disorder. However, in order to ensure sufficient practical experience in a multiprofessional obstetric setting, liberal use of cell salvage appears advisable.
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Recuperación de Sangre Operatoria , Humanos , Embarazo , Femenino , Recuperación de Sangre Operatoria/métodos , Recuperación de Sangre Operatoria/efectos adversos , Hemorragia Posparto/terapia , Transfusión de Eritrocitos/métodos , Transfusión de Eritrocitos/efectos adversos , Transfusión de Eritrocitos/normas , Transfusión de Sangre Autóloga/métodos , Transfusión de Sangre Autóloga/efectos adversos , Transfusión de Sangre Autóloga/normas , Pérdida de Sangre Quirúrgica/prevención & control , Embolia de Líquido Amniótico/terapia , Embolia de Líquido Amniótico/diagnóstico , Obstetricia/métodos , Obstetricia/tendencias , Obstetricia/normasRESUMEN
OBJECTIVE: Excess blood loss from obstetrical hemorrhage requires transfusion of donor blood, a finite resource. Intraoperative cell salvage collects a patient's own blood that has been lost during cesarean delivery and returns it to their own circulation. We performed a meta-analysis to examine the perioperative outcomes in patients receiving cell salvage at the time of cesarean delivery. DATA SOURCES: Scopus, PubMed, Cochrane Central Register of Controlled Trials, Ovid Medline, and clinicaltrials.gov were searched from database inception through October 2023. STUDY ELIGIBILITY CRITERIA: Eligible studies included randomized controlled trials comparing the use of cell salvage to standard-of-care during cesarean delivery. METHODS: Two authors independently extracted data. Preferred Reporting Items of Systematic Reviews and Meta-Analysis guidelines were used for data extraction and quality assessment. The primary outcomes were the rate of donor blood transfusion and change in hemoglobin level. The secondary outcomes included transfusion reaction, amniotic fluid embolism, and length of hospital stay. Results were summarized as weighted mean difference or risk ratio with associated 95% confidence intervals. Heterogeneity was measured using Higgins I2. RESULTS: A total of 5 randomized controlled trials (n=3361) comparing cell salvage to standard care during cesarean delivery met the inclusion criteria. Primary analysis showed a significant decrease in receiving allogeneic blood transfusion with intraoperative cell salvage use vs standard care (odds ratio, 0.32; 95% confidence interval, 0.23-0.46), with no change in hemoglobin drop (mean difference, -0.77; 95% confidence interval, -1.67 to -0.14). The secondary outcomes showed no difference in transfusion reaction (odds ratio, 0.56; 95% confidence interval, 0.06-5.59), and length of hospital stay (mean difference, -1.90; 95% confidence interval, -4.85 to 1.06). No cases of amniotic fluid embolism were reported among the 1685 patients who received cell salvage. CONCLUSION: Use of cell salvage during cesarean delivery reduced the overall need for allogeneic blood transfusion without increasing the risk of complications, including no cases of amniotic fluid embolism.
Asunto(s)
Cesárea , Recuperación de Sangre Operatoria , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Cesárea/métodos , Femenino , Embarazo , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Recuperación de Sangre Operatoria/métodos , Pérdida de Sangre Quirúrgica/prevención & control , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Transfusión de Sangre Autóloga/métodos , Transfusión Sanguínea/métodos , Transfusión Sanguínea/estadística & datos numéricos , Hemorragia Posparto , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapiaRESUMEN
ABSTRACT: Amniotic fluid embolism (AFE) is a rare, sudden, and catastrophic complication of pregnancy that can result in cardiopulmonary arrest, potentially leading to death. The pathophysiology of an AFE includes an inflammatory and coagulopathic response due to fetal materials entering maternal circulation with the hallmark triad of symptoms: acute respiratory distress, cardiovascular collapse, and coagulopathy. Management of AFE should include high-quality cardiopulmonary resuscitation, immediate delivery of the fetus if applicable, early intubation to provide adequate oxygenation and ventilation, fluid volume resuscitation, and ongoing evaluation of coagulopathy. Priorities include thromoboelastography interpretation if available, control of hemorrhage and coagulopathy with blood component therapy, and cardiovascular support through inotropes and vasopressor administration. More recent approaches include implementing the A-OK (atropine, ondansetron, and ketorolac) protocol for suspected AFE protocol, extracorporeal cardiopulmonary resuscitation (ECPR), and extracorporeal membrane oxygenation (ECMO) therapies to increase survival and decrease complications. Venoarterial ECMO is the highest form of life support that provides support in patients with pulmonary and cardiac failure. ECPR is the application of Venoarterial ECMO during cardiopulmonary resuscitation in cases where the cause of arrest is believed to be reversible. Early implementation of ECPR during the acute phase of AFE can provide support for end-organ perfusion in place of the weakened and recovering heart while optimizing oxygenation, making venoarterial ECMO an ideal adjunctive therapy. Because of the rarity of AFE, many obstetrical teams may have limited prior experience in managing these catastrophic cases; however, with ongoing education and simulation, teams can be better prepared in the recognition and management of these life-threatening events.
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Reanimación Cardiopulmonar , Embolia de Líquido Amniótico , Oxigenación por Membrana Extracorpórea , Paro Cardíaco , Femenino , Humanos , Embarazo , Reanimación Cardiopulmonar/efectos adversos , Reanimación Cardiopulmonar/métodos , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapia , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/métodos , Paro Cardíaco/complicaciones , Paro Cardíaco/terapiaRESUMEN
OBJECTIVE: Amniotic fluid embolism is one of the most serious pregnancy complications. It can cause sudden maternal collapse with high mortality and morbidity. We present a case report regarding the important of prompt decision making and multidisciplinary team work for management of amniotic fluid embolism to yield favorable maternal and neonatal outcome. CASE REPORT: This is a 35-year-old, gravida 2, para 1, woman underwent labor induction at gestational age of 37 + 6 weeks due to elective induction. She had sudden facial cyanosis and shortness of breath right after artificial rupture of membrane. Prompt decision of urgent cesarean section, aggressive and timely massive blood transfusion and multidisciplinary team work had spared patient from extracorporeal membrane oxygenation placement and prolonged hospitalization. A male infant was born with Apgar score 3' -> 5' with estimate body weight of 2958 gm; he was hospitalized for 10 days and no other complications was found at follow up pediatric outpatient clinic. CONCLUSION: One of the most dreadful, but rare pregnancy complications is amniotic fluid embolism (AFE). It can cause serious maternal and neonatal morbidity and mortality. Rapid recognition and multidisciplinary team management are essential to maternal and neonatal prognosis.
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Embolia de Líquido Amniótico , Complicaciones del Embarazo , Recién Nacido , Niño , Embarazo , Masculino , Humanos , Femenino , Lactante , Adulto , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapia , Cesárea , Pronóstico , Grupo de Atención al PacienteRESUMEN
OBJECTIVE: Amniotic fluid embolism (AFE) is a rare life-threatening complication in obstetrics, but the diagnosis lacks a consensual definition. The objective of this study was to compare two different AFE classification systems by analysing the AFE cases from two university hospitals. MATERIAL AND METHODS: In this retrospective study, all patients with a strong suspicion of AFE between 2014 and 2021 at two university hospitals, LMU Women's University Hospital Munich, and Women's University Hospital Basel, were included. Patient records were checked for the ICD-10 code O88.1 (AFE). Diagnoses were confirmed through clinical findings and/or autopsy. The presence of the diagnostic criteria of the Society of Maternal foetal Medicine (SMFM) and the AFE Foundation (AFEF) and of a new framework by Ponzio-Klijanienko et al. from Paris, France, were checked and compared using Chi-square-test. RESULTS: Within our study period, 38,934 women delivered in the two hospitals. Six patients had a strong suspicion of AFE (0.015%). Only three of six patients (50%) presented with all the four diagnostic criteria of the SMFM/AFEF framework. All six patients met the criteria of the modified "Paris AFE framework". CONCLUSION: Using the "Paris AFE framework" based exclusively on clinical criteria can help clinicians to diagnose AFE, anticipate the life-threatening condition of the patient and prepare immediately for best clinical care.
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Embolia de Líquido Amniótico , Embarazo , Humanos , Femenino , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapia , Estudios Retrospectivos , Centros de Atención Terciaria , Hospitales Universitarios , FranciaRESUMEN
Amniotic fluid embolism (AFE) is a rare but potentially fatal complication of pregnancy. Prompt and aggressive resuscitative strategies are crucial in promoting survivability. We present a case of AFE resulting in cardiopulmonary collapse and subsequent cardiac arrest where we were able to safely deliver the baby and resuscitate the mother with veno-arterial extracorporeal membrane oxygenation and Impella CP-a novel combination known as ECPELLA. We discuss the implications of this approach as a more efficacious strategy in resuscitating AFE-induced cardiogenic shock and arrest.
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Embolia de Líquido Amniótico , Oxigenación por Membrana Extracorpórea , Paro Cardíaco , Corazón Auxiliar , Embarazo , Femenino , Humanos , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapia , Oxigenación por Membrana Extracorpórea/métodos , Corazón Auxiliar/efectos adversos , Choque Cardiogénico/etiología , Choque Cardiogénico/terapia , Paro Cardíaco/etiología , Paro Cardíaco/terapiaRESUMEN
BACKGROUND Amniotic fluid embolism (AFE) is an extremely rare, life-threatening complication of labor that leads to hyper-acute induction of inflammation and disseminated intravascular coagulation (DIC). Usually, acute pulmonary hypertension results in acute right ventricular failure, while DIC manifests by hemorrhagic and ischemic complications, ultimately leading to multi-organ failure and death. CASE REPORT A 30-year-old primigravida and primipara woman with no prior medical history was admitted for labor after intrauterine fetal death at 37 weeks of gestation. After medical birth induction, she had a convulsive seizure and cardiorespiratory arrest. Short mechanical resuscitation was performed before spontaneous circulation returned. Simultaneously occurring severe vaginal hemorrhage and an ST-elevation myocardial infarction (STEMI) triggered the diagnosis of AFE. Laboratory results fulfilled the criteria for DIC, and hemostatic resuscitation and mechanical hemostasis were performed. Transesophageal echocardiography revealed hypokinesia to akinesia of the inferior wall. Owing to the ongoing DIC, coronary angiography could not be performed. After the patient's transfer to the Intensive Care Unit, ST-segment elevations resolved and the myocardial infarct was managed medically. Cardiac magnetic resonance imaging performed 3 months later demonstrated myocardial scarring in 2 different areas. Referring to the coronary artery anatomy in a computed tomography scan of the chest, the infarcted areas correlated with 2 different coronary supply territories. CONCLUSIONS AFE should be considered in women with acute cardiorespiratory failure during labor. This is the first report of a STEMI triggered by an AFE. The 2 separate areas of infarction, corresponding to the 2 different coronary territories, suggest an AFE-related thrombotic/thromboembolic etiology.
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Coagulación Intravascular Diseminada , Embolia de Líquido Amniótico , Hemostáticos , Infarto del Miocardio con Elevación del ST , Embarazo , Femenino , Humanos , Adulto , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapia , Embolia de Líquido Amniótico/etiología , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/etiología , Infarto del Miocardio con Elevación del ST/terapia , Coagulación Intravascular Diseminada/etiologíaRESUMEN
Venous thromboembolism (VTE) as well as other embolic events including amniotic fluid embolism (AFE) remain a leading cause of maternal death in the United States and worldwide. The pregnant patient is at a higher risk of developing VTE including pulmonary embolism. In contrast, AFE is a rare, but catastrophic event that remains incompletely understood. Here the authors review the cause of VTE in pregnancy and look at contemporary and evidence-based practices for the evaluation, diagnosis, and management in pregnancy. Then the cause and diagnostic difficulty of AFE as well as what is known regarding the pathogenesis are reviewed.
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Embolia de Líquido Amniótico , Embolia Pulmonar , Tromboembolia Venosa , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapia , Femenino , Humanos , Mortalidad Materna , Embarazo , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/terapia , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiología , Tromboembolia Venosa/terapiaRESUMEN
Amniotic fluid embolism (AFE) is a rare and often fatal obstetric complication, characterized by sudden cardiovascular collapse, dyspnea, seizures, mental alteration or coma and laboratory and clinically dia-gnosed disseminated intravascular coagulation (DIC). Patients reaction is typically biphasic with initial pulmonary hypertension and right ventricular failure, followed by left ventricular failure during or immediately right after labor. Early recognition of AFE is critical to a successful survival. Aggressive shock management is needed in collaboration with an anesthesiologist. Several aspects of the condition remain a controversy. This review critically examines, from the best available evidence, the current knowledge regarding the epidemiology, pathophysiology, dia-gnosis, and available treatment of AFE. This dia-gnosis still determines perinatal morbidity and mortality and potential permanent neurological symptoms for surviving patients.
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Coagulación Intravascular Diseminada , Embolia de Líquido Amniótico , Coagulación Intravascular Diseminada/diagnóstico , Coagulación Intravascular Diseminada/etiología , Coagulación Intravascular Diseminada/terapia , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapia , Femenino , Humanos , EmbarazoRESUMEN
Amniotic fluid embolism is frequently associated with coagulopathy. However, the exact nature and evolution of the bleeding disorder is incompletely understood. We report a case of clinically diagnosed amniotic fluid embolism associated with major haemorrhage and coagulopathy. We measured sequential levels of all individual clotting factors, thrombin generation, fibrinogen, and D-dimer levels over the course of the event, beginning shortly after the patient's initial collapse and during the subsequent resuscitation, to identify the specific abnormalities of coagulation from stored blood samples. A better understanding of amniotic fluid embolism and the associated coagulopathy is an important area of research to inform targeted treatment of the coagulopathy and improve outcomes for patients.
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Trastornos de la Coagulación Sanguínea , Embolia de Líquido Amniótico , Coagulación Sanguínea , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapia , Femenino , Fibrinógeno , Humanos , Embarazo , Resucitación/efectos adversosRESUMEN
Respiratory failure in pregnant and postpartum women is uncommon, but it is one of the leading causes of maternal admission into the intensive care unit and is associated with high mortality. The underlying causes include sequelae of underlying medical conditions, such as congenital heart diseases, but it is more often related to acute respiratory distress syndrome from obstetric complications like pre-eclampsia, effect of treatment like tocolysis, coincidental to pregnancy like transfusion-related acute lung injury, and accidental like amniotic fluid embolism. The pathophysiological mechanisms involved in many of these conditions remain to be clearly established, but maternal inflammatory response and activation of the immune and complement systems appear to play leading roles. Prompt recognition of maternal respiratory distress and related manifestations and aggressive and adequate supportive treatment, especially cardiopulmonary resuscitation, ventilation, maintenance of circulation, and timely termination of the pregnancy, play key roles in achieving survival of both mother and foetus.
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Embolia de Líquido Amniótico , Complicaciones del Trabajo de Parto , Síndrome de Dificultad Respiratoria , Embarazo , Femenino , Humanos , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapia , Embolia de Líquido Amniótico/etiología , Síndrome de Dificultad Respiratoria/terapia , Síndrome de Dificultad Respiratoria/complicaciones , Periodo PospartoRESUMEN
BACKGROUND: Amniotic fluid embolism (AFE) is a rare but often catastrophic complication of pregnancy that leads to cardiopulmonary dysfunction and severe disseminated intravascular coagulopathy (DIC). Although few case reports have reported successful use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with AFE, concerns can be raised about the increased bleeding risks with that device. METHODS: This study included patients with AFE rescued by VA-ECMO hospitalized in two high ECMO volume centers between August 2008 and February 2021. Clinical characteristics, critical care management, in-intensive care unit (ICU) complications, and hospital outcomes were collected. ICU survivors were assessed for health-related quality of life (HRQL) in May 2021. RESULTS: During that 13-year study period, VA-ECMO was initiated in 54 parturient women in two high ECMO volume centers. Among that population, 10 patients with AFE [median (range) age 33 (24-40), SAPS II at 69 (56-81)] who fulfilled our diagnosis criteria were treated with VA-ECMO. Pregnancy evolved for 36 (30-41) weeks. Seven patients had a cardiac arrest before ECMO and two were cannulated under cardiopulmonary resuscitation. Pre-ECMO hemodynamic was severely impaired with an inotrope score at 370 (55-1530) µg/kg/min, a severe left ventricular ejection fraction measured at 14 (0-40)%, and lactate at 12 (2-30) mmol/L. 70% of these patients were alive at hospital discharge despite an extreme pre-ECMO severity and massive blood product transfusion. However, HRQL was lower than age-matched controls and still profoundly impaired in the role-physical, bodily pain, and general health components after a median of 44 months follow-up. CONCLUSION: In this rare per-delivery complication, our results support the use of VA-ECMO despite intense DIC and ongoing bleeding. Future studies should focus on customized, patient-centered, rehabilitation programs that could lead to improved HRQL in this population.
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Embolia de Líquido Amniótico , Oxigenación por Membrana Extracorpórea , Adulto , Preescolar , Embolia de Líquido Amniótico/terapia , Oxigenación por Membrana Extracorpórea/métodos , Femenino , Humanos , Embarazo , Calidad de Vida , Estudios Retrospectivos , Choque Cardiogénico/terapia , Volumen Sistólico , Función Ventricular IzquierdaRESUMEN
BACKGROUND: Amniotic fluid embolism (AFE) is a rare disease that can lead to profound coagulopathy and hemorrhage, especially when combined with the laceration and bleeding of other organs. Intraoperative cell salvage (ICS) has been widely used for treating obstetric hemorrhage, but it remains unclear whether ICS can be used in the treatment of AFE. CASE PRESENTATION: We report the case of a 27-year-old woman at 39 weeks' gestation who suddenly developed severe abdominal pain, convulsions, loss of consciousness, and decreased vital signs during labor. Despite an emergency cesarean section being performed, the parturient experienced sudden cardiac arrest. Fortunately, the heart rate spontaneously recovered after effective cardiopulmonary resuscitation (CPR). Further abdominal exploration revealed right hepatic laceration with active bleeding. ICS was performed and the salvaged blood was promptly transfused back to the patient. Subsequently, the patient was diagnosed with AFE based on hypotension, hypoxia, coagulopathy, and cardiac arrest. The patient was transfused with 2899 mL salvaged blood during surgery with no adverse effects. At 60- and 90-day follow-ups, no complaints of discomfort or abnormal laboratory test results were observed in the mother or the baby. CONCLUSION: ICS was used to rescue patient with AFE, and ICS did not worsen the condition of patients with AFE. For pregnant women who received CPR, clinicians should explore the presence of hepatic laceration which can be fatal to patients.
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Reanimación Cardiopulmonar , Embolia de Líquido Amniótico , Paro Cardíaco , Laceraciones , Adulto , Cesárea/efectos adversos , Embolia de Líquido Amniótico/diagnóstico , Embolia de Líquido Amniótico/terapia , Femenino , Paro Cardíaco/etiología , Paro Cardíaco/terapia , Humanos , Laceraciones/complicaciones , EmbarazoRESUMEN
BACKGROUND: Amniotic fluid embolism (AFE) is a rare but potentially dangerous severe obstetrics complication, which is accompanied by an incidence between 1.9 and 6.1 per 100,000 births. CASE PRESENTATION: Here, we report an AFE case after cesarean delivery diagnosed on a cardiac arrest complicated by acute respiratory distress syndrome and coagulopathy. Diagnosis, risk factors and pathophysiology for AFE have been fully discussed, besides, extracorporeal membrane oxygenation in the early management of cardiac arrest was used, describing the indication, efficacy and successful performed of open-chest cardiopulmonary resuscitation for the patient. CONCLUSION: In AFE with cute cardiovascular collapse, extracorporeal membrane oxygenation support can be considered as the alternative therapies.