Practical use of C1 esterase inhibitor concentrate for clinical amniotic fluid embolism.

Amniotic fluid embolism (AFE) causes consumption coagulopathy, which requires a massive transfusion to save the mother's life. The preparation of such a massive transfusion is too time-consuming in extremely emergent clinical settings and occasionally leads to devastating side effects such as transfusion-associated acute lung injury. C1 esterase inhibitor (C1INH) is a protein with the ability to inhibit complement, coagulation and kinin pathways. The C1INH concentration in AFE patients is low, and it has been speculated that the administration of C1INH concentrate could have a striking and beneficial effect on AFE patients in critical condition by ameliorating their perturbed coagulation system. We report the case of a 32-year-old Japanese AFE patient in whom deteriorated vital signs and coagulopathy recovered within minutes after an injection of C1INH concentrate. C1INH concentrate can quickly revive the deteriorated vital signs and the atonic uterus that stem from AFE and may reduce the total amount of transfusion.

Confusion in the monitoring of coagulation function in pregnant and neonate patients with severe disease: A case reports and brief literature review.

RATIONALE: Different populations have their own unique physiological and pathological characteristics. However, in specialized maternal and child hospitals, there is currently a lack of standardized methods for assessing coagulation dysfunction, both domestically and internationally. PATIENT CONCERNS: A 19-day-old neonate was transferred to neonatal intensive care unit with cyanosis, nasal bleeding for 6 hours, and a consciousness disorder for 5 hours. A 33-year-old woman presented with hydramnios and a 39 + 3week intrauterine pregnancy. All indicators before delivery were normal, but postpartum hemorrhage occurred after delivery. DIAGNOSES: We retrospectively analyzed 1 neonate with pulmonary hemorrhage accompanied by thrombocytopenia and 1 pregnant patient with amniotic fluid embolism. INTERVENTIONS: The new coagulation indicators, such as thrombin-antithrombin complex, plasmin-alpha 2 antiplasmin complex, thrombomodulin, and tissue plasminogen activator-plasminogen activator inhibitor-1 complex, have been indicated to be valuable. In neonates, it is necessary to continuously monitor special items combined with specific therapeutic agents, such as tranexamic acid. In cases where postpartum hemorrhage occurs with low fibrinogen levels, it is essential to effectively identify patients with severe amniotic fluid embolism from a high incidence of specimen clotting. OUTCOMES: The neonate's oxygen saturation stabilized, and after 5 days of treatment with low molecular weight heparin, thrombin-antithrombin complex and plasmin-alpha 2 antiplasmin complex returned to normal levels. The pregnant began to remove the remaining thrombus, the patient's condition recovered, and she had a good prognosis. LESSONS: For pregnant and neonatal critical illnesses, it is necessary to develop personalized coagulation monitoring programs that provide realistic and reasonable treatment recommendations. Such programs should consider the unique physiological and pathological characteristics of different populations to ensure effective management of critically ill patients.

Use of recombinant factor VIIa in patients with amniotic fluid embolism: a systematic review of case reports.

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.

Amniotic Fluid Embolism Treated With Inhaled Milrinone: A Case Report.

We present a patient with sudden cardiovascular collapse during cesarean delivery that was attributed to amniotic fluid embolism (AFE). The syndrome of AFE may be initiated by an anaphylactoid response to amniotic fluid in the maternal circulation that triggers the release of pulmonary vasoconstrictors, with transient pulmonary vasospasm, causing hemodynamic collapse and profound left ventricular failure. Milrinone, a pulmonary vasodilator used in the management of emergent right ventricular failure, was administered via a nebulizer in an effort to decrease pulmonary vascular resistance. If used immediately after AFE, inhaled milrinone may mitigate pulmonary vasoconstriction, providing a bridge to extracorporeal membrane oxygenation.

Successful treatment of amniotic fluid embolism complicated by disseminated intravascular coagulation with rivaroxaban: A case report.

RATIONALE: An amniotic fluid embolism (AFE) is a rare, lethal syndrome that is commonly associated with disseminated intravascular coagulation (DIC). Anticoagulation therapy is the most important strategy to inhibit excessive activation of the coagulation cascade in patients with AFE and DIC. At present, treatment of AFE with rivaroxaban has not been reported. PATIENT CONCERNS: We report a 37-year-old woman (gravida 2, para 1) at 39 weeks' gestation with irregular contractions of the uterus was admitted to the obstetrical department. Ten minutes after the spontaneous rupture of the membranes, the patient complained of dyspnea and dysphoria and exhibited cyanosis of her lips. The patient's blood pressure decreased and heart rate increased rapidly, and 2100 mL of unclotted blood flowed from her vagina within 1 hour. Her platelet count dropped to 21 × 10/L, and the results from routine coagulation tests, and D-dimer and fibrin degradation product tests were obviously abnormal. DIAGNOSES: According to the current research consensus, AFE with DIC should be considered immediately when sudden cardiovascular collapse occurs around the time of labor and delivery, followed by the development of coagulopathy and hemorrhage. INTERVENTIONS: In addition, the variety of supportive treatments, rivaroxaban was used in anticoagulant therapy. OUTCOMES: At follow-up 30 and 60 days, there were no complaints of discomfort or abnormal laboratory assays. The patient recovered completely. LESSONS: This case highlights that rivaroxaban, as a direct inhibitor of activated factor Xa, demonstrates a good therapeutic efficacy for treating AFE with DIC.

Rotational thromboelastometry (ROTEM®)-guided diagnosis and management of amniotic fluid embolism.

Amniotic fluid embolism is a rare but often catastrophic emergency. The non-specific clinical features and lack of diagnostic tests make it a diagnosis of exclusion. Point-of-care visco-elastometric testing is being increasingly used during obstetric haemorrhage. We present a case of amniotic fluid embolism, diagnosed and managed using rotational thromboelastography. During a precipitous labour, a 21-year-old multiparous woman became pale, distressed and disorientated. The fetus was delivered using forceps. Simultaneously maternal cardiac arrest occurred and advanced life support was commenced. As there was no obvious bleeding, pulmonary embolism was considered the most likely diagnosis and preparation was made to thrombolyse. During resuscitation, rotational thromboelastometry demonstrated haemostatic failure, supporting a diagnosis of amniotic fluid embolism. This reversed the decision to thrombolyse and focused the team on resuscitation and management of coagulopathy. Targeted blood products were given using a local protocol specific to obstetric bleeding. Return of cardiac output was achieved. The total measured blood loss was more than 3.6 L and transfusion was guided by point-of-care tests. Transfused blood products were six units of packed red blood cells, one pool of platelets, 12 units of fresh frozen plasma and 14 g of fibrinogen concentrate. This case demonstrates amniotic fluid embolism with haemostatic failure, without initial revealed blood loss. The high mortality of amniotic fluid embolism necessitates rapid diagnosis and aggressive management. Laboratory tests in this context are impractical in informing clinical decisions, showing the value of point-of-care testing in facilitating team work and timely administration of targeted blood products.

Lipid Emulsion Rescue of Amniotic Fluid Embolism-Induced Cardiac Arrest: A Case Report.

Amniotic fluid embolism (AFE) is a rare and often fatal complication that occurs in the peripartum period. We present a patient with an AFE who developed disseminated intravascular coagulation and cardiovascular collapse who may have benefitted from intravascular lipid emulsion rescue. This is the first published case in which lipid emulsion was a part of the successful treatment of AFE.

Value of fibrinogen in cases of maternal death related to amniotic fluid embolism.

BACKGROUND: This study aimed to investigate the rate of coagulopathy progression in amniotic fluid embolism (AFE), using the level of fibrinogen. METHODS: We examined all cases of maternal death (46 cases) related to AFE between 2010 and 2013 in Japan (total number of deliveries: 4,291,459). Fibrinogen, blood loss from AFE onset to fibrinogen measurement, and time from onset to fibrinogen measurement were investigated. The correlations of fibrinogen with time from onset to fibrinogen measurement and blood loss at fibrinogen measurement were analyzed. RESULTS: Fibrinogen was undetectable (less than 50 mg/dL) in 14 cases (93%) and 65 mg/dL in one case (7%). All the cases involving not less than 1000 mL of blood loss or within 60 min from onset to fibrinogen measurement demonstrated low levels of fibrinogen. CONCLUSIONS: Coagulopathy in AFE was not directly proportional to bleeding. Furthermore, coagulopathy in AFE developed in a remarkably short length of time. If AFE is suspected, fibrinogen level should be measured rapidly for favoring a more AFE to decrease the risk of death from AFE. And, rapid treatment of coagulopathy can help reduce mortality from AFE.

[Activity of nuclear factor kappa B in rat pulmonary tissue after entrance of amniotic fluid into blood and inhibition with dexamethasone].

OBJECTIVE: To investigate the relationship between nuclear factor kappa B (NF-kappaB) and pulmonary injury in amniotic fluid embolism model of rat. METHODS: Seventy female Wistar rats were divided into five groups randomly: control group (6), amniotic fluid group (16), amniotic fluid + dexamethasone group (14), meconium group (20) and meconium + dexamethasone group (14). Different amniotic fluid was injected into jugular vein (dexamethasone was injected at 0.1 mg/100 g after entrance of amniotic fluid into blood) and blood pressure was examined. Pulmonary tissue was taken at 60 minutes. NF-kappaB activity was measured by Western-blot and percentage of NF-kappaB p65 positive cells in pulmonary tissue was determined by immunohistochemistry (HE). RESULTS: Dropsy, bleeding and neutrophil (PMN), macrophage, leukomonocyte infiltration were seen in four experimental groups. But none was found in control group. NF-kappaB activity in meconium group was 438,698 +/- 13,092, higher than those in amniotic fluid group, 377,982+/- 7,445, and in control group, 267,691 +/- 12 382 (F = 11.3, P < 0.01). With dexamethasone treatment, NF-kappaB activity was decreased, which was 308,826 +/- 13,771 in amniotic group and 339,516 +/- 17,358 in meconium group, respectively (t = 20.4 and t = 13.84, P < 0.01). Percentage of NF-kappaB p65 positive cells was higher in meconium group, 49.1 +/- 7.0, than in amniotic fluid group, 33.3 +/- 2.7, and control group, 13.3 +/- 2.1 (F = 1.17, P < 0.01). With dexamethasone treatment, the percentage decreased significantly to 22.9 +/- 3.0 and 21.4 +/- 3.6, respectively (t = 6.75 and t = 10.1, P < 0.05). CONCLUSIONS: NF-kappaB activity and percentage of NF-kappaB p65 positive cells are increased significantly, which is associated with pulmonary injury after entrance of amniotic fluid into blood and dexamethasone could inhibit NF-kappaB translocation to the nucleus to degrade NF-kappaB activity and alleviate pulmonary injury. NF-kappaB may be relevant to the occurrence and development of multiple organ dysfunction syndrome.

Cryoprecipitate therapy in amniotic fluid embolization.

Cryoprecipitate was administered to a patient with severe adult respiratory distress syndrome secondary to an amniotic fluid embolus, diagnosed cytologically. Following the administration of cryoprecipitate, cardiopulmonary and hematologic status markedly improved, and the patient recovered without apparent sequela. She is the sixth surviving patient reported to have an amniotic fluid embolus confirmed cytologically. On the basis of accumulating data on the relationship between fibronectin levels and the integrity of the reticuloendothelial system, it is quite possible that fibronectin (cold-insoluble globulin), and not fibrinogen, played the key role in her dramatic improvement and may well have been responsible for the clinical improvement in earlier patients treated with blood products containing fibronectin.

Presumed antepartum amniotic fluid embolism.

BACKGROUND: Amniotic fluid embolism is seldom recognized in nonperipartum patients. The pathophysiology is uncertain and diagnosis imprecise, making management after stabilization difficult. CASE: A 37-year-old woman at 28 weeks' gestation presented with signs and symptoms consistent with amniotic fluid embolism including disseminated intravascular coagulopathy. A ventilation-perfusion scan demonstrated unmatched perfusion defects, but other radiographic studies were negative; the patient was treated with heparin. Four days after presentation she had spontaneous rupture of membranes followed by hypoxemia, necessitating cesarean delivery. A pulmonary arteriogram after the operation showed multiple filling defects; the patient was discharged on warfarin. CONCLUSION: Amniotic fluid embolism is a difficult diagnosis to make, at best. Anticoagulation may be a therapeutic option.

Recombinant factor VIIa after amniotic fluid embolism and disseminated intravascular coagulopathy.

This case report illustrates the successful use of activated recombinant factor VIIa in the management of severe postpartum hemorrhage secondary to amniotic fluid embolism.

[Amniotic fluid embolism in a 24-year-old female after caesarean section - a case report]. / Zator plynem owodniowym u 24-letniej kobiety po ciazy rozwiazanej cieciem cesarskim.

A case of a 24-year-old female with amniotic fluid embolism following an urgent caesarean section is presented. Medical treatment was effective. Prognosis in this condition and differential diagnosis are discussed.

Survival after an amniotic fluid embolism following the use of sodium bicarbonate.

Amniotic fluid embolism (AFE) is a rare and potentially fatal complication of pregnancy. In this case report, we highlight the successful use of sodium bicarbonate in a patient with an AFE. We present a case of a 38-year-old mother admitted for an elective caesarean section. Following the delivery of her baby, the mother suffered a cardiac arrest. Following a protracted resuscitation, transoesophageal echocardiography demonstrated evidence of acute pulmonary hypertension, with an empty left ventricle and an over-distended right ventricle. In view of these findings and no improvement noted from on-going resuscitation, sodium bicarbonate was infused as a pulmonary vasodilator. Almost instantaneous return of spontaneous circulation was noted, with normalisation of cardiac parameters. We propose that in patients suspected with AFE and who have been unresponsive to advance cardiac life support measures, and where right ventricular failure is present with acidosis and/or hypercarbia, the use of sodium bicarbonate should be considered.

Algorithm-based coagulation management of catastrophic amniotic fluid embolism.

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.