J7Accid Emerg Med 1996;13:285-286 285

CASE REPORTS J Accid Emerg Med: first published as 10.1136/emj.13.4.285 on 1 July 1996. Downloaded from

Amniotic fluid : emergency management

S A Syed, C H Dearden

Abstract Initial blood tests showed a picture of dis- A case of successful outcome is described seminated intravascular (DIC) in a patient with embolism with depletion ofplatelets, clotting factors, and presenting to the accident and emergency fibrin and an increase in fibrin degradation department. Diagnostic features and guide- products: Hb 12-7 g/dl on admission, dropping lines for management are outlined. to 5-7 g/dl six hours later, platelets 58 000/lI, (_Accid Emerg Med 1996;13:285-286) prothrombin time 25A4 s (normal 15-19 s), PTTK 73 1 s (normal 39-51 s), thrombin Key terms: Amniotic fluid embolism; diagnosis; clotting time 34-4 s (normal 14-16 s), managment fibrinogen titre 0 7 g/litre (normal 2-5 g/litre), fibrin degradation products 320 pLg/ml (normal Amniotic fluid embolism is the most devas- <10 ,ug/ml). Treatment for DIC was started. tating condition known in pregnant women. The obstetrician felt that the diagnosis was The incidence is reported as 1 in 80 000 amniotic fluid embolism. was deliveries in England and Wales. The mortality thought to be an unlikely diagnosis because rate is 86% with 50% ofdeaths occurring in the there had been no pre-eclampsia in the first hour of the onset of symptoms.1 2 ; however, management of the two conditions with this presentation would have Case report been the same. He carried out an emergency A 36 year old pregnant woman arrived in the and evacuation of the uterus. accident and emergency (A&E) department at Some old clots were present in the uterus from 4.35 am. She was cyanosed, fitting, and had no the previous threatened and there was palpable pulse or recordable blood pressure. also fresh blood present. By the completion of At about 4.15 am she had got out of bed to surgery the patient had received 1-5 litres of go the the lavatory. Her husband, a general crystalloid, 1 litre of colloid, 2 units of practitioner, heard a bump and found his wife 0-negative uncrossmatched blood, 10 units of http://emj.bmj.com/ lying beside the wash basin. She was having a packed cells, some group specific and some generalised convulsion and had a small scalp crossmatched, 20 units of cryoprecipitate, 4 laceration. She was at 20 weeks gestation with units of fresh frozen plasma, and 6 packs of a twin pregnancy. She had maintained good platelets. Her pulse was 110 beats/min and health and had had normal deliveries in each blood pressure 100-l 10 mm Hg systolic. of her three previous . In this preg- She was transferred to the intensive care unit

nancy she was known to have a minor degree where she was electively ventilated for 48 on September 28, 2021 by guest. Protected copyright. of with an admission to hos- hours. Her cardiovascular indices and coagul- pital two weeks previously with some vaginal ation screen showed continuous improvement. bleeding. She had suffered no hypertension or Urinary output remained normal. She was . extubated two days after her presentation and Initial treatment consisted of external car- made an uneventful recovery with no perma- diac massage, intubation, ventilation, and nent sequelae. intravenous fluids in large volume. A wedge (foam pillow, blanket) was placed under the Discussion patient's right lumbar region to prevent Clark3 postulates that amniotic fluid embolism compression of the inferior vena cava by the occurs when abnormal amniotic fluid enters gravid uterus. She had pinpoint petechial the maternal circulation: normal amniotic fluid haemorrhages over the chest wall and bleeding may enter without ill effect. The two main from the nose, mouth, vagina, and needle pathological effects are haemodynamic col- puncture sites. lapse and coagulopathy. A biphasic model' 3 The initial differential diagnosis included has been postulated to describe the haemo- Accident and eclampsia, sepsis with a possible coagulopathy, dynamic consequences. The initial response to Emergency or subarachnoid haemorrhage. A neurosur- the amniotic fluid is vasospasm with resul- Department, Royal geon and obstetrician were called. tant transient pulmonary and Victoria Hospital, hypertension Belfast BT12 6BA, After resuscitative measures her blood profound . This phase lasts 15-30 United Kingdom pressure improved to 70-80 mm Hg systolic. minutes, and may account for the 50% of S A Syed The neurosurgeon felt that the history of head patients who die in the first hour. The second C H Dearden injury and the presence of fitting indicated the phase involves left heart failure with a variable Correspondence to: Dr C H Dearden. need to exclude intracranial pathology. A secondary increase in pulmonary artery pres- Accepted for publication computerised tomography scan of the brain sure and return to normal right heart function. 24 January 1996 revealed no abnormality. The left ventricular failure may be due to 286 Syed, Dearden

hypoxic injury to the left ventricle secondary wide bore cannulae should be obtained. The J Accid Emerg Med: first published as 10.1136/emj.13.4.285 on 1 July 1996. Downloaded from to reduced coronary artery blood flow or preload should be optimised by giving rapid myocardial depression.3-5 infusion of intravenous fluids, and dopamine In addition to the haemodynamic collapse, should be used to improve the left ventricular 40% ofpatients develop coagulopathy, ranging failure. from DIC to a minor disturbance of platelet count. The mechanism is not clearly under- Coagulopathy stood but the potent thromboplastic-like As soon as there is any concern, 15 ml of blood effects of trophoblast are well recognised and should be taken and used as follows: 2 5 ml may trigger the coagulopathy. into EDTA for full blood count with emphasis on the packed cell volume and platelet coufit; CLINICAL PRESENTATION 4-0 ml into citrate for coagulation screen and The condition most frequently presents during fibrin degradation products, and the rest into labour but cases have been reported in first and a plain tube for cross matching. All these tests second trimester abortion and as late as 48 are straightforward and should be available hours postpartum. from any routine haematology laboratory; a The first symptom is the sudden onset of high powered coagulation laboratory is not dyspnoea and , which is often necessary. followed in minutes by cardiovascular collapse Once the blood has been taken, treatment and respiratory arrest. In 10-20% of cases should be begun before the results of the tests these initial events may be heralded by seizure- are known. Fresh frozen plasma (FFP) does like activity, as in this case. The fall against the not have to be cross matched but should be the wash basin was obviously due to the cardio- same ABO and rhesus group as the patient. vascular collapse. In 40/o of patients this is While waiting for FFP and blood, circulating followed by coagulopathy. In 10-15% of volume must be restored with plasma sub- patients coagulopathy may be the presenting stitutes to avoid renal shutdown. If effective manifestation1 2 6 circulation is restored without too much delay, fibrin degradation products will be cleared DIAGNOSIS from the blood mainly by the liver, which will This is based on the clinical presentation of further aid restoration of normal haemostasis. cardiovascular collapse and the laboratory This is an aspect ofmanagement which is often findings of coagulopathy in a pregnant woman. not appropriately emphasised. '° The differential diagnosis includes aspiration pneumonia, acute myocardial infarction, CONCLUSIONS pulmonary embolus, and in cases where coa- Amniotic fluid embolism is a rare but gulopathy is a dominant feature, placental dangerous complication of otherwise normal abruption, septic abortion, intrauterine infec- pregnancy. The rapid onset means that these tion, pre-eclampsia, and eclampsia. Blood patients may present to the A&E depart- http://emj.bmj.com/ abnormalities show depletion of fibrinogen, ment. The condition carries a high mortality platelets, and other clotting factors, increase in which may be reduced by aggressive early fibrin degradation products, and prolonged resuscitation. partial thromboplastin and prothrombin We are grateful to the patient, her husband and Dr D Boyle, times. consultant obstetrician, for permission to report this case; Squamous cells and other debris of fetal Dr C Boyd, heamatologist, for advice about coagulopathy; and Mrs M Loughran for typing the manuscript. origin may be demonstrated in blood aspirated on September 28, 2021 by guest. Protected copyright. from the central veins of pulmonary artery 1 Clark SL. Amniotic fluid embolism. Clin Perinatol 1986; circulation. Recent studies of pregnant women 13:801-11. undergoing pulmonary artery catheterisation, 2 Morgan M. Amniotic fluid embolism. Anaesthesia 1979; 34:20-32. however, have shown that the detection of 3 Clark S. New concepts ofamniotic fluid embolism: a review. squamous cells in the maternal pulmonary Obstet GynecolSurv 1990;45:360-7. 4 Courtney LD. Coagulation failure in pregnancy. BMJ artery circulation is a common finding and not i:691. diagnostic of amniotic fluid embolism.7-9 5 Richards DS, Carter LS, Corke B, Spielman F, Cefalo RC. The effect of human amniotic fluid on the isolated perfused rat heart. Am Jf Obstet Gynecol 1988; TREATMENT 158:210-14. 6 Courtney LD. Amniotic fluid embolism. Obstet Gynecol Surv The three goals of treatment are aggressive 1974;29: 169-72. oxygenation, treatment of circulatory collapse, 7 Clark SL, Pavlova A, Hornstein J. Squamous cells in the maternal pulmonary circulation. Am J Obstet Gynecol and combating the coagulopathy. 1986;154:104-6. 8 Lee W, Ginsburg KA, Cotton DB, Kaufman RH. Squamous and tropho-blastic cells in the maternal Circulatory collapse pulmonary circulation identified by invasive haemo- In patients with no cardiac output, cardiopul- dynamic monitoring during the peripartum period. Am J Obstet Gynecol 1986;155:999-1001. monary resuscitation is begun. Oxygen should 9 Plauche WC. Amniotic fluid embolism. Am _J Obstet Gynecol be given at high concentrations and uncon- 1983;147:982. 10 Letsky EA. Coagulation problems during pregnancy. scious patients should be immediately intu- In: Disseminated intravascular coagulation. Edinburgh: bated and ventilated. Intravenous access with Churchill Livingstone, 1985.