On a prenatal visit 6 weeks prior, her hemoglobin was 12 g/dL and platelets 254,000/mm 3. This 34-year-old gravida 3 para 2 woman had a 9-year-old and a 7-year-old from uncomplicated pregnancies. At 19:09 attempted resuscitation was halted and the patient pronounced dead, 54 minutes after the onset of dyspnea. Despite repeated defibrillation, at 19:02 she became asystolic. At 18:59 the patient developed ventricular fibrillation. Additional fluid infusion was to no avail. Endotracheal epinephrine briefly boosted the heart rate to 130/minute, but still without a pulse. She remained without a carotid pulse and unresponsive to atropine and epinephrine. The patient's cardiovascular status did not improve after delivery. The baby's Apgar scores were 4 at 1 minute and 8 at 5 minutes. An emergency cesarean section was performed. The patient was intubated and ventilated with 100% oxygen, but remained cyanotic. Cardiopulmonary resuscitation was initiated. At approximately 18:30 she became pulseless. An emergent sonogram showed a heart rate around 60/minute and dropping. The fetal heart rate was difficult to ascertain with the electrode. Fetal heart tones were difficult to auscultate externally and a fetal scalp electrode was applied. The patient initially had a palpable pulse and sustained respiratory effort. An anesthesiologist, who had been in the next room, entered the room and found the patient unresponsive and cyanotic, with tonic-clonic seizure activity. The husband ran out of the room to summon help. Labor proceeded uneventfully, with the cervix dilated to 5 cm, until about nine hours after admission.Īt approximately 18:15, according to the husband, the patient sat up and reported the sudden onset of deep back, rib and flank pain, and shortness of breath. A total of 24 MU of oxytocin was given from 13:30 to 18:15. An intravenous infusion of lactated Ringer's solution was started, and the patient received prophylactic penicillin. At 10:15 the patient's hemoglobin was 11.6 g/dL. Fetal heart rate was normal at 120-130/minute. The patient's temperature was 36.3 o C, pulse 86/minute, blood pressure 135/85 mm Hg and respirations 20/minute. Her outpatient medications included only salmeterol/fluticasone inhaler for asthma, and prenatal vitamins. She was having irregular mild contractions. ©2018 American Association of Critical-Care Nurses.This 35-year-old mother of two was admitted to an urban hospital in the Midwest USA at 37 4/7 weeks gestation at 09:21 with spontaneous rupture of membranes since 04:00. Staff debriefing and psychological support for the woman and family are vital.Īmniotic fluid embolism critical care disseminated intravascular coagulation heart failure posttraumatic stress. Treatment is supportive, with a focus on reversal of hypoxia and hypotension, delivery of the fetus, and correction of coagulopathy. Diagnosis is by exclusion and clinical presentation. The presentation is abrupt, with profound cardiovascular and respiratory compromise, encephalopathy, fetal distress, and disseminated intravascular coagulopathy. Risk factors may include maternal age over 35 years and conditions in which fluid can exchange between the maternal and fetal circulations. This complication may result from activation of an inflammatory response to fetal tissue in the maternal circulation. The condition occurs in approximately 1 in 40 000 births and has an average case-fatality rate of 16%. Amniotic fluid embolism is a rare, unpredictable, and often catastrophic complication of pregnancy that is suspected in a woman who experiences cardiac arrest after a cesarean section. Obstetric emergencies often require intensive care intervention.
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