Amniotic fluid embolus

Abstract

Case reportIn 1987, a 27-yr-old healthy woman presented for an elective Caesarean section. She had had a previous Caesarean section under general anaesthesia without difficulty. There were no problems found on history or physical examination. The patient decided after discussion with her general practitioner and anaesthetist to have an epidural an- Accepted for publication 25th June, 1993. aesthetic for pain control. Haemoglobin and urinalysis were normal. She was given 30 ml Na citrate outside the OR.At 08:00 a continuous epidural catheter was inserted with the patient in the seated position with no difficulty. The patient was positioned with a wedge under her right hip. Intermittent injections to a total of 22 ml lidocaine 2% with epinephrine were placed in the epidural space. One litre of normal saline was given /v. The monitors were a hard copy blood pressure (BP) showing normal fluctuating BP and pulse and an ECG. The epidural level was tested and found to be at the T~_ 6 level. Surgery started 20 min after the epidural was inserted. The patient was carrying on a normal social conversation.At 08:45 (as the head of a normal crying infant was delivered through the anterior abdominal wall) the mother suddenly complained of shortness of breath (SOB), began to hyperventilate, coughed and became cyanosed. The blood pressure decreased, the sinus heart rate increased, and she may have suffered a seizure (there was thrashing of both arms). Almost immediately BP and pulse on the Dinemapp recorder were undetectable (Table I -8:48) but the ECG showed sinus tachycardia. The airway was managed initially with mask and oxygen and then the trachea was intubated without difficulty. Breathing was managed initially with mask ventilation with oxygen and continued with bag ventilation through the endotracheal tube. There was no bronchospasm and air entry was equal bilaterally.Circulation was managed by the infusion of fluid, drugs which included ephedrine, epinephrine, NaHCO3, isuprel and atropine, and cardiac massage. Other drugs given included Na citrate preoperatively, succinylcholine, atracurium, thiopentone, and oxytocin. At various times another anaesthetist, two intensive care physicians and nurses were in the operating room observing and helping with the resuscitation. These manoeuvres were successful in returning blood pressure but the patient remained cyanosed in spite of an adequate blood pressure and positive pressure ventilation with 100% 02.The blood pressure decreased a second time (Table I -9:01) and again the patient was resuscitated. The fwst inadequate blood pressure (taken from the Dinemapp) was recorded at 08:48 (only one reading at this level). The total time between adequate blood pressures was seven minutes. The total time of inadequate blood CAN J ANAESTH 1993 / 40:I0 / pp 971-80

The Amniotic Fluid Embolism Syndrome: 10 Years' Experience at a Major Teaching Hospital

“…In addition, leukotrienes and other arachidonic acid metabolites have been shown to have procoagulant activity (23). The mechanism of DIC may also relate to tissue damage caused by the effects of hypoxaemia and a low cardiac output (21).…”

Amniotic fluid embolism

“…36 Components of the¯uid which may be demonstrated include epithelial squames shed from fetal skin, lanugo hair, vernix caseosa, mucin and bile pigments deriving from meconium, and decidual cells. The foramen ovale does not completely close after birth in 35% of the normal population and in others may re-open during the early phase of severe pulmonary hypertension which is seen during AFE.…”

“…26 16 12 134 1.4 Cardiac index 15 43 28 14 ± 2.28 Cardiac index 16 46 18 9 156 41 17 36 13 12 ± 8.1 Cardiac Output * Normal values 13 + 5 mm Hg, mean + SD. 26 16 12 134 1.4 Cardiac index 15 43 28 14 ± 2.28 Cardiac index 16 46 18 9 156 41 17 36 13 12 ± 8.1 Cardiac Output * Normal values 13 + 5 mm Hg, mean + SD.…”

Case 9-1998

“…Most reports have documented normal-to-decreased cardiac output and normal pulmonary-artery pressure associated with pulmonary edema or the adult respiratory distress syndrome. [11][12][13] In a model involving a catheterized goat, Hankins et al 14 reported a transient marked pressor response in both the systemic and pulmonary circulations, with a minimal, brief increase in cardiac output. If the amniotic fluid contained meconium, however, the cardiac output was sharply depressed, with an even greater vascular pressor response.…”