CASE REPORT: Maternal death after intrapartum saline amnioinfusion—report of two cases

Abstract

Case reportIntrapartum transcervical amnioinfusion is an accepted therapeutic measure in the presence of variable decelerations with or without meconium-stained amniotic fluid. 1 Widely varying protocols are being used and have been thought to be safe.2 Amniotic fluid embolism and or pulmonary oedema in patients undergoing amnioinfusion have been described in six cases reports although no causal link has been established. We report two fatal cases of probable amniotic fluid embolism after saline amnioinfusion. Case 1A 23-year-old nulliparous woman presented to our hospital at 41 þ2 weeks of gestation with vaginal leakage of clear fluid for 5 hours. She was previously well and her pregnancy had been uncomplicated. On examination she was not anaemic, there was no tachycardia or fever and her blood pressure was 110/70 mmHg. Examination of her abdomen revealed a single term fetus in a cephalic presentation with reduced amniotic fluid. The uterus was soft with the vertex was at the pelvic brim and there were normal fetal heartbeats on auscultation. A vaginal examination confirmed ruptured membranes and revealed a soft, partly effaced cervix with a closed os.Prostaglandin E 2 gel (0.5 mg) was administered intracervically for cervical ripening with a second dose of 0.5 mg given 6 hours later. Five hours after the second dose, the uterus was contracting regularly and intermittent auscultation of the fetal heartbeat revealed no abnormality. Vaginal examination revealed that the cervix was fully effaced and 3 cm dilated. The membranes were absent and thick meconium-stained amniotic fluid was draining. An amnioinfusion with normal saline infused under gravity was administered through a transcervical sterile rubber catheter and labour was augmented with an infusion of 2.5 mU/ minute oxytocin. The infusion rate was not changed through labour. A total of 1000 mL of saline was infused into the amniotic cavity over 1 hour 40 minutes. Within 3 hours of starting the amnioinfusion, the patient was found to be in second stage and had a spontaneous vaginal delivery of a 2.7-kg fetus in good condition. No additional oxytocics were administered at delivery. Immediately after delivery of the placenta, the patient had acute dyspnoea, hypotension, tachycardia, cyanosis and frothing at the mouth, which quickly evolved into a full cardiac arrest. The patient was intubated and cardiopulmonary resuscitation initiated promptly but she could not be revived. There had been no postpartum haemorrhage or trauma to the genital tract. The relatives did not give permission for a postmortem examination. Case 2A 23-year-old woman with two living children (G3P2) presented at 40 weeks of pregnancy with vaginal leakage of fluid and labour pains. She had been previously well and her pregnancy had been uneventful. On examination she was not anaemic or pyrexial, and her blood pressure was 100/60 mmHg. Abdominal examination revealed a single term fetus in a cephalic presentation, with reduced amniotic fluid and mild uterine contractions every 5 minutes. On au...

Intrapartum amnioinfusion for meconium‐stained amniotic fluid: a systematic review of randomised controlled trials

“…Complications including uterine overdistension and hypertonia, uterine rupture in association with previous uterine scar, fetal heart rate abnormality, umbilical cord prolapse, and chorioamnionitis have been reported. [47][48][49][50] In summary, our main meta-analysis that is based on trials with high-quality scores suggests no evidence of effectiveness of AI in the reduction of the risk of MAS in clinical settings with standard peripartum surveillance. However, in settings with limited peripartum surveillance, AI appeared to reduce the risk of MAS.…”

Obstetric approaches to the prevention of meconium aspiration syndrome

“…Complications including uterine overdistension and hypertonia, uterine rupture in association with previous uterine scar, FHR abnormality, umbilical cord prolapse and chorioamnionitis have been reported. [56][57][58][59] Four cases of maternal deaths have been reported associated with the AI. 58,59 Several authors have reported the occurrence of excessive uterine contractions or unusually rapid labor progress related to AI.…”

“…[56][57][58][59] Four cases of maternal deaths have been reported associated with the AI. 58,59 Several authors have reported the occurrence of excessive uterine contractions or unusually rapid labor progress related to AI. In the AI group of Fraser et al's 55 trial, 10 women (1.1%) experienced bleeding, and in 63 (6.9%) women, hypertonicity, hydramnios or uterine overdistension was diagnosed during the procedure whereas the incidence of other maternal complications were comparable between AI and control groups.…”

Fruchtwasserembolie

“…Kochsalzlösung zur Mekoniumaspirationsprophylaxe wurden mehrere Fälle mit Fruchtwasserembolie beschrieben [12]. Ein stumpfes Bauchtrauma kann ebenfalls zur Fruchtwasserembolie führen [13].…”