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Amniotic fluid embolism with second trimester pregnancy termination: a case report

[Embolie amniotique lors d’une interruption de grossesse au deuxième trimestre : exposé d’un cas]

Barry K. Ray, MD^*, Manuel C. Vallejo, MD^*, Mitchell D. Creinin, MD, Kelly T. Shannon, MD^*, Gordon L. Mandell, MD^*, Bupesh Kaul, MD^* and Sivam Ramanathan, MD^*

^* From the Departments of Anesthesiology,
Obstetrics, Gynecology and Reproductive Sciences, Magee Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Address correspondence to: Dr. Manuel C. Vallejo, Magee Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA. Phone: 412-641-4260; Fax: 412-641-4766; E-mail: vallejomc{at}anes.upmc.edu

Purpose: Describe the diagnosis, clinical features, pathophysiology, treatment and anesthetic management of amniotic fluid embolism (AFE) in a patient undergoing second trimester pregnancy termination.

Clinical features: A 30-yr-old gravida 2, para 1, woman was admitted for a dilatation and evacuation procedure for underlying intra-uterine fetal demise in her second trimester of pregnancy. Hypotension, shock, respiratory arrest, pulseless electrical activity, hemorrhage, disseminated intravascular coagulopathy, requiring cardiopulmonary resuscitation and blood transfusion complicated her intraoperative care. AFE was considered the most likely cause of this intraoperative event.

Conclusions: It is now recognized that the pathophysiological features of AFE are similar to a type-1 hypersensitivity reaction ranging from mild systemic reaction to anaphylaxis and shock. AFE has a high maternal and fetal morbidity and mortality rate, requiring prompt recognition and treatment. In patients with cardiovascular instability, the treatment of AFE is similar to anaphylaxis requiring aggressive fluid hydration, cardiopulmonary resuscitation, administration of blood products and the use of vasopressors.