Amniotic fluid embolism and isolated disseminated intravascular coagulation

Abstract

Purpose

Disseminated intravascular coagulation (DIC) is a well-known complication of an amniotic fluid embolus. However, clinical experience has shown that, in some patients, clinical hemorrhage may be the initial presentation. Mortality in this subset of patients is high. This report describes a patient with a suspected amniotic fluid embolus who survived and in whom the initial presentation was post partum hemorrhage.

Clinical Features

During the post delivery repair of a fourth degree perineal tear a 29 yr old prima gravida was noted to have excessive vaginal bleeding despite a well contracted uterus. Laboratory investigations revealed a decrease in hemoglobin from 126 g·l−1 to 86 g·l−1 and a severe disseminated intravascular coagulopathy (PT 27.5 sec, APPT 149 sec, direct fibrinogen < 0.6 g·l−1, FDP > 640 g·l−1). Treatment included massive blood component therapy and, eventually, total abdominal hysterectomy. The patient subsequently recovered without sequelae. In the absence of any other explanation, the coagulopathy was considered to be secondary to amniotic fluid embolus.

Conclusion

Amniotic fluid embolus remains an important cause of maternal mortality. Clinical reports, reviews of the literature, and the development of the national registry have all contributed to our understanding of this syndrome. Contrary to earlier beliefs, not all patients present with sudden cardiorespiratory collapse. As the present case illustrates, a less common presentation is the development of an isolated DIC in the peripartum period without antecedent hemodynamic or respiratory instability. Therefore, anesthesiologists must maintain a high index of suspicion for the disorder in order to facilitate early recognition and treatment.

Résumé

Objectif

La coagulation intravasculaire disséminée (CIVD) est une complication connue de l’embolie du liquide amniotique. Cependant, l’expérience a démontré que, chez certaines patientes, l’hémorragie peut être le premier signe clinique. La mortalité est élevée dans ce sous-groupe de patientes. Nous décrivons ici le cas d’une patiente qui a survécu à une embolie probable du liquide amniotique dont le premier signe était une hémorragie post-partum.

Éléments cliniques

Pendant la réparation post-partum d’une déchirure périnéale du quatrième degré chez une primigeste de 29 ans, on a noté des saignements excessifs en dépit d’un utérus bien contracté. Les examens de laboratoires ont révélé une baisse de l’hémoglobine de 126 g·L−1 à 86 g·L−1 et une sévère coagulopathie intravasculaire disséminée (TP 27,5 sec, TPA 149 sec, le fibrinogène direct < 0,6 g·L−1, PDF > 640 g·L−1). Le traitement a consisté en transfusions sanguines massives et, finalement, en une hystérectomie abdominale complète. La récupération a été sans complications. En l’absence d’autre explication, la coagulopathie a été considérée secondaire à une embolie du liquide amniotique.

Conclusion

Lembolie du liquide amniotique demeure une cause importante de mortalité maternelle. Les résumés cliniques, les revues de littérature et la production d’un registre national ont tous contribué à nous la faire connaître. Contrairement à ce que nous pensions auparavant, les patientes ne présentent pas toutes un collapsus cardio-respiratoire soudain. Comme dans le cas actuel, une présentation plus rare est le développement d’une CIVD en période péripartum sans antécédents d’instabilité hémodynamique ou respiratoire. En conséquence, les anesthésiologistes doivent être vigilants face à ce problème afin d’en faciliter le diagnostic et le traitement précoces.

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Correspondence to Sharon Davies.

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Davies, S. Amniotic fluid embolism and isolated disseminated intravascular coagulation. Can J Anesth 46, 456–459 (1999). https://doi.org/10.1007/BF03012944

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Keywords

  • Obstet Gynecol
  • Amniotic Fluid
  • Disseminate Intravascular Coagulation
  • Disseminate Intravascular Coagulation
  • Post Partum Hemorrhage