Scholarly Review of NEJM Case Study of Amniotic Fluid Embolism

Background: Amniotic Fluid Embolism (AFE) is an unpredictable and rapidly-progressing obstetric emergency producing acute cardiovascular, hemodynamic and hematologic abnormalities. The annual incidence of AFE is difficult to determine but is estimated to be anywhere from 1 in 8,000 to 1 in 80,000 deliveries. Case Presentation: A 35-year-old African American G4P1021 female presented to labor and delivery at 36.4 weeks gestation for planned cesarean section. During the course of the pregnancy, she was diagnosed with an anteriorly placed placenta and complete placenta previa, and was evaluated twice for vaginal bleeding. Shortly after delivery of a healthy infant, the uterus became blanched with minimal bleeding. The patient became unresponsive and was noted to be in pulseless electrical activity with normal sinus rhythm on the monitor; resuscitation measures were initiated. Hysterectomy was required to control uterine hemorrhage. Transesophageal echocardiogram showed acute right ventricular failure and labs were consistent with disseminated intravascular coagulopathy. To increase preload and cardiac contractility and decrease afterload, inotropic agents and inhaled nitric oxide were administered. She received pRBCs (15 units), FFP (15 units), platelets (18 units) and cryoprecipitate (500 mL) to address her blood loss and coagulopathy. Tranexamic acid was also administered to prevent fibrin degradation. The patient stabilized in the cardiac surgical ICU and continued to show improvement, culminating in her discharge on postoperative day 5. Conclusions: This case illustrates a favorable outcome following a rare, commonly fatal, occurrence of AFE in a highly complicated pregnancy.