UTILIZATION OF POINT-OF-CARE ULTRASOUND AND ROTATIONAL THROMBOELASTOMETRY TO DIAGNOSE AND MANAGE AMNIOTIC FLUID EMBOLISM PRESENTING AS POST-PARTUM HEMORRHAGE AND CARDIAC ARREST

ABSTRACT

TOPIC Critical Care TYPE Medical Student/Resident Case Reports INTRODUCTION: Amniotic fluid embolism (AFE) is a life-threatening obstetrical emergency. Despite its clinical significance there is little guidance on diagnosis and management[1, 2, 3]. In the absence of more specific diagnostic guidelines, point-of-care ultrasound (POCUS) in combination with rotational thromboelastometry (ROTEM) can aid in the diagnosis and management of AFE and have a significant impact on clinical outcomes[4]. CASE PRESENTATION A 29-year-old, previously healthy, gravida 1 female presented at 39 weeks' gestation for induction of labor due to gestational diabetes and concerns surrounding the COVID-19 pandemic. The patient was laboring for approximately 10 hours when she suddenly started to feel nauseous, lightheaded, and subsequently suffered a syncopal episode complicated by fetal bradycardia. She was tachycardic, poorly responsive and in respiratory distress. She was transferred to the operating room (OR) for emergency Cesarean section. After the uterine incision, the intubated patient developed circulatory collapse followed by a sinus tachycardia pulseless electrical activity (PEA) arrest. Chest compressions were initiated, and the hospital code/resuscitation team was called to the OR. The patient started bleeding from her incision leading to an initial diagnosis of hemorrhagic shock. The code team, equipped with point-of-care ultrasound skill obtained an apical 4-chamber view (Figure 1) that revealed a severely dilated and hypokinetic right ventricle, and a hyperdynamic, underfilled left ventricle. The ultrasound findings in combination with significant bleeding were felt to be consistent with AFE not hemorrhagic shock and the extracorporeal membrane oxygenation (ECMO) team was activated for bedside cannulation. ROTEM (Figure 2) demonstrated markedly prolonged clotting time, prolonged clotting formation time and very low clot amplitude consistent with DIC, further supporting the diagnosis of AFE and prompted the difficult decision to withhold heparin after VA-ECMO cannulation. Following stabilization, patient was transferred to the intensive care unit with a diagnosis of AFE complicated by DIC and post-partum hemorrhage. She left the hospital with no physical or neurologic deficits 31 days later with her healthy baby boy. DISCUSSION: The description of POCUS use during cardiovascular resuscitation in the setting of AFE and other obstetric emergencies is rare. Identifying a dilated right ventricle on ultrasound can narrow the diagnosis of circulatory collapse in the peripartum patient to pulmonary embolism (PE) and AFE. ROTEM can help differentiate AFE from PE by identifying DIC with one study estimating the occurrence of DIC in PE at 1 % compared to 30-77% in AFE[5]. CONCLUSIONS: The use of POCUS and ROTEM in the diagnosis and management of AFE can guide lifesaving clinical decision making in the peripartum patient who develops circulatory collapse followed by cardiac arrest. REFERENCE #1 Sitaula S, Das D, Sitaula S, Chhetry M. Amniotic fluid embolism A rare cause of maternal collapse-A case report. Clin Case Rep. 2020;8(12)3359-3361. Published 2020 Oct 26. doi10.1002/ccr3.3433 REFERENCE #2 Loughran JA, Kitchen TL, Sindhakar S, Ashraf M, Awad M, Kealaher EJ. Rotational thermoelectrometry (ROTEM®)-guided diagnosis and management of amniotic fluid embolism. Int J Obstet Anesth. 2019;38127-130. doi10.1016/j.ijoa.2018.09.001 REFERENCE #3 Rath WH, Hoferr S, Sinicina I. Amniotic fluid embolism an interdisciplinary challenge epidemiology, diagnosis and treatment. Dtsch Arztebl Int. 2014;111(8)126-132. doi10.3238/arztebl.2014.0126 DISCLOSURES No relevant relationships by Angela Phillips, source=Web Response No relevant relationships by David Tierney, source=Web Response