Extracorporeal Cardiopulmonary Resuscitation for Amniotic Fluid Embolism: Review and Case Report.

ABSTRACT: Amniotic fluid embolism (AFE) is a rare, sudden, and catastrophic complication of pregnancy that can result in cardiopulmonary arrest, potentially leading to death. The pathophysiology of an AFE includes an inflammatory and coagulopathic response due to fetal materials entering maternal circulation with the hallmark triad of symptoms: acute respiratory distress, cardiovascular collapse, and coagulopathy. Management of AFE should include high-quality cardiopulmonary resuscitation, immediate delivery of the fetus if applicable, early intubation to provide adequate oxygenation and ventilation, fluid volume resuscitation, and ongoing evaluation of coagulopathy. Priorities include thromoboelastography interpretation if available, control of hemorrhage and coagulopathy with blood component therapy, and cardiovascular support through inotropes and vasopressor administration. More recent approaches include implementing the A-OK (atropine, ondansetron, and ketorolac) protocol for suspected AFE protocol, extracorporeal cardiopulmonary resuscitation (ECPR), and extracorporeal membrane oxygenation (ECMO) therapies to increase survival and decrease complications. Venoarterial ECMO is the highest form of life support that provides support in patients with pulmonary and cardiac failure. ECPR is the application of Venoarterial ECMO during cardiopulmonary resuscitation in cases where the cause of arrest is believed to be reversible. Early implementation of ECPR during the acute phase of AFE can provide support for end-organ perfusion in place of the weakened and recovering heart while optimizing oxygenation, making venoarterial ECMO an ideal adjunctive therapy. Because of the rarity of AFE, many obstetrical teams may have limited prior experience in managing these catastrophic cases; however, with ongoing education and simulation, teams can be better prepared in the recognition and management of these life-threatening events.

Maternal Sepsis: Presentation, Course, Treatment, and Outcomes.

PURPOSE: The current adult definition of sepsis and septic shock, as developed in 1992, does not adequately define sepsis in the pregnant and peripartum women due to the alteration of sepsis presentation in the maternal population. The purpose of this study was to determine potential causative factors for sepsis with the aim of prevention and reducing morbidity and mortality. STUDY DESIGN AND METHODS: A descriptive observational design via a retrospective medical record review was used with a convenience sample of 22 women who were identified after admission as having sepsis. The setting was the labor and delivery unit of a large urban hospital in Fort Worth, Texas, with over 5,000 births per year. RESULTS: The most common diagnoses related to maternal sepsis included urinary tract infections, endometritis, chorioamnionitis, and wound infections. Main causative agents identified were predominantly Escherichia coli ( E. coli ), followed by group B streptococcus (GBS), and group A streptococcus (group A strep). The most prevalent presenting symptom was hypothermia or hyperthermia, followed by tachycardia. Primary laboratory results included above and below normal white blood cell count and elevated lactate levels. Sixty-four percent of patients diagnosed with sepsis were readmitted postpartum and 41% gave birth via cesarean. CLINICAL IMPLICATIONS: Findings are applicable for nursing care and maternal sepsis protocol development. Early identification of mothers at risk for maternal sepsis and tool development for early diagnosis would be beneficial to support the ongoing work on decreasing maternal morbidity and mortality that have a devastating effect on women, their families, and their health care team. Early warning signs of sepsis can be shared by nurses with new mothers and their families as part of routine postpartum discharge teaching so they know when to call their primary health care provider and when to seek care in person.

Posterior Reversible Encephalopathy Syndrome.

Posterior reversible encephalopathy syndrome (PRES) is a newly defined syndrome; therefore, this transient clinical condition is not well known and probably underdiagnosed. It develops quickly with symptoms that are usually indistinguishable from eclampsia. Nurses need to be knowledgeable and aware of identifying symptoms and appropriate treatment. The condition is thought to share pathophysiology with eclampsia, and it is suggested that endothelial dysfunction combined with hypertension causes disruption in the blood brain barrier resulting in cerebral edema. Seizures develop secondary to cerebral edema, and mark later stages of the disease. Treatment is aimed at reducing blood pressure (BP) with antihypertensive therapy and seizure control with magnesium sulfate. When PRES is treated early, symptoms typically disappear within a few days and imaging studies normalize in several weeks. Permanent brain damage can occur if diagnosis and treatment are delayed. If PRES is suspected, thorough focused assessments and increased communication among the healthcare team are essential for patient care. When pregnant or postpartum women present with elevated BP accompanied with neurologic symptoms, imaging studies should be considered. An exemplar case is presented of a woman with normal prenatal course that is complicated by rapidly developing preeclampsia, eclampsia, and PRES.

Amniotic Fluid Embolism.

Amniotic fluid embolism (AFE) is a rare but serious and potentially deadly complication of pregnancy that is unpreventable and unpredictable. Most AFE events occur during labor; however, approximately one third happen during the immediate postpartum period. Presentation is abrupt and thought to be an abnormal response to fetal materials entering maternal circulation through the placental insertion site. Care providers must recognize the signs and symptoms of AFE and react quickly to treat potential complications. This can be challenging as there are no set diagnostic criteria or specific laboratory tests. Generally, the diagnosis is based on clinical status when the classic triad of hypoxia, hypotension, and subsequent coagulopathy are noted in a laboring woman or woman who just gave birth, and no other plausible explanation can be determined. Proper treatment of AFE requires a multidisciplinary approach to decrease maternal morbidity and mortality. Knowledge, simulation, and familiarization of a Massive Obstetric Transfusion protocol can help all members of the perinatal team recognize and respond to women with AFE in a timely and effective manner. A case study is presented of a woman with a seemingly normal obstetric course that became complicated rapidly following development of an AFE.

Implementing Skin-to-Skin Care in the Operating Room After Cesarean Birth.

BACKGROUND: After vaginal birth, newborns who have been skin-to-skin (STS) with their mother have greater temperature and glucose stability and higher exclusive breastfeeding rates at discharge. There are minimal data about STS in the operating room (OR) after cesarean birth. Although implementing STS in the OR can be challenging, it may promote positive maternal and infant outcomes. PURPOSE: The purpose of this quality improvement project was to evaluate maternal satisfaction and maternal perception of pain when babies were placed STS immediately after cesarean birth in the OR. STUDY DESIGN AND METHODS: This quality improvement project was conducted at Baylor All Saints Medical Center-Andrews Women's Hospital, an urban, nonprofit, private hospital with an average of 5,000 births per year. Over a 90-day period, all women having cesarean birth were evaluated for two outcomes, maternal birth experience and pain perception during surgery. Following scheduled repeat cesarean, satisfaction of the birth experience was compared to the previous birth experience. Pain control during surgery of women having cesarean birth with and without STS was evaluated. Postpartum interviews with the new mothers and review of their anesthesia records were used to determine project findings. RESULTS: Maternal satisfaction was higher and maternal perception of pain was lower for women who experienced STS in the OR when compared to women where STS was not performed. CLINICAL IMPLICATIONS: Babies can be placed STS in the OR with positive implications for mothers' satisfaction with the birth experience and their perception of pain during the surgical procedure. Infant safety should be supported by a nurse with the mother and baby during the STS process.

Peripartum cardiomyopathy.

Peripartum cardiomyopathy is a very rare, but serious life-threatening emergency. Early recognition of signs and symptoms, along with radiologic imaging and blood work, can facilitate timely diagnosis. Once peripartum cardiomyopathy is diagnosed, a multidisciplinary team can facilitate the delivery of quality care to promote optimal outcomes.