Amniotic fluid embolism vs. pulmonary artery embolism – challenges in therapy and diagnosis based on a case report

Introduction This case report shows the challenges to diagnose correctly the rare cases of amniotic fluid embolism (AFE) and pulmonary embolism (PE). In this case we saw the diagnostic criteria for both types of embolism partly fulfilled and a dramatic further course, which finally led to an acceptable outcome due to high level of intensive care at a university hospital.

Case presentation The 32-y G4/P0 woman presented with PROM at 40+6 pregnancy weeks.

Her obstetric history showed two surgical abruptions and one drug induced abruption. No allergies, normal BMI, no other surgical history or previous illness were reported.

After 24h we induced the birth with misoprostol orally. In the course we decided to perform cesarean section because of obstructed labour and a persistent pathological CTG by cervix opening of 8cm.

During the disinfection in the theater, a swollen right leg was reported.

Instantly after detaching the baby from the placenta, patient passed out after problems with speaking showing dilated, fixed and asymmetric pupils and had a cardiac arrest with asystole after some seconds. We started immediately CPR. During CPR a severe intraabdominal bleeding occurred. Clotting parameters got worse due to DIC ([Fig. 1]).

Fig. 1  acute coagulopathy with thrombocytopenia due to DIC, low fibrinogen and prolonged clotting time.

We had no return of spontaneous circulation. After 50 minutes an extracorporal life support (ECLS) was successfully installed. Mass transfusion of blood products was performed during the whole operation because of the massive blood loss (20 RBCs). The patient was transferred to intensive care unit.

Result In our case we saw an extended thromboembolic event and many criteria for an AFE fulfilled, which made it challenging to find the correct therapy. DIC and neurological symptoms are more likely to occur in AFE. Our patient was hemodynamic instable after seconds post-delivery and had a total cardiac arrest without any ROSC until ECLS was installed. The coagulopathy occurred quite fast after the initial event (Figure 1.). Body-CT after surgery showed a subsegmental pulmonary artery embolism of right inferior lobe and a total thromboembolic occlusion of the right iliac vein and proximal femoral vein.

Discussion The leading therapy aim in the acute situation was to restore the patient circulation and oxygenation, which was just possible by using an ECLS. The other problem was the extensive bleeding due to DIC and liver injury caused by CPR, which made an acute therapy for the thrombosis impossible.

Finally, the cause of the cardiac arrest may stay unclear and seeing all facts, diagnostics and interventions together, we may saw a very rare case of AFE and pulmonary artery embolism at the same time.

Publication History

Article published online:
15 November 2023