"A JAR FULL OF PINK FROTH": AN ATYPICAL CASE OF AMNIOTIC FLUID EMBOLISM AFTER A DILATION AND CURETTAGE AT SEVEN WEEKS GESTATION

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Amniotic fluid embolism (AFE) is one of the leading causes of death during pregnancy in developed countries. It is an uncommon, life-threatening complication often associated with advanced maternal age, multi-parity, and placental rupture. It is extremely rare in the first trimester, as the small amount of amniotic fluid and fetal cells are unlikely to breach the maternal circulation. Here, we present an atypical case of AFE occurring at 7 weeks gestation. CASE PRESENTATION: The patient is a healthy 29-year-old nulliparous woman who developed acute onset chest pain, dyspnea, and productive cough with pink frothy sputum within 30 minutes of dilation and curettage (D&C), which she underwent after spontaneous abortion at 7 weeks gestation. Her symptoms were accompanied by acute hypoxemic respiratory failure, shock, and coagulopathy. She did not have any rash or skin changes. Computed tomography angiography of the chest was negative for pulmonary embolism but showed bilateral patchy opacities in all lobes. Transthoracic echocardiogram showed normal biventricular and valvular function. The patient required supportive care with as many as three vasopressors and Bilevel Positive Airway Pressure at 100% FiO2 and left the intensive care unit after approximately 72 hours. She was discharged home after 7 days, by which time she had fully recovered. DISCUSSION: Amniotic fluid embolism is a diagnosis of exclusion, without rapid and accurate diagnostic options available. For this reason, early and atypical cases of AFE are likely underreported. In AFE, the normal physiology is altered due to increased immunological response upon physical breach of amniotic fluid into maternal circulation, releasing procoagulant and vasoactive mediators to cause anaphylactic reaction to the fetal antigen (1). Hence, the imbalance can cause multi-organ failure, exhibited through a classic triad of hypotension, hypoxia, and coagulopathy that were demonstrated in our case without clear etiology for shock and respiratory decompensation. Management is focused on adequate cardiovascular, pulmonary, and hematologic support. Because no cases of recurrence have been reported, current data suggests successful subsequent pregnancies (2). CONCLUSIONS: Our case highlights a patient at 7 weeks gestation with unexplained shock, respiratory failure, and coagulopathy less than 1-hour status post D&C, and may represent the earliest documented case of AFE. Diagnosis of AFE is based upon clinical findings and symptoms, with treatment focused on providing adequate hemodynamic support. Due to limited understanding of its pathophysiology, an emphasis on early diagnosis and treatment is critical to prevent significant mortality. REFERENCE #1: Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org, Pacheco LD, Saade G, Hankins GD, Clark SL. Amniotic fluid embolism: diagnosis and management. Am J Obstet Gynecol. 2016 Aug;215(2):B16-24. doi: 10.1016/j.ajog.2016.03.012. Epub 2016 Mar 14. PMID: 26987420. REFERENCE #2: 177: The risk of amniotic fluid embolism reoccurrence in subsequent pregnancy, Irene Stafford, Presley S. Parkes, Amir Moaddab, Miranda Klassen, Steven L. Clark, Michael A. Belfort, Gary A. Dildy, American Journal of Obstetrics and Gynecology, Volume 218, Issue 1, Supplement, https://doi.org/10.1016/j.ajog.2017.10.054. DISCLOSURES: No relevant relationships by Wahaaj Khan, source=Web Response No relevant relationships by Do Yun Kim, source=Web Response No relevant relationships by Andrew Toscano, source=Web Response