A 43-year-old patient, gravida 6, para 5, at 39 weeks gestation has a brief generalized tonic-clonic seizure in the delivery room. She became disoriented, lightheaded, breathless, and cyanotic 20 minutes after an uncomplicated spontaneous vaginal delivery of a healthy neonate and placenta. Her pregnancy was uncomplicated, and she has no past medical history. Her blood pressure is 80/40 mm Hg, pulse is 110/min, and respirations are 30/min. Oxygen saturation is 75% on facemask. Examination shows an unconscious woman who is no longer seizing. A generalized purpuric rash and bleeding from the intravenous line site are seen. Which of the following is the most appropriate next step in management of this patient?

Question

A 43-year-old patient, gravida 6, para 5, at 39 weeks gestation has a brief generalized tonic-clonic seizure in the delivery room.  She became disoriented, lightheaded, breathless, and cyanotic 20 minutes after an uncomplicated spontaneous vaginal delivery of a healthy neonate and placenta.  Her pregnancy was uncomplicated, and she has no past medical history.  Her blood pressure is 80/40 mm Hg, pulse is 110/min, and respirations are 30/min.  Oxygen saturation is 75% on facemask.  Examination shows an unconscious woman who is no longer seizing.  A generalized purpuric rash and bleeding from the intravenous line site are seen.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da98_1743_bc81_33546e91e8c5_MD0003_00 This patient's presentation is concerning for respiratory failure from amniotic fluid embolism syndrome (AFES), a rare but catastrophic complication during pregnancy or shortly after delivery. This patient's risk factors include advanced maternal age and high gravida (>5 live births or stillbirths). Amniotic fluid can enter the maternal circulation through endocervical veins, placental insertion site, or areas of uterine trauma (eg, cesarean incision site). This leads to an inflammatory response causing vasospasm, cardiogenic shock, hypoxemic respiratory failure, and coagulopathy with disseminated intravascular coagulopathy (DIC). Hypoxia can lead to seizures and loss of consciousness, as in this patient. > AFES is diagnosed clinically after excluding other causes of sudden postpartum cardiorespiratory failure (eg, eclampsia, peripartum cardiomyopathy, pulmonary embolism). Treatment is mainly supportive to correct the hypoxemia (eg, oxygen, intubation, mechanical ventilation) and hypotension (eg, vasopressors). Early recognition with respiratory and hemodynamic support can reduce maternal and fetal mortality, but survivors have a high incidence of neurological damage. This patient did not improve with facemask ventilation and requires intubation with mechanical ventilation as the next step in improving the hypoxemia. (Choice A) Abdominal ultrasound can assess for intraperitoneal bleeding, which can be due to uterine rupture in a multiparous patient such as this. Although massive hemorrhage can cause hypotensive shock, this patient's rapid respiratory decompensation requires intubation for ventilatory support before performing ultrasound. (Choice B) Intramuscular or intravenous magnesium can prevent and treat eclamptic seizures. Although eclampsia can cause seizures in pregnancy, patients usually have hypertension. This patient's significant hypotension makes eclampsia less likely. In addition, magnesium can potentially lower the blood pressure. (Choice C) Furosemide can treat pulmonary edema and improve hypoxia due to fluid overload. Although pulmonary edema does commonly occur with AFES, this patient's respiratory failure requires initial intubation and mechanical ventilation before further treatment with furosemide. (Choice D) Heparin anticoagulation is generally indicated for pulmonary thromboembolism, which can cause acute cardiopulmonary failure. However, this patient's purpuric rash is concerning for DIC. Heparin should not be administered in a patient with significant bleeding or signs of platelet dysfunction. This patient's failing respiratory status must be managed first. Educational objective: Amniotic fluid embolism syndrome typically presents with rapid onset of respiratory failure, severe hypotension, and disseminated intravascular coagulopathy during labor or the immediate postpartum period. The diagnosis is made clinically, and management is supportive. Amniotic fluid embolism syndrome is rare, unpredictable, and associated with poor maternal and fetal outcomes. References: Amniotic fluid embolism. (http://www.ncbi.nlm.nih.gov/pubmed/19372342)

A 43-Year-Old Patient, Gravida 6, Para 5, at 39 Weeks