A 23-year-old woman, gravida 3 para 2, at 35 weeks gestation comes to the emergency department due to vaginal bleeding that started after intercourse, 2 hours prior to arrival, and has soaked through 3 perineal pads. The patient reports normal fetal movement and mild intermittent cramping but no leakage of amniotic fluid. Her only prenatal visit was at 7 weeks gestation, when an ultrasound was normal. The patient has a history of 2 prior cesarean deliveries at term. The first delivery was performed for a category III fetal heart rate tracing; the second was an elective repeat. The patient has a history of intravenous drug use and smokes a pack of cigarettes a day. She has no known drug allergies. Blood pressure is 130/70 mm Hg and pulse is 98/min. The fetal heart rate tracing is 140/min with moderate variability, accelerations, and no decelerations. The tocometer shows contractions every 5 minutes. On examination, the patient is in no distress. The abdomen is gravid, soft, and nontender. There is frank blood on the patient's perineal pad. A bedside ultrasound reveals a low, posterior placenta that extends over the internal cervical os. The patient continues to have heavy vaginal bleeding, and a cesarean delivery is performed under spinal anesthesia. The infant and placenta are delivered without difficulty. However, prior to repair of the uterine incision, the patient reports increasing shortness of breath and becomes unresponsive. Blood pressure is 70/40 mm Hg, pulse is 124/min, and respirations are 34/min. Pulse oximetry is 86% on room air. A lung examination reveals decreased breath sounds bilaterally. Endotracheal intubation is performed and the airway is secured. Profuse bleeding is noted from the uterine incision and placental bed. Examination of the Foley catheter reveals frank blood in the collection bag. Which of the following is the most likely diagnosis in this patient?

Question

A 23-year-old woman, gravida 3 para 2, at 35 weeks gestation comes to the emergency department due to vaginal bleeding that started after intercourse, 2 hours prior to arrival, and has soaked through 3 perineal pads.  The patient reports normal fetal movement and mild intermittent cramping but no leakage of amniotic fluid.  Her only prenatal visit was at 7 weeks gestation, when an ultrasound was normal.  The patient has a history of 2 prior cesarean deliveries at term.  The first delivery was performed for a category III fetal heart rate tracing; the second was an elective repeat.  The patient has a history of intravenous drug use and smokes a pack of cigarettes a day.  She has no known drug allergies.  Blood pressure is 130/70 mm Hg and pulse is 98/min.  The fetal heart rate tracing is 140/min with moderate variability, accelerations, and no decelerations.  The tocometer shows contractions every 5 minutes.  On examination, the patient is in no distress.  The abdomen is gravid, soft, and nontender.  There is frank blood on the patient's perineal pad. A bedside ultrasound reveals a low, posterior placenta that extends over the internal cervical os.  The patient continues to have heavy vaginal bleeding, and a cesarean delivery is performed under spinal anesthesia.  The infant and placenta are delivered without difficulty.  However, prior to repair of the uterine incision, the patient reports increasing shortness of breath and becomes unresponsive.  Blood pressure is 70/40 mm Hg, pulse is 124/min, and respirations are 34/min.  Pulse oximetry is 86% on room air.  A lung examination reveals decreased breath sounds bilaterally.  Endotracheal intubation is performed and the airway is secured.  Profuse bleeding is noted from the uterine incision and placental bed.  Examination of the Foley catheter reveals frank blood in the collection bag.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c01e_1545_8f63_0dbe81729046_MD0005_00 This patient has acute-onset hypoxemia, hypotension, and disseminated intravascular coagulopathy (eg, hematuria, hemorrhage), a presentation consistent with amniotic fluid embolism syndrome (AFES). AFES, a rare but catastrophic complication of pregnancy, typically occurs during labor or in the immediate postpartum period. Amniotic fluid enters the maternal circulation through the endocervical veins, the placental implantation site, or areas of uterine trauma (eg, cesarean incision site). The amniotic fluid triggers a massive anaphylactoid reaction that results in vasospasm, cardiogenic shock, pulmonary edema, respiratory failure, seizures, and disseminated intravascular coagulation. Risk factors for AFES include cesarean/operative delivery, placenta previa, and abruptio placentae. Treatment is supportive, focused on correcting hypoxemia (eg, oxygen, intubation) and hypotension (eg, vasopressors, transfusion). AFES is associated with a high risk of maternal and neonatal mortality and, among survivors, a high risk of significant neurological sequelae. placenta previa abruptio placentae (Choice B) High spinal anesthesia occurs when the local anesthetic agent used in neuraxial anesthesia spreads to a more cephalad spinal level than intended. High spinal anesthesia typically presents with hypotension due to loss of sympathetic response and dyspnea due to paralysis of the diaphragm and other respiratory muscles. There is no associated coagulopathy, making the diagnosis unlikely for this patient. (Choice C) Peripartum cardiomyopathy typically presents in the late third trimester or early postpartum period with symptoms of heart failure (eg, dyspnea, orthopnea, hemoptysis, pedal edema). There is no associated coagulopathy, making this diagnosis unlikely. (Choice D) Placenta accreta, the direct attachment of the placenta to the myometrium, can present with difficulty separating the placenta from the uterus after fetal delivery and with a postpartum hemorrhage that can lead to coagulopathy. This diagnosis is unlikely as the patient's placenta delivered without difficulty. Placenta accreta (Choice E) Preeclampsia can present with complications of pulmonary edema and coagulopathy; however, the diagnosis requires hypertension, which is not seen in this patient. Educational objective: Amniotic fluid embolism syndrome (AFES) presents during labor or immediately postpartum with acute onset of hypoxemia, hypotension, and disseminated intravascular coagulopathy. AFES is a massive inflammatory response due to the release of fetal amniotic fluid into the maternal circulation. Treatment is supportive. References: Amniotic fluid embolism: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/26987420)

A 23-Year-Old Woman, Gravida 3 Para 2, at 35 Weeks