Abstract Introduction Amniotic Fluid embolism (AFE) is a rare obstetric emergency estimated at 1.9 to 6.1 cases per 100,000 deliveries presenting during labor or thereafter. Though poorly understood, it is hypothesized that introduction of amniotic fluid into maternal systemic circulation causes a catastrophic systemic inflammatory response-like syndrome. Case Report A 34-year-old female, G2P1001, with no medical history was admitted at 39 weeks for labor induction for fetal growth restriction. On initial exam she was afebrile, with stable hemodynamics and respiratory status. Fetal heart rate (FHR) was 140 with moderate variability on continuous fetal monitoring. Labor induction was initiated per institutional protocol and an epidural nerve block administered for pain management. As labor proceeded FHR decelerations were noted while patient endorsed nausea and hot flashes which quickly escalated to seizure-like activity that resolved with medications. Due to terminal fetal bradycardia, she underwent emergent cesarean section. The infant was delivered via Pfannenstiel incision in under one minute however during closure the patient became asystolic. ACLS protocol was promptly initiated and ROSC achieved after 5 minutes. As closure resumed, despite a hemostatic hysterotomy, large amounts of blood emanating from the upper quadrants was visualized. General surgery was consulted, and emergent exploratory laparotomy was performed. It revealed large hemoperitoneum and a significant left hepatic lobe laceration. Intraoperatively she required three vasopressors while simultaneously receiving massive transfusion protocol (MTP). Due to the extent of injury, left hepatectomy was performed. Post-procedure she was transferred to the medical ICU where resuscitative efforts continued with assistance of obstetrics/gynecology, general surgery and neurology. Discussion With acute cardiopulmonary arrest within 30 minutes of delivery and apyrexia, our patient met three of four criteria proposed by the Society for Maternal-Fetal Medicine in collaboration with the Amniotic Fluid Embolism Foundation for diagnosing AFE. The fourth criteria, DIC, was confounded by hemorrhagic shock requiring MTP due to liver laceration during ACLS. Despite this, in the absence of pulmonary embolism, systemic anaphylaxis or anesthesia complication, AFE remained the most likely explanation.Liver lacerations is a rare complication of chest compressions as the left hepatic lobe is at risk of being pierced by the xiphoid process due to their proximity. It is likely that intraoperative positioning skewed compression landmarks leading to this complication. While bleeding from liver injury is expected, the extent observed could suggest compromised hemostasis. AFE is unpredictable and catastrophic. Early recognition and a collaborative multidisciplinary approach are necessary to improving patient outcomes. This abstract is funded by: None
Spooner et al. (Fri,) studied this question.