Veno-arterial ECMO successfully bridged a postpartum patient with refractory cardiogenic shock from presumed amniotic fluid embolism to recovery, improving ejection fraction from 5% to 55%.
Case Report (n=1)
V-A ECMO can be safely and effectively utilized as a bridge to recovery in amniotic fluid embolism-related cardiogenic shock.
Abstract Introduction Amniotic fluid embolism (AFE) is a rare obstetric emergency characterized by abrupt cardiopulmonary collapse and disseminated intravascular coagulation (DIC) or hemorrhage. Although there is no clear international consensus on AFE, in the U.S., it is often described as occurring within 30 minutes of delivery. AFE is a diagnosis of exclusion, with no specific diagnostic criteria. Treatment is supportive, and veno-arterial extracorporeal membrane oxygenation (V-A ECMO) can be utilized as a potential rescue therapy in cases of refractory cardiogenic shock. We describe the case of a young postpartum patient who developed a postpartum hemorrhage and presumed AFE leading to cardiogenic shock necessitating V-A ECMO support. Case Report A 24-year-old G1P0 female with severe pre-eclampsia presented in labor. She was delivered via caesarean section without apparent complications. Approximately 12 hours postpartum, she developed a postpartum hemorrhage and sustained hypotension requiring massive transfusion. POCUS at that time was concerning for impaired RV function. Shortly thereafter, she developed flash pulmonary edema, hypercapnic respiratory failure and encephalopathy. She was subsequently intubated, after which she developed refractory shock. Echocardiogram showed an EF of 5% and severely reduced RV function. Additionally, she had severe hypoxemia and poor lung compliance. She was cannulated on V-A ECMO for support. She then underwent IABP placement for LV unloading. After 48 hours, all vasopressors and inotropes were weaned, and she was successfully decannulated from V-A ECMO. Her follow up echocardiogram showed resolution of her biventricular heart failure, now with EF of 55%. Discussion This case highlights a dramatic example of cardiopulmonary collapse following postpartum hemorrhage due to presumed AFE. AFE is a diagnosis of exclusion, often characterized by sudden cardiopulmonary decompensation and hemorrhage secondary to DIC. Although the diagnostic criteria in the U.S. suggest that symptom onset occurs within 30 minutes of delivery, there is no international consensus, and some countries recognize a much wider time frame (up to 12-24 hours). Early multidisciplinary coordination among critical care, obstetric, and ECMO teams is essential. This patient had no pre-existing or history of heart failure, and her cardiac function recovered much faster than would be expected of other disease processes, such as stress cardiomyopathy or myocarditis. Transfusion-associated circulatory overload was a concern, but RV dysfunction was evident on POCUS exam prior to large-volume blood transfusion, suggesting an alternative etiology. Finally, this case further highlights how V-A ECMO can be safely and effectively utilized as a bridge to recovery in AFE-related cardiogenic shock. This abstract is funded by: None
Bailey et al. (Fri,) conducted a case report in Postpartum cardiogenic shock from presumed amniotic fluid embolism (n=1). Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was evaluated. Veno-arterial ECMO successfully bridged a postpartum patient with refractory cardiogenic shock from presumed amniotic fluid embolism to recovery, improving ejection fraction from 5% to 55%.