ID:63 FC-D10-10 ECMO Management for Atypical Amniotic Fluid Embolism Without DIC: A Report of Two Successful Cases

Background: Atypical amniotic fluid embolism (AFE) without disseminated intravascular coagulation (DIC) poses significant diagnostic challenges. Extracorporeal membrane oxygenation (ECMO) serves as a vital salvage therapy for such refractory cardiopulmonary collapse occurring in the peripartum period. Clinical Course: We report two cases of atypical AFE without DIC, both occurring after emergency cesarean section. Case 1: A 39-year-old female developed shock and hypoxia following a cesarean delivery. POCUS demonstrated severe biventricular dysfunction. Veno-arterial (VA) ECMO was initiated. Systemic anticoagulation was administered, which resulted in significant clinical challenges due to a large, progressive surgical site hematoma. Post-decannulation, a vascular complication (CFA occlusion) was identified. Surgical repair was successfully performed after the resolution of the hematoma and full systemic recovery. Case 2: A 39-year-old female with a twin pregnancy diagnosed as intrauterine fetal demise (IUFD) of Twin 2, developed profound hypoxia following a cesarean section. She was initially managed with veno-venous (VV) ECMO. However, due to persistent hypotension, POCUS revealed biventricular dysfunction, necessitating an emergent conversion to veno-arterial-venous (VAV) ECMO. To minimize bleeding risks, an anticoagulation-free strategy was successfully maintained. Both patients achieved full cardiac recovery and survived to discharge. Discussion: Atypical AFE can manifest as isolated cardiopulmonary collapse following delivery without hallmark coagulopathy. Case 1 emphasizes the bleeding risks of early postpartum heparinization, while Case 2 demonstrates that an anticoagulation-free approach is feasible when high circuit flows are maintained. The utilization of POCUS was instrumental in guiding the timely transition between ECLS modalities. Conclusion: Early ECMO initiation and flexible management strategies, supported by POCUS for modality selection, are essential for optimizing maternal outcomes in atypical AFE.