Amniotic fluid embolism rescued using venoarterial extracorporeal membrane oxygenation without initial anticoagulation: A case report and literature review

Abstract

Rationale: Amniotic fluid embolism (AFE) is a fatal obstetric condition that often rapidly leads to severe respiratory and circulatory failure. It is complicated by obstetric disseminated intravascular coagulation (DIC) with bleeding tendency; therefore, the introduction of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is challenging. We report the case of a patient with AFE requiring massive blood transfusion, rescued using VA-ECMO without initial anticoagulation.

Patients concerns: A 39-year-old pregnant patient was admitted with a complaint of abdominal pain. An emergency cesarean section was performed because a sudden decrease in fetal heart rate was detected in addition to DIC with hyperfibrinolysis. Intra- and post-operatively, the patient had a bleeding tendency and required massive blood transfusions. After surgery, the patient developed lethal respiratory and circulatory failure, and VA-ECMO was introduced.

Diagnosis: Based on the course of the illness and imaging findings, the patient was diagnosed with AFE.

Interventions: By controlling the bleeding tendency with a massive transfusion and tranexamic acid administration, using an antithrombotic ECMO circuit, and delaying the initiation of anticoagulation and anti-DIC medication until the bleeding tendency settled, the patient was managed safely on ECMO without complications.

Outcomes: By day 5, both respiration and circulation were stable, and the patient was weaned off VA-ECMO. Mechanical ventilation was discontinued on day 6. Finally, she was discharged home without sequelae.

Lessons: VA-ECMO may be effective to save the lives of patients who have AFE with lethal circulatory and respiratory failure. For safe management without bleeding complications, it is important to start VA-ECMO without initial anticoagulants and to administer anticoagulants and anti-DIC drugs after the bleeding tendency has resolved.

Figure 1.

Clinical course, anticoagulation, and anti-DIC therapy after ICU admission. After admission to the ICU, an additional 1 g of TXA was administered along with blood transfusion. Three hours after admission, the patient’s blood pressure decreased and she developed oliguria, therefore CRRT was initiated. Four hours after admission, she developed lethal respiratory and circulatory failure under intensive care. VA-ECMO was introduced without anticoagulation. After bleeding tendency was controlled by massive transfusion, 2400 IU of rAT was administered for DIC treatment. In addition, NM for anticoagulation was started at a low dose of 5 mg/h on ICU day 2 and gradually increased; rhTM for DIC treatment at a dose of 25,600 IU was started on ICU day 3. By ICU day 5, both respiration and circulation were stable, and the patient was weaned off VA-ECMO. Mechanical ventilation was discontinued on ICU day 6. She was weaned off CRRT on ICU day 9 and transferred to a ward on ICU day 10. BP = blood pressure, CRRT = continuous renal replacement therapy, DIC = disseminated intravascular coagulopathy, HR = heart rate, ICU = intensive care unit, NM = nafamostat mesylate, rAT = recombinant antithrombin, rhTM = recombinant human soluble thrombomodulin, TXA = tranexamic acid, VA-ECMO = venoarterial extracorporeal membrane oxygenation.

Figure 2.

Parasternal short axis view on transthoracic echocardiography showing the marked enlargement of the right ventricle and collapse of the left ventricle (white arrow). LV = left ventricle, RV = right ventricle.