Amniotic fluid embolism during vaginal delivery under analgesia. Case report

Amniotic fluid embolism is a rare occurrence; it has a sudden onset and high morbidity. The objective of this report was to present a case of amniotic fluid embolism in a primipara undergoing analgesia for vaginal delivery. CASE REPORT This is a 38-year old pregnant woman with amniotic sac ruptured, cervix with 5-cm dilation, complaining of severe pain; the patient was agitated, diaphoretic, and with tachysystoly. After venipuncture, Ringer's lactate with 5 IU of oxytocin was infused slowly, blood pressure (BP) 110 x 70 mmHg, heart rate (HR) 115 bpm with sinus rhythm, and SpO2 98%. It was decided to use a combined technique: 2.5 mg of heavy bupivacaine and 20 microg of fentanyl were administered in the subarachnoid space and a catheter was inserted into the epidural space. Twenty minutes after the institution of analgesia, the patient complained of sudden onset of severe pruritus, she was agitated, with nausea and vomiting, pale, HR 160 bpm, tachypneic, SpO2 80%, and BP could not be detected. Normal saline (500 mL) associated with hydrocortisone, ephedrine (50 mg), and oxygen with a face mask at 10 L.min(-1) were administered. At that moment, she presented BP 60 x 30 mmHg, HR 150 bpm, and SpO2 92%. Since BP tended to decrease, a total of 7 mg of metaraminol were administered divided in several doses. After vaginal delivety the patient was transferred to the ICU with BP90 x 60 mmHg, HR 110, and tachypnea. Two hours later, she developed bleeding and hypotension; disseminated intravascular coagulation (DIC) was diagnosed and the patient treated with crystalloid solutions, packed red blood cells and fresh frozen plasma. She was discharged from the ICU in the 3rd postoperative day (PO).

Due to the dramatic presentation, severity, and fast installation of the symptoms, the speed and objectivity of the measures instituted to maintain vital signs are fundamental and decisive for survival of pregnant patients. We alert for the importance of monitoring during labor analgesia.