A 38-year-old G6P4 undergoes a primary cesarean delivery under regional analgesia for malpresentation of twins at 37 weeks. Immediately after the delivery of the placenta, the anesthesiologist notes maternal seizure activity with profound hypoxia and hypotension. The patient is intubated and provided with circulatory support with vasopressors. Massive hemorrhage from the surgical site ensues, and the patient is given uterotonic agents and blood products.
What is the most likely cause of her hemorrhage?A. Amniotic fluid embolism
Amnionic fluid embolism is a complex disorder characterized by abrupt onset of maternal hypoxia, hypotension, and disseminated intravascular coagulopathy. Amnionic fluid enters the maternal circulation from a breach in the normal maternal-fetal physiological barriers. This typically happens with labor and delivery, and cesarean delivery offers ample opportunity. The typical clinical presentation is dramatic. Patients may gasp for air, develop seizures from hypoxia, and have cardiopulmonary collapse, followed by massive hemorrhage from consumptive coagulopathy. It unfortunately often results in death given the quickness of events. Immediate support with oxygenation through intubation and circulatory support and blood products is vital. Profound neurological impairment is common in survivors. While halogenated anesthetic agents and multiple gestations can cause uterine atony leading to hemorrhage and while placenta accreta can also be a cause of hemorrhage, these are not the culprits in this drastic presentation.