Case 121227 "Amniotic-fluid embolism"

9:53| "A 43-Year-Old Woman with Cardiorespiratory Arrest after a Cesarean Section", a CASE RECORD OF THE MASSACHUSETTS GENERAL HOSPITAL by Jeffrey Ecker and colleagues.
A 43-year-old woman (a multigravida) was admitted to the labor and delivery service of this hospital at 36.4 weeks of gestation because of vaginal bleeding.
Marginal placenta previa was seen on obstetrical ultrasonography, and two episodes of bleeding occurred, at 27.7 weeks and 32.7 weeks of gestation, which resolved after the patient was admitted for bed rest, hydration, and the administration of betamethasone. She was advised to maintain bed rest at home. At a routine prenatal visit 8 days before this presentation (at 35.3 weeks of gestation), obstetrical ultrasonography revealed an anterior placenta with the edge covering the internal os, a finding consistent with placenta previa.
Heavy vaginal bleeding developed on the day of admission. Plans were made for emergency cesarean delivery. A healthy boy was delivered. The placenta previa was removed.
Twenty minutes after delivery, as the abdominal fascia was being closed, the patient's systolic blood pressure fell to 70 to 80 mm Hg, the pulse to 30 to 39 beats per minute, and oxygen saturation to 70 to 80%. The patient reported chest pain, and her lips became white; apnea developed rapidly thereafter, and she became unresponsive. Examination revealed pulseless electrical activity.
In situations such as this clinicians must focus promptly on a most-likely diagnosis in order to direct problem-specific therapies.