Title: Breaking Barriers in Amniotic Fluid Embolism Management with Interventional Radiology

Introduction: Amniotic fluid embolism (AFE) is a rare obstetric emergency with high mortality rates. Prompt recognition and supportive, multidisciplinary treatment is vital for enhancing patient outcomes. This case highlights the successful treatment of AFE with interventional radiology (IR).

Background: Amniotic fluid embolism is a rare medical emergency that can occur during labor and postpartum. The pathogenesis is theorized to be due to a release of inflammatory cytokines reacting to amniotic fluid in the maternal bloodstream, causing cardiovascular collapse, respiratory failure, and disseminated intravascular coagulation (DIC) 1. Diagnosis is based on clinical findings of hypoxia, hypotension, and coagulopathy in peripartum or postpartum women 2.

Treatment is supportive, including respiratory, cardiac, hemostatic, and hemodynamic resuscitation. This requires a multidisciplinary team to be heavily involved in the patient’s care, with primary contributions from obstetrics, critical care, cardiology, and pulmonology 3.

The prognosis is grim. Studies suggest maternal mortality ranges from 20% to 60% 4. With placenta accreta spectrum disorder, mortality doubles 5.

Case: Our patient is a 27-year-old now G2P2 female with a history of placenta accreta who developed seizure-like activity, hypotension, and respiratory distress shortly after delivery, all concerning for AFE. Initial labs revealed a fibrinogen of 69 and INR of 1.2, findings consistent with disseminated intravascular coagulation (DIC). She developed pulseless ventricular tachycardia that spontaneously resolved and was transferred to our facility for further workup.

Upon arrival, she was cyanotic, tachypneic, tachycardic, and hypotensive. CXR revealed pulmonary edema. Bedside echocardiogram revealed an ejection fraction of 35-40%. Troponins were elevated at 50,000. MTP was subsequently activated.

Plans were made to undergo CTA C/A/P to exclude a pulmonary embolism; however, due to hemodynamic instability, she was taken to the IR suite for embolization of the bilateral uterine and internal iliac arteries. Following the procedure, her vital signs normalized without vasopressor support.

Later that evening, she became hypotensive and tachycardic. CXR was concerning for flash pulmonary edema. She developed two episodes of supraventricular tachycardia that responded to vagal maneuvers. Intubation was performed for hypoxemia and respiratory distress.

After a multidisciplinary discussion, the decision was made to take the patient for a repeat diagnostic pelvic angiogram, which revealed brisk arterial extravasation from the left inferior epigastric artery which was not conspicuous on the initial angiogram. IR then performed coil embolization of the left inferior epigastric artery. A conventional pulmonary arteriogram was also performed to exclude a large pulmonary embolus given her worsening hypoxemia.

She was subsequently stabilized and remained so for the duration of her admission, receiving a total of 14 pRBCs, 13 FFP, 3 platelets, and 3 cryoprecipitates.

Discussion: IR’s prompt identification and treatment of arterial extravasation were monumental in stabilizing the patient and mitigating the risk of further deterioration. In obstetric emergencies, especially those involving severe hemorrhage, rapid and precise interventions are crucial. IR offers minimally invasive techniques that can effectively and quickly control emergent bleeding and provide patient stabilization without the need for vasopressor support or general anesthesia.

There is currently no specific research or case documentation highlighting the significance of IR procedures in managing AFE. Further studies are warranted to analyze the significance of incorporating IR into the standard management of AFE across medical facilities.

While interventional radiology may not traditionally be a primary component of the management for AFE, its inclusion in this case demonstrates its ability to significantly optimize patient outcomes and warrants more frequent consideration in similar emergencies.

Conclusion: The prompt integration of IR into our multidisciplinary approach played a pivotal role in the successful management of AFE, highlighting the significant impact IR can have on optimizing patient outcomes.

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