Episode 55 — Term Pregnancy Part 2 With Mike Hofkamp
Highlights
- Amniotic Fluid Embolism
Summary:
There's a lot of different embolic disorders. The one that first comes to mind is amniotic fluid embolism which we'll talk about in a second isn't really an embolist like pulmonary embolism. When it starts off as is when amniac fluid enters the maternal bloodstream and that causes an immunologic response that can be devastating for patients. Current mortality is estimated to be anywhere between 25 to 80 percent.
Transcript:
Speaker 1
Well you there's a lot of different embolic disorders. The one that first comes to mind is amniotic fluid embolism which we'll talk about in a second isn't really an embolist like pulmonary embolism you think of it's more of an immune problem but when it starts off as is when amniac fluid enters the maternal bloodstream and that causes an immunologic response that can be devastating for patients. It's a diagnosis of exclusion that's often assigned only after autopsy of all the maternal deaths that actually accounts for about 12% and currently the mortality is estimated to be anywhere between 25 to 80 percent. And so when you get amniac fluid in your circulation there's a biphasic response to it. The early phase you get pulmonary vasospasm which causes right heart failure which causes low correct output which causes a BQ mismatch. This is where you get to your hypoxemia. The second phase you're gonna get left ventricular failure and pulmonary edema. You're also going to see a destruction of the normal client cascade and this will occur as many as 66% of patients and if you're able to make it to the operating room you're going to get going to occur. (Time 0:01:04)
- Amniac Fluid Embolism
Summary:
Amniac fluid embolism is not so much an embolic event as it's an intra vascular exposure to field tissue. You're going to get these nonspecific signs like hypotension, fetal compromise and pulmonary edema. It presents as a well first of all you gotta think of amniac fluid Embolism as a diagnosis of exclusion.
Transcript:
Speaker 2
Yeah this is really a catastrophic occurrence right when we think of it. How does it present?
Speaker 1
It presents as a well first of all you gotta think of amniac fluid embolism as a diagnosis of exclusion. You want to rule out other things. So you're going to get these nonspecific signs like hypotension, fetal compromise, pulmonary edema. You could see chronic arrest, you get cyanosis, you can get coagulopathy, you can get dyspnea, you can get seizures, you can get urinatne, you can talk with before, you can get some bronchospasm from the immunologic reaction, you can get a cough and you can headache. And I think again I cannot emphasize enough that amniac fluid embolism is not so much an embolic event as it's an intra vascular exposure to field (Time 0:02:25)
- Intra-Lipid Is an Emerging Therapy
Summary:
Amniac fluid embolism is more of a systemic cascade rather than as a single embolism the way like you said with a PE or an air embolism would be. Supportive care with antarachial intubation, possibly prosters, support the blood pressure. In cardiac arrest we'll talk about this a little bit later. A prompt perimorum delivery will improve the maternal and field outcomes.
Transcript:
Speaker 2
Right so it's a little bit of a misnomer in the sense of how it presents is more of a systemic cascade rather than as a single embolism the way like you said with a PE or an air embolism would be.
Speaker 1
That's a perfect way to think of it. So with amniac fluid embolism the management is you gotta resuscitate the patient so a lot of times unfortunately this is ACLS. Supportive care with antarachial intubation, possibly prosters, support the blood pressure. Now in cardiac arrest we'll talk about this a little bit later. A prompt perimorum delivery will improve the maternal and field outcomes and it sounds pretty gruesome but you've got to do a bedside hystereotomy to take the baby in the labor delivery suite if that's where the patient happens to be. There's no time to go the operating room to take care of this and an emerging therapy is administering intra lipid. There have been some case reports including one of my own institution that was published in ANA case reports earlier this year and for reasons that we don't completely understand intra lipid can kind of shield the immune system from seeing these essentially foreign antigens and (Time 0:03:24)
- Is It a PE?
Summary:
You can also use ultrasound in the legs to look for a DDT. We'll do it as intensivists but certainly if we want to confirm the diagnosis we'll get a form of formal echo. Unless the patient is actually unstable and crashing then if we see that dilated right ventricle we may act on that sort of suspicionthat that makes it more likely that it's a PE.
Transcript:
Speaker 2
You can also use ultrasound in the legs to look for a DDT. Now what about the other thing we will do sometimes at the ICU might give we will do an ultrasound or an echo to look at the right heart for a right ventricular dilation in the setting of a PE that might be causing right heart strain.
Speaker 1
Yes that's also a very reasonable study to do if you have the capabilities of doing so. Do you have cardiologists do that or are you skilled personally enough to put a trans thoracic pro bond and make that assessment?
Speaker 2
Yeah we'll do it as intensivists but certainly if we want to confirm the diagnosis we'll get a form of formal echo. Unless the patient is actually unstable and crashing then if we see that dilated right ventricle we may act on that sort of suspicion that that makes it more likely that it's a PE.
Speaker 1
Yeah that sounds very very reasonable.
Speaker 2
All right so what other kinds of embolism do we see other than the amniotic fluid that we talked about in the sort of traditional PE? Are there other things?
Speaker 1
Well you can get this so called septic pelvic vein thrombosis and these can occur after vaginal or cesarean delivery and again you've got workhouse triad at play where you get this vascular (Time 0:09:54)
- Placental Abruption and the Monitoring Strip
Summary:
Epidural Aztecs were thought to mask the pain of placental abruption. The clinical diagnosis is made largely from the monitoring strip. premature rupture of membranes, Oreo amniitis and vaginal bleeding.
Transcript:
Speaker 1
Premature rupture of membranes, Oreo amniitis, the diagnosis is made with vaginal bleeding, incurant tenderness, increase urine activity and classically epidural Aztecs were thought to mask the pain of placental abruption but the clinical diagnosis is made largely from the monitoring strip and so I remember when I was my first job out in prior practice they I was taking care of the patient who was a child labor after Caesarean section and I had mentioned to the obstetrician about my concern of masking the possible placental abruption and what happens is that the strip is going to tell you first that there's a problem with fetus as opposed to the pain from that would be masked for an epidural so you don't have to worry about your epidural covering these things up the strip is going to tell you what's going on. (Time 0:17:40)