The initial fibrin formation and polymerization (FIBTEM A5; amplitude at 5 minutes) of 7 mm indicated significant hypofibrinogenemia (Table). The extrinsic coagulation pathway (EXTEM) clotting time was within normal limits. Progression of the ROTEM trace showed narrowing at 12 minutes and the EXTEM and FIBTEM maximum lysis were >15%. A value of 100% of maximum clot firmness at <20 minutes demonstrated hyperfibrinolysis (Figure 2; Table). Corresponding laboratory blood investigations 30 minutes later confirmed hypofibrinogenemia (Table) and correlated with our suspicions of DIC.
As per our critical bleeding ROTEM algorithm, EXTEM A10 of 23 mm (range, 43–65 mm) in combination with FIBTEM A10 <12 mm indicated the need for platelet and fibrinogen administration and maximum lysis 100% indicated the need for tranexamic acid. Following these results, the patient received 3 g fibrinogen concentrate, 2 units of platelets, 8 units of cryoprecipitate, and 1 g of tranexamic acid. Our institutional protocol did not call for the off-label use of recombinant activated factor VIIa.
Under TEE-guided volume resuscitation, 2 L of balanced electrolyte solution and 1.5 L of 4% albumin were administered. Two doses of 10 mL of 10% calcium gluconate were administered prophylactically during resuscitation.
An hour later, ROTEM showed improvement. However, reduced FIBTEM A5 of 6 mm indicated continued hypofibrinogenemia (Table). Guided by these results, another 3 g of fibrinogen concentrate was administered.
Two hours after the initial arrest, the uterus contracted, core temperature was 35.5°C, and hemodynamic stability maintained with a noradrenaline infusion at 17 µg/min and the patient was transferred to the intensive care unit. After consultation of cardiologists and cardiac surgeons, plans were made to transfer the patient to the nearby cardiothoracic center for potential extracorporeal membrane oxygenation and surgical pulmonary embolectomy.
A transthoracic echocardiography performed in the intensive care unit demonstrated improved LV contractility (ejection fraction 0.55–0.60), with a severely dilated RV and impaired systolic function. There was mild pulmonary hypertension (RV systolic pressure 32 mm Hg, range 12–16 mm Hg). Milrinone was commenced to support RV contractility and decrease pulmonary vascular resistance and vasopressin to support systemic vasoconstriction. Further ROTEM results revealed improvements in the coagulopathy (Table); however, there was ongoing uterine bleeding with a further decrease in hemoglobin to 59 g/L (range, 115–161 g/L; Table). Because of the continuing uterine bleeding, anemia, and the planned transfer of the patient to a hospital without obstetric facilities, the patient underwent a hysterectomy. This occurred 4 hours after the initial arrest with further 4 units of packed red blood cells being administered. No further coagulation correction was required, because ROTEM had normalized (Figure 3; Table) and clinically the coagulopathy had resolved.
Following hysterectomy, formal laboratory tests confirmed a resolved coagulopathy with stabilized hemoglobin concentration (Table) and the interhospital transfer occurred. Further interventions were not necessary because the patient stabilized and was extubated the following day.
A computerized tomography pulmonary angiogram (Figure 4) performed following extubation demonstrated a saddle embolus extending into the segmental branches of the upper and middle lobes. Ultrasound of the lower limbs excluded deep venous thrombosis. Abdominal ultrasound investigation suggested a possible right ovarian thrombosis.
The patient was discharged home 3 weeks after the cesarean delivery for continued outpatient care. A repeat transthoracic echocardiography demonstrated a normal LV size with low normal systolic function, ejection fraction 0.54, and a normal RV with low normal systolic function. The patient had no significant neurophysiological deficits and formal neuropsychology review revealed intact cognition. She continued to be on anticoagulation treatment under the guidance of the hematologists.
Thrombosis and thromboembolism remains the leading cause of direct maternal death (11% maternal mortality).1,2 Massive pulmonary thromboembolism constitutes 10% of all presentations of venous thromboembolism.3
Sudden maternal cardiopulmonary collapse followed by coagulopathy is often attributed to amniotic fluid embolism.4 TEE findings after ROSC suggested a massive PE, confirmed in the subsequent computerized tomography pulmonary angiogram. We hypothesize that a thrombosis of the proximal veins in the pelvis was dislodged at the time of delivery of the baby.
This patient had multiple antepartum risk factors for thromboembolism, including advanced maternal age,5,6 parity,5,6 antepartum hemorrhage,6 and hospitalization for nondelivery reasons for >3 days.7 Prophylactic anticoagulation was withheld due to ongoing antepartum hemorrhage, known placenta previa, and the potential for emergent delivery.
DIC after massive PE has been reported in both obstetric and nonobstetric patients.8–10 Up to 9% of patients who suffer a cardiopulmonary arrest secondary to a PE fulfill overt DIC criteria.11 It is proposed that the presence of a large PE results in insufficiently contained thrombin generation at the clot surface causing an overflow of active coagulation factors into the systemic circulation. Hyperfibrinolysis has also been demonstrated using ROTEM after presumed amniotic fluid embolism.12
ROTEM is a point-of-care test of coagulation, used in trauma, maternity, hepatic, and cardiac surgery.13 It rapidly analyzes the entire process of coagulation, facilitating the targeted correction of coagulopathy. The standard panel comprises EXTEM, intrinsic coagulation pathway, and FIBTEM.
Using TEE during resuscitation facilitated the early diagnosis of the pulmonary arterial mass and guided fluid management. Coupled with ROTEM to select blood products, we avoided overtransfusion and RV strain.13–15 Early detection and aggressive correction of the hypofibrinogenemia was key to the successful management of the coagulopathy.
Obtaining a formal TEE during stabilization of the patient provided vital diagnostic information. Continuous consultation between our intensivists and the cardiothoracic center permitted patient transfer as soon as it was feasible.
This is the first published case report of maternal cardiac arrest with DIC successfully managed using ROTEM and TEE. This patient had a definitive diagnosis of a massive PE causing cardiopulmonary collapse with DIC during an elective cesarean delivery. Effective interdisciplinary communication was essential in our tertiary hospital, particularly because of the lack of an on-site cardiac surgery service. The use of TEE and ROTEM throughout resuscitation allowed targeted therapy and may well have contributed to the positive outcome.
Name: Hannah Brown, BMBS, FANZCA.
Contribution: This author helped care for the patient and write the manuscript.
Name: Helen L. Barrett, FRACP, PhD.
Contribution: This author helped provide expert opinion and edit the manuscript.
Name: Julie Lee, BPharm, MBBS, FANZCA.
Contribution: This author helped provide expert opinion and write the manuscript.
Name: Jason M. Pincus, MBBS, FANZCA, FCICM.
Contribution: This author helped care for the patient and edit the manuscript.
Name: Rebecca M. Kimble, MBBS, FRANZOG.
Contribution: This author helped care for the patient and write the manuscript.
Name: Victoria A. Eley, MBBS, FANZCA, PhD.
Contribution: This author helped care for the patient, and write and edit the manuscript.
This manuscript was handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.
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© 2018 International Anesthesia Research Society
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