From the Guidelines
Disseminated intravascular coagulation (DIC) secondary to amniotic fluid embolism during cesarean section is a life-threatening complication that requires prompt recognition and treatment.
Diagnosis
The diagnosis of DIC in this setting is primarily clinical, based on the presence of severe hemorrhage, hypotension, and laboratory evidence of coagulopathy, including prolonged activated partial thromboplastin time (aPTT) and international normalized ratio (INR), as well as thrombocytopenia [ 1 ].
Management
Management involves administration of blood products, including fresh frozen plasma (15-20 mL/kg) and cryoprecipitate (1-2 units), as well as platelet transfusions (1-2 units) to maintain a platelet count above 50,000/μL [ 1 ].
- Massive transfusion protocols should be initiated early, with a ratio of 1:1:1 for packed red blood cells, fresh frozen plasma, and platelets [ 1 ].
- Antifibrinolytic therapy with tranexamic acid (1 gram intravenously every 8 hours) may be considered to stabilize the coagulation cascade [ 1 ].
- Recombinant activated factor VII (rFVIIa) may be considered at a dose of 90 μg/kg every 2 hours for a maximum of 3 doses, in cases where hemorrhage cannot be controlled with massive blood component replacement and surgical interventions [ 1 ].
Uterine Atony and Hemorrhage
Uterine atony is common in amniotic fluid embolism and should be managed aggressively with uterotonic agents, such as oxytocin, ergot derivatives, and prostaglandins [ 1 ].
- Uterine tamponade with packing or commercially available intrauterine balloons may be necessary in refractory cases [ 1 ].
- Bilateral uterine artery ligation, B-Lynch stitch, or hysterectomy may be required in extreme cases [ 1 ].
Hemodynamic Support
Hemodynamic support is crucial in the management of amniotic fluid embolism, with a focus on rapid maternal hemodynamic stabilization [ 1 ].
- Inotropes, such as dobutamine and milrinone, may be used to improve right ventricular output [ 1 ].
- Vasopressors, such as norepinephrine or vasopressin, may be necessary to treat hypotension [ 1 ].
Post-Cardiac Arrest Management
After successful resuscitation, post-cardiac arrest management is of paramount importance, with a focus on maintaining a mean arterial blood pressure of 65 mm Hg and avoiding hyperoxia and fever [ 1 ].
- Mild therapeutic hypothermia may be considered in patients without significant disseminated intravascular coagulation and bleeding [ 1 ].
From the Research
Diagnosis of Disseminated Intravascular Coagulation (DIC) secondary to amniotic fluid embolism during a C-section
- The diagnosis of DIC should encompass both clinical and laboratory information, using scoring systems such as the International Society for Thrombosis and Haemostasis (ISTH) DIC scoring system 2.
- Laboratory investigations may reveal a decrease in hemoglobin, prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), low fibrinogen levels, and elevated fibrin degradation products (FDP) 3.
- Clinical presentation may include postpartum hemorrhage, excessive vaginal bleeding, and hemodynamic or respiratory instability 3, 4.
Management of DIC secondary to amniotic fluid embolism during a C-section
- The cornerstone of treatment is the identification and treatment of the underlying condition, in this case, amniotic fluid embolism 5, 2.
- Transfusion of platelets or plasma (components) should be reserved for patients who present with bleeding, and not primarily based on laboratory results 2.
- In patients with DIC and bleeding or at high risk of bleeding, transfusion of platelets should be considered if the platelet count is <50 x 10^9/L 2.
- Administration of fresh frozen plasma (FFP) may be useful in bleeding patients with prolonged PT and aPTT, but should not be instituted based on laboratory tests alone 2.
- Severe hypofibrinogenemia (<1 g/L) that persists despite FFP replacement may be treated with fibrinogen concentrate or cryoprecipitate 2.