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Amniotic Fluid Embolism Complicating Late Abortion
AMNIOTIC FLUID EMBOLISM COMPLICATING LATE ABORTION 0RIAN
C.
WESTBROOK,
-:\I.D.,
AXD JoHx
R.
THo~us,
M.D.,
HousTON, TExAs
(From the DepaTtments of Obstetrics and Pathology of the Hermann Hospital)
N
UMEROCS reports have appeared concerning the syndrome of amniotic fluid embolism. These papers have dealt with the problems of shock. anoxia, bleeding tendencies, and other effects of this dread maternal hazard. In those eases which ended fatally and in which postmortem examinations were made, the pulmonary findings of desquamated fetal squamous epithelium, lanugo hair, and fat droplets of the yernix have been tabulated. This case presents a problem of the same category except that the maternal death occurred at an early stage of gestation.
E. U. B. rHermann Hospital No. 53-18i03), ali-year-old Negro primigravida, was ad· mitted to the hospik'll at approximately 24 weeks' gestation with the diagnosis of acute pyelo· ureteronephritis of pregnancy. Examination disclosed an oral temperature of 101.8° F., bilateral renal and flank tenderness, a gravid uterus the size of a 28 weeks' gestation, and a negative Homans sign. Urinalysis showed many white blood cells in the catheterized, un· centrifug-ed specimen. The patient was plaee•l on oral :fluids and antibiotics. Twelve hours after admission she began to have uterine contractions. X-ray of the abdomen showed a twin intrauterine pregnancy. After a labor of approximately two hours, the patient was given :y;_50 grain of atropine by hypodermic. injection and \Yas taken to the Delivery Room. Under a general anesthetie of gas-oxygen-ether, a nonmacerated abortus and a liveborn infant that died five minutes later were delivered spontaneously without difficulty. The blood loss was eonsidere
Jnasmuch as the clinical signs and symptoms were so characteristic of the previously described cases of amniotic fluid embolism, an explanation for the cause of this paradox was sought. Many additional blocks of uterus, uterine veins, inferior vena cava, and lung were sectioned, but no distinct amniotic contents were found. A review of the literature disclosed that the reported cases had occurred at term or much nearer to term than this case. It has been shown that, at this early stage of gestation, amniotic fluid does not contain appreciable amounts of squames, lanugo hairs, or fat globules. 447
448
WESTBROOK AXD THOMAS
\m .. L Obst. & Gyne.:. February, 1956
Williams, 1 in his discussion of the microscopic detection of ruptured membranes, points out that this test is valueless prior to the thirty-second week of gestation because of the lack of demonstrable debris in the amniotic iluhl. We verified this by the examination of t('ll samples of amniotic fluid hom different periods of gestation. In no instan(·p bel'ore the mid-third trinwster were diagnm;tie particles present.
Comment There are probably cases of amniotic fluid embolism which end fatally and in which the typical material is not demonstrated for val'ious reasons. We believe that this case demonstrates the possibility of an amniotic fluid embolism occurring during the early periods of gestation and creating a diagnostic problem because of the normal a bsenee of the expected amniotic fluid particles. The sudden death in this case, due to acute pulmonary edema, and without mechanieal obstruction of pulmonary vessels, tends to substantiate the argument for anaphylaxis in amniotic fluid embolism. 2 • 3 Summary A case of amniotic fluid embolism complicating late abortion is presented. The signs and symptoms were characteristic for this syndrome. However. initial postmortem diagnosis was difficult because it was not realized that the absence of desquamated fetal squames and fat droplets in the amniotic fluid may be normal at that early state of gestation.
References 1. Eastman, N. J.:
Williams Obstetrics, l'd. 10, New York, 1950, Appleton·Century·CroftR, Inc., p. 191. 2. Sluder, Harold M., and Lock, Frank R.: AM. J. OBST. & GYNEC. 64: ll8, 1952. 3. Cron, R. S., Kilkenny, G. S., Wirthvrein, C..• and Evrard, J. R.: AM. J. OBST. & GYNEC. 64: 1360, 1952.
C.
WESTBROOK,
-:\I.D.,
AXD JoHx
R.
THo~us,
M.D.,
HousTON, TExAs
(From the DepaTtments of Obstetrics and Pathology of the Hermann Hospital)
N
UMEROCS reports have appeared concerning the syndrome of amniotic fluid embolism. These papers have dealt with the problems of shock. anoxia, bleeding tendencies, and other effects of this dread maternal hazard. In those eases which ended fatally and in which postmortem examinations were made, the pulmonary findings of desquamated fetal squamous epithelium, lanugo hair, and fat droplets of the yernix have been tabulated. This case presents a problem of the same category except that the maternal death occurred at an early stage of gestation.
E. U. B. rHermann Hospital No. 53-18i03), ali-year-old Negro primigravida, was ad· mitted to the hospik'll at approximately 24 weeks' gestation with the diagnosis of acute pyelo· ureteronephritis of pregnancy. Examination disclosed an oral temperature of 101.8° F., bilateral renal and flank tenderness, a gravid uterus the size of a 28 weeks' gestation, and a negative Homans sign. Urinalysis showed many white blood cells in the catheterized, un· centrifug-ed specimen. The patient was plaee•l on oral :fluids and antibiotics. Twelve hours after admission she began to have uterine contractions. X-ray of the abdomen showed a twin intrauterine pregnancy. After a labor of approximately two hours, the patient was given :y;_50 grain of atropine by hypodermic. injection and \Yas taken to the Delivery Room. Under a general anesthetie of gas-oxygen-ether, a nonmacerated abortus and a liveborn infant that died five minutes later were delivered spontaneously without difficulty. The blood loss was eonsidere
Jnasmuch as the clinical signs and symptoms were so characteristic of the previously described cases of amniotic fluid embolism, an explanation for the cause of this paradox was sought. Many additional blocks of uterus, uterine veins, inferior vena cava, and lung were sectioned, but no distinct amniotic contents were found. A review of the literature disclosed that the reported cases had occurred at term or much nearer to term than this case. It has been shown that, at this early stage of gestation, amniotic fluid does not contain appreciable amounts of squames, lanugo hairs, or fat globules. 447
448
WESTBROOK AXD THOMAS
\m .. L Obst. & Gyne.:. February, 1956
Williams, 1 in his discussion of the microscopic detection of ruptured membranes, points out that this test is valueless prior to the thirty-second week of gestation because of the lack of demonstrable debris in the amniotic iluhl. We verified this by the examination of t('ll samples of amniotic fluid hom different periods of gestation. In no instan(·p bel'ore the mid-third trinwster were diagnm;tie particles present.
Comment There are probably cases of amniotic fluid embolism which end fatally and in which the typical material is not demonstrated for val'ious reasons. We believe that this case demonstrates the possibility of an amniotic fluid embolism occurring during the early periods of gestation and creating a diagnostic problem because of the normal a bsenee of the expected amniotic fluid particles. The sudden death in this case, due to acute pulmonary edema, and without mechanieal obstruction of pulmonary vessels, tends to substantiate the argument for anaphylaxis in amniotic fluid embolism. 2 • 3 Summary A case of amniotic fluid embolism complicating late abortion is presented. The signs and symptoms were characteristic for this syndrome. However. initial postmortem diagnosis was difficult because it was not realized that the absence of desquamated fetal squames and fat droplets in the amniotic fluid may be normal at that early state of gestation.
References 1. Eastman, N. J.:
Williams Obstetrics, l'd. 10, New York, 1950, Appleton·Century·CroftR, Inc., p. 191. 2. Sluder, Harold M., and Lock, Frank R.: AM. J. OBST. & GYNEC. 64: ll8, 1952. 3. Cron, R. S., Kilkenny, G. S., Wirthvrein, C..• and Evrard, J. R.: AM. J. OBST. & GYNEC. 64: 1360, 1952.