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A fatal case of amniotic fluid embolism
A FATAL
T
~CASE OF AM?$IOTIC
HIS case is of special fluid was located.
interest
FLUID
because the point
EMBOLISIW
of entry
of the amniotic
The patient, a gravida v, para iii, had an uneveutful pregnancy. On April 18, 1950, she was admitted to Fairview Hospital about four hours after the onset of labor with the cervix dilated 2 cm. Labor progressed slowly. She was given Demerol, 75 mg., and scopolamine. !$oo grain. The pains became more regular and the cervix dilated to 3 cm. She was taken to the delivery room 45 minutes later because of marked nausea with the pains. She twice vomited small amounts of greenish liquid. She was drowsy and rested well between pains. One-ha1.f hour later she had an involumtary defecation and urination and 45 minutes later the nurse made the following entries: i ‘ The patient turned on side by herself, became rigid with head thrown sharply bacsk. Very cyanotic and does not respond, respirations gasping. Pulse imperceptible. R.P. 130/60. Patient dead. ” The lungs lvere moderately An autopsy was performed by Dr. Koucky on the same day. hravy and edematous. The left lung weighctl 450 grams and the right weighed 440 grams. The IOWW lobes were partially atelcctatic. The bronchi and the trac*hea showed no foreign material, and the pulmonary arteries showed no emboli. No air was present in the heart. Examination of the external surfacr of the uterus showed no suggestion of trauma, hemorrhage, or other changes. The uterus contained a normal term female infant, in left vertex anterior presentation. The membranes w(‘re ruptured with about 200 e.c. of thick greenish fluid in the uterine cavity, and this was present in the interspaces between the legs and the arms and in tho spacae arountl the neck. The fetal hrad was in the lower uterine segment, The wall and the muscle of the Lowe uterine segment were bare for distances varying from 2 to 4 inches. On the exposed posterior wall of tlrtx utel’us, a small depression was observed which, when explored with thr tip of a forceps, proved to be a sizable channel (Fig 1). A rubber catheter of the type used in male c~athrterization easily passed through the opening into the interior of the uterine wall and appeared in the large veins of the right broad ligament. Blood recovered from the right rommon iliac vein and from the lower vena rava, when spread out on the white porcelain tahletop, showed numerous flakes of green mucoid material. One of the larger pieces IT-as ailout 1 mm. in diameter and 5 or 6 mm. in length. Approximation of the fetus into its clriginal position within thcx uterus indicated that the opening iuto the uterine vein was in about the same position of the space formed by the fetal neck and the small parts. Microscopic study showed about the sanle picture in all lobes of the lungs. In every section there were many small arterioles and capil1aric.s containing foreign material made up nf squamous epithelial debris, amorphous material, mucus, and leukocytes (Fig. 2). A few foci of leukocytes were present in the lung parenchyma which had the appearance of beginning exudation. Two impressions were receired from the microscopic study of the lungs in this case. The early exudative reaction suggested that the embolism of amniotic sediment was not a terminal explosive event but had heen going on for many minutes or even hours. Perhaps the patient’s nausea, vomiting, involuntary howe movement and urination indicated the be*present&
1954.
at
a
meeting
of the Minnesota
Obstetrical
an<1
Gynecological
Society,
Dec.
12.
Volume Number
70 3
F,4TAL
CASE
OF
AMNIOTIC
FLUID
661
EMROLISM
ginn ,ing of the embolism. The second impression was that the degree of embolism proi lucea only moderate vascular occlusion and that death was due to causes other than mechanica 1 obstrll ction. It is very likely that “shock” similar to that caused by foreign material in a bloo d transfusion may have been the final cause of death.
Fig.
l.-Posterior
wall interior
Fig.
of
2.-Small
uterus with male catheter of uterus and large veins
arteriole
in
lung
fllled
in small depression of right broad ligament.
with
particulate
communicating
matter.
with
662
STONE,
KOUCKY,
AND
J,ELANI)
.\,,I. .I. Obst. s; Qoer. Septembrr. 1355
Study of report,ed cases indicates that there is no specific etiology. It is obvious that congenital disturbances in structure or ~losition of blootl vessels cam not. he a factor, Imansc the majority of patients have had previous pregnancies without, complications. ,- eincr and Lashbaugh suggest. that. intact membranes St or c>losurc of’ the uterine ontlct. t)y t.he fetal head, together with hard uterine contractions, may force amniotic fluid into the placental veins. Leary ant1 Hertig demonstrated squamous cells from amniotic fluid within the placenkr and it,s membranes? and suggested that. such estmvasations a.re not uncommon in labor. Landing found squamous cells prosent in t.he ut.erine vessels in from one-third to one-fonrth of the uteri removed as opcratiye or autopsy specimens in cases of placenta accrcla, tnpt,nred uterus, cesarean section, retention 01 placenta, and premature scyaration of the placenta. In three of his cases, Sqllam~JllS cells from t,he anlniotic fluid were also found in the lungs. These studies indicate that the entr)~ of amniotic fluid into uterine vessels may not he \mcommon and that. subclirric:rl 01’mild forms of amniotic fluid embolism might occu1’.
In about one-half of th(x reported cases,some tear or surgical incision into t Ite uterus, cervix, or placenta was present. This case is unique in that a vets> lar:re communication between the uterine cavity and t,he maternal circulai.iolt \ras demonstrated.
References I,anding, H. H. : New England J. Med. 243: 590, 19.50. I,eary, 0. C., and Hertig, A. T.: New England J. Med. 243: 58S, 1950. Lushbaugh, C. C., and Steiner, P. E.: AM. J. OBST. L GYNEC. 43: 833, 1943.
T
~CASE OF AM?$IOTIC
HIS case is of special fluid was located.
interest
FLUID
because the point
EMBOLISIW
of entry
of the amniotic
The patient, a gravida v, para iii, had an uneveutful pregnancy. On April 18, 1950, she was admitted to Fairview Hospital about four hours after the onset of labor with the cervix dilated 2 cm. Labor progressed slowly. She was given Demerol, 75 mg., and scopolamine. !$oo grain. The pains became more regular and the cervix dilated to 3 cm. She was taken to the delivery room 45 minutes later because of marked nausea with the pains. She twice vomited small amounts of greenish liquid. She was drowsy and rested well between pains. One-ha1.f hour later she had an involumtary defecation and urination and 45 minutes later the nurse made the following entries: i ‘ The patient turned on side by herself, became rigid with head thrown sharply bacsk. Very cyanotic and does not respond, respirations gasping. Pulse imperceptible. R.P. 130/60. Patient dead. ” The lungs lvere moderately An autopsy was performed by Dr. Koucky on the same day. hravy and edematous. The left lung weighctl 450 grams and the right weighed 440 grams. The IOWW lobes were partially atelcctatic. The bronchi and the trac*hea showed no foreign material, and the pulmonary arteries showed no emboli. No air was present in the heart. Examination of the external surfacr of the uterus showed no suggestion of trauma, hemorrhage, or other changes. The uterus contained a normal term female infant, in left vertex anterior presentation. The membranes w(‘re ruptured with about 200 e.c. of thick greenish fluid in the uterine cavity, and this was present in the interspaces between the legs and the arms and in tho spacae arountl the neck. The fetal hrad was in the lower uterine segment, The wall and the muscle of the Lowe uterine segment were bare for distances varying from 2 to 4 inches. On the exposed posterior wall of tlrtx utel’us, a small depression was observed which, when explored with thr tip of a forceps, proved to be a sizable channel (Fig 1). A rubber catheter of the type used in male c~athrterization easily passed through the opening into the interior of the uterine wall and appeared in the large veins of the right broad ligament. Blood recovered from the right rommon iliac vein and from the lower vena rava, when spread out on the white porcelain tahletop, showed numerous flakes of green mucoid material. One of the larger pieces IT-as ailout 1 mm. in diameter and 5 or 6 mm. in length. Approximation of the fetus into its clriginal position within thcx uterus indicated that the opening iuto the uterine vein was in about the same position of the space formed by the fetal neck and the small parts. Microscopic study showed about the sanle picture in all lobes of the lungs. In every section there were many small arterioles and capil1aric.s containing foreign material made up nf squamous epithelial debris, amorphous material, mucus, and leukocytes (Fig. 2). A few foci of leukocytes were present in the lung parenchyma which had the appearance of beginning exudation. Two impressions were receired from the microscopic study of the lungs in this case. The early exudative reaction suggested that the embolism of amniotic sediment was not a terminal explosive event but had heen going on for many minutes or even hours. Perhaps the patient’s nausea, vomiting, involuntary howe movement and urination indicated the be*present&
1954.
at
a
meeting
of the Minnesota
Obstetrical
an<1
Gynecological
Society,
Dec.
12.
Volume Number
70 3
F,4TAL
CASE
OF
AMNIOTIC
FLUID
661
EMROLISM
ginn ,ing of the embolism. The second impression was that the degree of embolism proi lucea only moderate vascular occlusion and that death was due to causes other than mechanica 1 obstrll ction. It is very likely that “shock” similar to that caused by foreign material in a bloo d transfusion may have been the final cause of death.
Fig.
l.-Posterior
wall interior
Fig.
of
2.-Small
uterus with male catheter of uterus and large veins
arteriole
in
lung
fllled
in small depression of right broad ligament.
with
particulate
communicating
matter.
with
662
STONE,
KOUCKY,
AND
J,ELANI)
.\,,I. .I. Obst. s; Qoer. Septembrr. 1355
Study of report,ed cases indicates that there is no specific etiology. It is obvious that congenital disturbances in structure or ~losition of blootl vessels cam not. he a factor, Imansc the majority of patients have had previous pregnancies without, complications. ,- eincr and Lashbaugh suggest. that. intact membranes St or c>losurc of’ the uterine ontlct. t)y t.he fetal head, together with hard uterine contractions, may force amniotic fluid into the placental veins. Leary ant1 Hertig demonstrated squamous cells from amniotic fluid within the placenkr and it,s membranes? and suggested that. such estmvasations a.re not uncommon in labor. Landing found squamous cells prosent in t.he ut.erine vessels in from one-third to one-fonrth of the uteri removed as opcratiye or autopsy specimens in cases of placenta accrcla, tnpt,nred uterus, cesarean section, retention 01 placenta, and premature scyaration of the placenta. In three of his cases, Sqllam~JllS cells from t,he anlniotic fluid were also found in the lungs. These studies indicate that the entr)~ of amniotic fluid into uterine vessels may not he \mcommon and that. subclirric:rl 01’mild forms of amniotic fluid embolism might occu1’.
In about one-half of th(x reported cases,some tear or surgical incision into t Ite uterus, cervix, or placenta was present. This case is unique in that a vets> lar:re communication between the uterine cavity and t,he maternal circulai.iolt \ras demonstrated.
References I,anding, H. H. : New England J. Med. 243: 590, 19.50. I,eary, 0. C., and Hertig, A. T.: New England J. Med. 243: 58S, 1950. Lushbaugh, C. C., and Steiner, P. E.: AM. J. OBST. L GYNEC. 43: 833, 1943.