Utilization of point-of-care ultrasound and rotational thromboelastometry (ROTEM) in the diagnosis and management of amniotic fluid embolism presenting as post-partum hemorrhage and cardiac arrest

Abstract

Abstract Objectives To describe the integration of point-of-care ultrasound (POCUS) and rotational thromboelastometry (ROTEM) in the diagnosis and management of cardiac arrest secondary to amniotic fluid embolism (AFE). Case presentation A 29-year-old female presented for induction of labor at 39 weeks. Labor was complicated by hemorrhage and subsequent sinus tachycardia pulseless electrical activity (PEA) arrest. Intra-arrest POCUS demonstrated right ventricular dilation and hypokinesis adding to a presumed hemorrhagic arrest etiology. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated at the bedside following the POCUS findings. ROTEM further clarified the etiology of hemorrhage as disseminated intravascular coagulation (DIC), and in combination with the POCUS findings led to a final diagnosis of amniotic fluid embolism with DIC. The patient was maintained on VA-ECMO without heparin in the setting of DIC. She had a complicated hospital course but was discharged home with her healthy child and no residual physical or neurologic deficits. Conclusions In the absence of more specific testing modalities the utilization of rapidly available POCUS in conjunction with ROTEM can impact clinical decision making of cardiovascular resuscitation in patients during labor and delivery by narrowing the differential between pulmonary embolism and AFE.