Case ReportCase Report
The case presented in this paper describes 37 years old
woman, who was pregnant for the second time, in the 38th week
of gravidity. She was obese and diabetic treated by antidiabetic
therapy and with placenta in lower level. The birth was induced
by prostaglandins. Thirty minutes after disruption of amnion,
nausea, dyspnoea, consciousness alternated with unconsciousness,
cyanosis development of upper part of the body, followed by
tachypnoea, symptom of blue mask, tachycardia, blood pressure
was not possible to be measured, without clear symptoms of
haemorrhage, babies’ hearts activity was 140 per minutes.
According to the examination strong dilatation and dysfunction of
right heart chamber were found. According to the hypercontrability
of the left heart chamber a suspicion of massive lung embolism
was stated. Cardiac surgeon congress agreed with the diagnosis.
From that moment foetus sounds to 60 per minutes altered.
After stabilizing the patient in collaboration with obstetrics and
anaesthetist, cardiologist, cardiac surgeon, and internal specialist
Caesarean section with bilateral ligation artery hypogastricae and
B - lynch stich for haemocoagulative disorder were performed.
The foetus was born but after 48 hours she died because of
consequences of strong intrauterine hypoxia. After the surgery
the patient was stabilized at anaesthesiological department
with final diagnoses of embolism caused by amniotic fluid and
massive lung vasoconstriction. After half of a year the patient had
only neurological symptoms in the meaning of disorders tactile
motoric that was presented in reading and connected with anxious
depressive disease. From the gynaecological point of view there
are currently no obstacles. 37 years old woman secondly pregnant
in the 38th weeks of pregnancy, obese, with diagnosis pregnancy
diabetes treated antidiabetic therapy and with lower contact
placentas. She was admited for induction of labour and the birth
was induced by prostaglandins. When the regular contractions
started, the disruption amniotic sack was done. After 30 minutes all
dyspnoea, nausea, development of unconsciousness at the patient
appeared. Cyanosis was developed on the upper part of her face,
glycemy control 9mmol/l. Peripheral venous cannula, urethral
catheterization, laboratory samples and oxygen delivery were
performed. As the latest phase an anaesthesiologist was called.
After 5 minutes of tachypnoea, shallow breathing – symptom of
blue mask, the patient was saturated with 40% oxygen. ECG showed
bigemminie and aberration QRS complex. The blood pressure was
not possible to measure; venous carotids were without pathological
filling. At that moment the patient was without symptoms of
haemorrhage.
The control of foetus vitality, foetus sounds 140/min. The
cardiologist came due to clinical state of patient. He performed a
bed side ECHO resulting in strong dilatation and dysfunction of the
right heart chamber, blood stagnation in the right heart chamber
without evidence of intracardial thrombus and hypercontraction
of left chamber. According to the results obtained from the ECHO
examination, the suspicion of massive lung embolism was stated.
We put our effort to stabilizing the patient together in collaboration with anaesthesiologist, internist, cardio surgeon and cardiologist.
During the artificial pulmonary ventilation, the oxygenation was
95%, ECG showed tachycardia 140/min, blood pressure was
dropping down and even support for adrenalin controlling ECHO
resulted in relative tonisation of right heart chamber. We controlled
the foetus sounds and there was bradycardia to 60/min. After 45
minutes from the first symptom the patient was stabilized and
prepared to surgery in general anaesthesia. A female foetus was
delivered, 2840 grams and 47 centimeter’s, Apgar score 0-0-4.
The newborn baby died after 48 hours. Because of haemorrhage
and coagulation disorders during Caesarean section bilateral
ligation and B-lynch stich was done. The complete blood loss was
4 litres and was compensated by blood derivate. After stabilizing
the patient and stopping bleeding the patient was transferred to
anaesthe-siological clinic.
The first day at the anaesthesiological clinic she was treated
by pharmacologically, GCS 3, on artificial pulmonary ventilation,
circulation was stable without catecholamines. ECG showed regular
heart activity without rhythm disorder. Haemorrhage symptoms/
epistaxis, leaking injury, gynae-cological bleeding/. Antibiotic
therapy - PNC, Gentamicin, Avrazor, LMWH /Fraxiparine/ and
diuretics with ion substitution were applied. ECHO control of
the heart was monitored. It was found out that the left heart
chamber was without rhythm disorders and pericardial fluid,
with adequate systolic function. The right chamber was wider
with light pulmonary hypertension and strong tricuspidal
regurgitation. Venous ultrasound of the legs confirmed that there
was no thrombosis. Pulmonary X-ray - lungs full without focus.
The second day of hospitalization at anaesthesiological clinic the
pharmacological sedation was decreased, GCS 14, patient was
conscious, collaborating, during the spontaneous ventilation
breathing clear, circulation state without any support, diuresis
without diuretics. The patient still received the antibiotic therapy,
LMWH, infusion and nootropics. Control CT pneumoangiography
proved no evidence of lung embolus. Gynaecological examination
was without any additional therapy.
The third day of hospitalization at anaesthesiological clinic
the patient was fully conscious, GCS 15, well oriented, without
bleeding. Surgical wound was without symptoms. Antibiotic
therapy, analgetic, prokinetic, ion substitution, LMWH went on.
She orally accepted nutrition and physiotherapy started. She was
transferred to cardiological emergency to compensate states.
After the last examination the patient was without evidence of
typical embolism. The diagnosis was determined as amniotic fluid
embolism with massive pulmonary vasoconstriction. 11th day
after the Caesarean section her circulation was stable, neurological
finding in norm, haematologist ordered the usage of prophylaxis
LMWH till the end of confinement. According to the ECHO the slight
hypertrophy of the left chamber remained, but all other parameters
were as expected. Nine months later after the embolism the
opthalmological examination was performed. Both outer and inner
finding did not show any symptoms. Neurological finding involved
tactile motoric and executive functions. The result of psychological
examination proved anxious depressive disease, affective and
cognitive disorders of mid degree. The patient is prepared to be
pregnant. On the base of all examinations, it was recommended to
postpone the pregnancy for minimum one year.
