Question

A woman aged 28 years is in labour when she suddenly collapses. This is her fourth pregnancy and she has had three previous spontaneous vaginal deliveries at term. This pregnancy has been uncomplicated and she has been admitted with contractions at 37 weeks and 6 days.

On arrival on the labour ward the fetus was palpated to be normal size, cephalic and 3/5

palpable abdominally. The cervix was 3 cm dilated and the membranes were intact. Blood

pressure and urinalysis were normal. Initial auscultation of the fetus was reassuring and

the heart rate has continued to be normal (around 140/min) on intermittent auscultation.

Five minutes ago spontaneous rupture of membranes occurred during a contraction, with

a large gush of clear fluid from the vagina. The woman reported an urge to push at that

stage and then became confused and disorientated saying that she could not breathe and

was going to die. Immediately following this she collapsed.

Examination

The woman is unconscious and unrouseable to painful stimuli. The blood pressure is

98/40 mmHg and heart rate 120/min. The oxygen saturation is 86 per cent on air and

respiratory rate 20/min. The heart sounds are normal but on chest examination there are

inspiratory crackles throughout the chest.

The abdomen is soft with intermittent contractions continuing, and in fact the fetal head

is now visible at the perineum. There is no vaginal bleeding.

Questions

• What is the likely diagnosis and differentia diagnosis?

• How would you manage this woman?

Answer 1

1) Patient had a symptoms of history od sudden collapse without any chest pain,rupture of membranes

based on above symptoms the diagnosis is Amniotic fluid embolism.

Differential diagnosis:

• Pulmonary embolism
• Myocardial infarction
• Vasovagal attack

Premonitory symptoms of Amniotic fluid embolism patient is confusion,cyanosis and restlessness.A vasovagal attack is usually associated with decreased heart rate without any signs of chest pain or decreased oxygen saturation

These was occurs when the amniotic fluid enters into the maternal blood circulation that was usually happen during labour or after delivery.These was very rare.If the fluid entered into circulation the patient would die with in hour because of acute hypoxia,cardiac arrest and coagulopathy.

2)Management:

The foetus should delivered immediately because that will make effective resuscitation to the mother. In this condition a simple forceps delivery should be carried out.If the foetus was not delivered through normal proceed Caesarean section.Massive postpartum hemorrhage is present and oxytocin was infused with postpartum hemorrhage such as carboprost, ergometrine and hysterectomy.