Atropine (1 mg IV) and epinephrine (1 mg IV) were administered with subsequent return of spontaneous circulation. Advanced cardiovascular life support protocol was initiated, and a maternal code blue was activated. The patient underwent rapid sequence intubation, after which pulseless electrical activity (PEA) was noted. Her heart rate decreased to 40/min, oxygen saturation dropped to 44% on room air, and the patient exhibited decorticate posturing. Approximately 15 minutes after delivery, while the subcutaneous tissue closure was being completed, the patient complained of a feeling of impending doom. Delivery of the neonate and placenta was uneventful. Upon admission, the patient was taken to the operating room for the planned procedure under regional anesthesia. Her medical history was otherwise uncomplicated. The patient's pregnancy was complicated by chronic hypertension, but she required no medication during pregnancy. In this case, the patient survived after prolonged cardiac arrest and is neurologically intact.Ī 34-year-old gravida 4, para 2012 presented for a scheduled repeat cesarean section and bilateral tubal ligation at 39 weeks of gestation. We present a case of presumed AFE causing immediate postpartum cardiac arrest and the use of the AOK adjunctive protocol. However, very few documented case reports show the utility and success of AOK for treatment of AFE. 3 The use of atropine (1 mg intravenously ), ondansetron (8 mg IV), and ketorolac (30 mg IV) (AOK) as an adjunctive treatment is widely discussed by obstetric providers as a treatment option that should be considered to supplement other treatment modalities. 1 Current guidelines for management of AFE focus on combating acute right heart failure and subsequent cardiogenic shock due to left heart failure. The activation of these substances leads to multiple detrimental physiologic changes resulting in pulmonary artery hypertension, acute cor pulmonale, and eventual complete cardiovascular collapse. 1, 2 AFE is hypothesized to occur when amniotic fluid enters the maternal circulation, causing massive constriction of the pulmonary vessels from the activation of physiologic mediators such as histamine, endothelin, and leukotrienes. Risk factors for AFE include advanced maternal age (35 years or older), cesarean or operative delivery, placental abnormalities, and eclampsia. Amniotic fluid embolism (AFE) is a rare cause of severe maternal morbidity and mortality.
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