Limits...
Nontraumatic Fat Embolism Found Following Maternal Death after Cesarean Delivery.

Schrufer-Poland T, Singh P, Jodicke C, Reynolds S, Maulik D - AJP Rep (2014)

Bottom Line: On postoperative day 2 the patient was found to be unresponsive.Despite resuscitative efforts, the patient succumbed.Furthermore, there was no histological evidence of either amniotic fluid embolism or thromboembolism.

View Article: PubMed Central - PubMed

Affiliation: Department of Obstetrics and Gynecology, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri.

ABSTRACT
Introduction Fat embolism is a rare form of nonthrombotic embolization. Limited literature exists regarding the diagnosis of fat embolism during the perinatal period. We present the first case of maternal death that resulted from nontraumatic fat embolization following Cesarean delivery. Case Description A 29-year-old gravida 1 with a complex medical and surgical history underwent a primary Cesarean delivery at term. On postoperative day 2 the patient was found to be unresponsive. Despite resuscitative efforts, the patient succumbed. Autopsy findings were remarkable for diffuse pulmonary fat emboli. Furthermore, there was no histological evidence of either amniotic fluid embolism or thromboembolism. The primary cause of death was attributed to nontraumatic fat embolization. Discussion Multiple risk factors may have contributed to the development of nontraumatic fat embolization in our patient. Obstetricians should maintain a high level of suspicion for nontraumatic fat embolization in cases of maternal respiratory decompression and sudden maternal mortality.

No MeSH data available.


Related in: MedlinePlus

Hematoxylin and eosin stain of transverse sections of the pulmonary parenchyma with arterioles containing intravascular blood elements and intracellular debris, magnified to ×20 (left), special stain with pan-cytokeratin demonstrating absence of squamous cells within the pulmonary vasculature, magnified to ×20 (right).
© Copyright Policy
Related In: Results  -  Collection


getmorefigures.php?uid=PMC4502621&req=5

FI140030-2: Hematoxylin and eosin stain of transverse sections of the pulmonary parenchyma with arterioles containing intravascular blood elements and intracellular debris, magnified to ×20 (left), special stain with pan-cytokeratin demonstrating absence of squamous cells within the pulmonary vasculature, magnified to ×20 (right).

Mentions: A 29-year-old primigravida presented to our high-risk obstetrical clinic at 18 gestational weeks with a complex medical history significant for Arnold-Chiari malformation, hydrocephalus, spina bifida with tethered cord syndrome, neurogenic bladder, and chronic decubitus ulcerations as a result of prolonged immobility. Her surgical history consisted of ventriculoperitoneal shunting, multiple lumbosacral laminectomies, numerous irrigation, and debridement for perineal ulcerations eventually necessitating a diverting colostomy and an ileovesicostomy. As the patient had minimal support infrastructure, a social service consultation was made to assist with nursing home placement and transportation to her outpatient appointments. The patient declined genetic screening and her initial prenatal laboratory values, fetal anatomy survey, and serial fetal growth evaluations were normal. At 28 gestational weeks, she developed gestational diabetes and was successfully treated with oral hypoglycemic agents. Her antepartum surveillance consisted of weekly biophysical profiles beginning at 28 gestational weeks which were reassuring. At 38 weeks, the patient developed mild preeclampsia that necessitated delivery. Due to the inability to provide the patient with regional anesthesia due to her history of complex spinal surgery coupled with the difficulty in maintaining dorsal lithotomy position through the second stage of labor as a result of her lower extremity contractures and the patient's desire to avoid a vaginal delivery in the absence of reliable pain control, a Cesarean delivery under general anesthesia was undertaken. The neonate was delivered without complications and the remainder of the Cesarean section was uneventful. On postoperative day 1 the patient was alert and responsive as well as tolerating medications and fluids by mouth. Although the patient's blood pressure remained mildly elevated, she denied any other symptoms of preeclampsia and had normal laboratory values. On the morning of postoperative day 2, however, the patient was found to be unresponsive, without an obtainable pulse or blood pressure. Bilateral intraosseous lines were placed and cardiopulmonary resuscitation (CPR) was initiated. Despite several cycles of CPR, no response was obtained and the patient was pronounced dead. Autopsy examination revealed pulmonary vasculature with optical clearing of the lumens suggestive of fat emboli (Fig. 1A). The Oil Red O stain showed scattered fat droplets in alveolar spaces and distal, smaller blood vessels in different areas throughout the lungs (Fig. 1B). Immunohistochemical stain for pan-cytokeratin and special staining for c were performed on lung sections and were negative for fetal squamous cells or mucinous debris which are often associated with amniotic fluid embolism (Figs. 2 and 3). The remainder of the autopsy findings were unremarkable, including no evidence of rib or long bone fractures, amniotic fluid embolism, or thromboembolism. The cause of death was attributed to multiple nonthrombotic pulmonary fat emboli.


Nontraumatic Fat Embolism Found Following Maternal Death after Cesarean Delivery.

Schrufer-Poland T, Singh P, Jodicke C, Reynolds S, Maulik D - AJP Rep (2014)

Hematoxylin and eosin stain of transverse sections of the pulmonary parenchyma with arterioles containing intravascular blood elements and intracellular debris, magnified to ×20 (left), special stain with pan-cytokeratin demonstrating absence of squamous cells within the pulmonary vasculature, magnified to ×20 (right).
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4502621&req=5

FI140030-2: Hematoxylin and eosin stain of transverse sections of the pulmonary parenchyma with arterioles containing intravascular blood elements and intracellular debris, magnified to ×20 (left), special stain with pan-cytokeratin demonstrating absence of squamous cells within the pulmonary vasculature, magnified to ×20 (right).
Mentions: A 29-year-old primigravida presented to our high-risk obstetrical clinic at 18 gestational weeks with a complex medical history significant for Arnold-Chiari malformation, hydrocephalus, spina bifida with tethered cord syndrome, neurogenic bladder, and chronic decubitus ulcerations as a result of prolonged immobility. Her surgical history consisted of ventriculoperitoneal shunting, multiple lumbosacral laminectomies, numerous irrigation, and debridement for perineal ulcerations eventually necessitating a diverting colostomy and an ileovesicostomy. As the patient had minimal support infrastructure, a social service consultation was made to assist with nursing home placement and transportation to her outpatient appointments. The patient declined genetic screening and her initial prenatal laboratory values, fetal anatomy survey, and serial fetal growth evaluations were normal. At 28 gestational weeks, she developed gestational diabetes and was successfully treated with oral hypoglycemic agents. Her antepartum surveillance consisted of weekly biophysical profiles beginning at 28 gestational weeks which were reassuring. At 38 weeks, the patient developed mild preeclampsia that necessitated delivery. Due to the inability to provide the patient with regional anesthesia due to her history of complex spinal surgery coupled with the difficulty in maintaining dorsal lithotomy position through the second stage of labor as a result of her lower extremity contractures and the patient's desire to avoid a vaginal delivery in the absence of reliable pain control, a Cesarean delivery under general anesthesia was undertaken. The neonate was delivered without complications and the remainder of the Cesarean section was uneventful. On postoperative day 1 the patient was alert and responsive as well as tolerating medications and fluids by mouth. Although the patient's blood pressure remained mildly elevated, she denied any other symptoms of preeclampsia and had normal laboratory values. On the morning of postoperative day 2, however, the patient was found to be unresponsive, without an obtainable pulse or blood pressure. Bilateral intraosseous lines were placed and cardiopulmonary resuscitation (CPR) was initiated. Despite several cycles of CPR, no response was obtained and the patient was pronounced dead. Autopsy examination revealed pulmonary vasculature with optical clearing of the lumens suggestive of fat emboli (Fig. 1A). The Oil Red O stain showed scattered fat droplets in alveolar spaces and distal, smaller blood vessels in different areas throughout the lungs (Fig. 1B). Immunohistochemical stain for pan-cytokeratin and special staining for c were performed on lung sections and were negative for fetal squamous cells or mucinous debris which are often associated with amniotic fluid embolism (Figs. 2 and 3). The remainder of the autopsy findings were unremarkable, including no evidence of rib or long bone fractures, amniotic fluid embolism, or thromboembolism. The cause of death was attributed to multiple nonthrombotic pulmonary fat emboli.

Bottom Line: On postoperative day 2 the patient was found to be unresponsive.Despite resuscitative efforts, the patient succumbed.Furthermore, there was no histological evidence of either amniotic fluid embolism or thromboembolism.

View Article: PubMed Central - PubMed

Affiliation: Department of Obstetrics and Gynecology, Kansas City School of Medicine, University of Missouri, Kansas City, Missouri.

ABSTRACT
Introduction Fat embolism is a rare form of nonthrombotic embolization. Limited literature exists regarding the diagnosis of fat embolism during the perinatal period. We present the first case of maternal death that resulted from nontraumatic fat embolization following Cesarean delivery. Case Description A 29-year-old gravida 1 with a complex medical and surgical history underwent a primary Cesarean delivery at term. On postoperative day 2 the patient was found to be unresponsive. Despite resuscitative efforts, the patient succumbed. Autopsy findings were remarkable for diffuse pulmonary fat emboli. Furthermore, there was no histological evidence of either amniotic fluid embolism or thromboembolism. The primary cause of death was attributed to nontraumatic fat embolization. Discussion Multiple risk factors may have contributed to the development of nontraumatic fat embolization in our patient. Obstetricians should maintain a high level of suspicion for nontraumatic fat embolization in cases of maternal respiratory decompression and sudden maternal mortality.

No MeSH data available.


Related in: MedlinePlus