CASE REVIEW
A 32-YEAR-OLD WOMAN WITH POSTPARTUM
CARDIAC ARREST
Authors: Joseph Taylor, BSN, RN, MHA, FACHE, and Laura Taylor, MS, RN, CNM, Petoskey, MI
Section Editor: Laura M. Criddle, PhD, RN, CEN, CCNS, FAEN
Contribution to Emergency Nursing Practice:
• To inform emergency nurses of a life-threatening
obstetric condition that can be encountered in the
hospital setting
• To reinforce the emergency nurse’s role in the
resuscitative care of patients experiencing amniotic
fluid embolism
pproximately 211 million pregnancies occur world-
A wide annually, 1 with greater than 6.5 million in the
United States alone. 2 Despite advances in medical
technology and the availability of prenatal care, maternal
mortality remains high, with 830 women dying of pregnancy-
related complications daily throughout the world. 3 The United
States is not immune from that which is commonly thought to
be a problem in third-world nations only. In the United States,
the rate of maternal mortality has doubled, from an estimated
12 to 28 deaths per 100,000 births between 1990 and 2013. 4
Although women die in pregnancy primarily from severe
hemorrhage, infections, hypertensive disorders, complications
from delivery, and unsafe abortions, 3 this case discusses a
lesser-known risk: amniotic fluid embolism (AFE).
Case Report
It was an uneventful night shift in the emergency department
of a small community hospital until the following overhead
announcement was heard: “Code Blue, Labor and Delivery,
Joseph Taylor, Member, Little Traverse Bay Chapter 345, is recently retired
from the United States Navy.
Laura Taylor is Nursing Faculty, School of Nursing, North Central Michigan
College, Petoskey, MI.
For correspondence, write: Joseph Taylor, 3396 Siebenhar Way, Petoskey, MI
49770; E-mail: joseph.l.taylorbu@gmail.com.
J Emerg Nurs ■.
0099-1767
Copyright © 2017 Published by Elsevier Inc. on behalf of Emergency
Nurses Association.
http://dx.doi.org/10.1016/j.jen.2017.05.014
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involving an adult.” The ED staff paused to consider if the
announcement was a mistake. Calls for assistance in the
obstetrics department typically involve delivery complications
or neonatal resuscitation. As part of the hospital’s code
response, the ED team and an intensive care unit nurse raced
to the Labor, Delivery, Recovery, and Postpartum (LDRP)
unit to provide critical assistance.
A 32-year-old, 32-week pregnant (gravida 2, para 1)
woman had been admitted to the LDRP complaining of
painful labor contractions, spaced 2 to 4 minutes apart. She
denied any vaginal bleeding, loss of fluid, decreased fetal
movement, or other pregnancy-related problems. Medica-
tions included prenatal vitamins, iron, calcium, and folate.
Both her medical and surgical histories were unremarkable.
Fetal growth had been normal, and there was no
discordance noted on ultrasound. However, the woman’s
previous pregnancy was significant for preeclampsia,
postpartum hemorrhage, and umbilical cord avulsion
during the third stage of labor, requiring manual extraction
of the placenta and blood transfusion.
After evaluation by the provider and discussion with the
patient, the woman was taken to the OR for an elective,
nonurgent cesarean section. Her operative course was routine,
and her vital signs remained stable throughout the uneventful
delivery. The newborn weighed 3,000 gm with Apgar scores
of 6/8/8 at 1, 5, and 10 minutes. Estimated blood loss was
750 mL. Postoperatively, maternal blood pressure dropped to
100/50 mm Hg. Her uterine tone was described as “boggy,”
with moderate lochia. She was given IV ephedrine (10 mg)
and oxytocin (20 units), as well as intramuscular methyler-
gonovine (200 mcg), and 2 liters of IV crystalloids. Blood
pressure improved to 120/75 mm Hg.
By the time the patient was transferred from the OR to
the LDRP room for postoperative recovery, blood pressure
and heart rate were 120/50 mm Hg and 84/min,
respectively. Routine care for both mother and newborn
was provided by the labor and delivery staff while the
woman conversed with her family at bedside. The patient
complained of generalized pruritus and was given 50 mg of
IV diphenhydramine. Ten minutes after administration of
the drug, the woman began gasping for breath, became
cyanotic, and was unresponsive.
Nursing staff initiated code blue notification and
cardiopulmonary resuscitation (CPR). The code team arrived
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CASE REVIEW/Taylor and Taylor
within 3 minutes to provide advanced life support. The cardiac
monitor displayed ventricular tachycardia. No pulse was
palpable, so the patient was defibrillated. With CPR in progress,
the woman was endotracheally intubated and given 1 mg IV
epinephrine. These interventions produced a palpable pulse.
Chest compressions were discontinued, and endotracheal tube
placement was radiographically confirmed. The patient’s blood
pressure was maintained at 90/50 mm Hg with the aid of
continuous infusion of epinephrine. Her heart rate was 120/
min, and oxygen saturation was greater than 95%. Vaginal and
surgical-site bleeding were noted. Potential causes for this
cardiac arrest were considered, and pulmonary embolism was
strongly suspected. A decision was made to transfer the woman
to a tertiary medical facility for further care. While the transfer
was being arranged, she experienced another cardiac arrest and
developed disseminated intravascular coagulopathy (DIC).
Despite extensive resuscitation efforts, this new mother was
pronounced dead 4 hours later.
Amniotic fluid embolus (AFE), also known as anaphylac-
toid syndrome of pregnancy, is an obstetric emergency that
requires immediate life-saving interventions. 1–4 First described
in 1926, AFE was not recognized as a disease process until
1941. 1,2 AFE is a rare disorder affecting only 0.8 to 6.1 cases
per 100,000 deliveries. 1,3–6 The true incidence is difficult to
determine, owing to varying definitions of AFE, inconsistent
research methodologies, and underdiagnosis. 5 Case fatality
estimates range from 13% to 86%. 1,3,5,7,8 Strict adherence to
AFE signs and symptoms, as described in recent studies, place
maternal mortality at about 60%. 6 Neonatal outcomes are also
poor if onset of AFE occurs prior to delivery. Even when
recognized early, fetal mortality is 65%. 1–3
Although AFE presents much like other acute embolic
events, the condition is precipitated by maternal circulatory
system contact with amniotic fluid or fetal debris. This contact
causes an anaphylactoid (anaphylaxis-like) response producing
shock, DIC, and death. 1,2 It is not unusual for amniotic fluid
or fetal debris to enter maternal circulation, but most pregnant
women will not experience this profound reaction. AFE
consists of 2 phases. The early phase involves acute respiratory
failure and cardiac arrest. If the patient survives these events, the
second phase is primarily hemorrhagic in nature, characterized
by DIC, bleeding at incisional or venipuncture sites, and
inhibition of coagulation. 3,4 Many AFE risk factors have been
identified or hypothesized, including abdominal trauma,
advanced maternal age, cervical lacerations, cesarean section,
early placental separation, eclampsia, induced labor, intense
labor contractions, multiparity, placental abnormalities, poly-
hydramnios, precipitous delivery, tears in the uterus or cervix,
and uterine rupture. 1,4,6,8
Clinical findings associated with AFE include sudden
onset of chills, cough, dyspnea, pulmonary edema, acute
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pulmonary hypertension, and cyanosis; agitation, altered
mentation, encephalopathy, seizures, and coma; coagulop-
athy and diffuse bleeding; tachycardia, bradycardia, dys-
rhythmias, fetal or maternal hypotension, fetal heart rate
abnormalities, and cardiovascular collapse. 1,2,4,6 Blood tests
(electrolytes, type and crossmatch, whole blood count, and
coagulation studies), chest radiography, electrocardiogra-
phy, and echocardiography all facilitate patient manage-
ment, 1 but there are no laboratory or imaging studies
specific to AFE. Diagnosis is based on patient history and
examination, after eliminating other possible conditions.
Autopsy may be required for a definitive diagnosis.
Likewise, no AFE preventative measures exist. Treat-
ment of AFE involves supportive care only, including
endotracheal intubation and mechanical ventilation for
airway management and oxygenation, vasopressors to
support blood pressure, and blood component therapy to
reverse coagulopathies. 1,6–8 Other interventions, —such as
exchange transfusion, extracorporeal membrane oxygena-
tion, administration of hydrocortisone or recombinant
factor VIIa, and uterine artery embolization—have been
reported with mixed results. 2,6,8 Careful attention to a
pregnant patient’s medical history, risk factors, and
presentation of symptoms facilitate early recognition of
AFE and rapid intervention. Nevertheless, as in this
patient’s case, AFE is unpredictable, onset is sudden, and
the outcome is usually fatal.
Acknowledgment
We thank Gretchen K. Carroll, EdD, JD, SHRM-SCP, for
her critical review of this article.
REFERENCES
1. Kaur K, Bhardwaj M, Kumar P, Singhal S, Singh T, Hooda S. Amniotic
fluid embolism. J Anaesthesiol Clin Pharmacol. 2016;32:153-159.
2. Gist RS, Stafford IP, Leibowitz AB, Beilin Y. Amniotic fluid embolism.
Anesth Analg. 2009;108:1599-1602.
3. Amniotic Fluid Embolism Foundation. What is an amniotic fluid
embolism? http://afesupport.org/what-is-amniotic-fluid-embolism/. Pub-
lished 2015. Accessed January 5, 2017.
4. Mayo Foundation for Medical Education and Research. Amniotic fluid
embolism. http://www.mayoclinic.org/diseases-conditions/amniotic-fluid-
embolism/basics/definition/con-20035462. Published September 11,
2015. Accessed January 21, 2017.
5. Knight M, Berg C, Brocklehurst P, et al. Amniotic fluid embolism
incidence, risk factors and outcomes: a review and recommendations. Br
Med J. 2012:2-7.
6. Clark SL. Amniotic fluid embolism. Obstet Gynecol. 2014;123(2):337-348.
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7. Fong A, Chau CT, Pan D, et al. Amniotic fluid embolism: antepartum,

intrapartum and demographic factors. J Matern Fetal Neonatal Med. 2014:1-6. Submissions to this column are encouraged and may be sent to:
8. Conde-Agudelo A, Romero R. Amniotic fluid embolism: an evidence- Laura M. Criddle, PhD, RN, CEN, CCNS, FAEN
based review. Am J Obstet Gynecol. 2009;201(5):445.e1-445.e13. http://ees.elsevier.com/jen

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