On the day of the procedure a singleton fetus with fetal heart tones was confirmed by ultrasound, monitored anesthesia care was administered with fentanyl, midazolam and propofol in an operating room, osmotic cervical dilators were removed, and a paracervical block with 1% lidocaine was performed. The day prior to the procedure the patient had osmotic cervical dilators placed in the office. The patient’s pre-procedure systolic blood pressures ranged from 80 to 100 s mmHg. No history of pre-pregnancy thrombocytopenia was noted. Workup prior to the procedure included a complete blood count which revealed a hemoglobin of 12.1 g/deciliter and platelets of 134 × 10 3/μl. The patient is a 29-year-old previously healthy female, gravida 1 para 0, who presented for a scheduled induced abortion via dilation and evacuation at 22-weeks gestation, in the setting of a pregnancy complicated by a fetus with trisomy 22 confirmed on amniocentesis and multiple fetal anomalies. We present this case to highlight the potential role for ROTEM® viscoelastic point-of-care coagulation analysis in directed and timely management of AFE associated coagulopathy, including as a rare complication of legal induced second trimester surgical abortions. While viscoelastic point-of-care coagulation analyzers have been used for years in trauma, cardiac, and liver surgery, their use in management of pregnancy-related coagulopathy is not yet widespread. In comparison to traditional laboratory coagulation tests, viscoelastic point-of-care coagulation analyzers provide more rapid results and facilitate targeted blood component therapy. Thromboelastography (TEG® Haemonetics Corp, Braintree, MA) and rotational thromboelastography (ROTEM® Tem International GmbH Munich Germany) are real-time, point of care techniques for assessing specific viscoelastic properties of whole blood as it clots under low shear conditions. We present the case of a second trimester surgical abortion complicated by a suspected AFE, where profound coagulopathy was successfully managed using targeted blood component repletion guided by viscoelastic point-of-care coagulation analysis. Analysis of the 2011–2013 Pregnancy Mortality Surveillance System attributed 5.5% of maternal deaths in the United States to AFE, with 1 of the 111 reported AFE related maternal deaths occurring following an abortion. The incidence of AFE in the setting of legal induced abortion is unknown but is likely low given the very low morbidity and mortality associated with legal induced abortion. AFE involves a complex sequence of abnormal activation of proinflammatory mediators in the setting of disruption of the maternal-fetal interface, typically presenting as sudden cardiorespiratory collapse, followed in the majority of cases by disseminated intravascular coagulopathy. Amniotic fluid embolism (AFE) is a rare complication of pregnancy associated with significant morbidity and mortality.
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