An 18 yr old nulliparous women was admitted at 41 weeks gestation

							POST CAESAREAN SECTION ARREST:A DIAGNOSTIC DILEMMA
Tony Thomas StR 3 Wishaw General Hospital

An 18 yr old nulliparous woman was admitted at 41 weeks gestation in an otherwise
uneventful pregnancy in spontaneous labour. Post admission BP was elevated[systolic
180-142/diastolic 86-102] with a maternal tachycardia of 100-146.Urine dipstick showed
4+ proteinuria and investigations were normal except for a urate level of 4.3mg/dL.She
received a one off dose of 10mg nifedepine[used as patient was asthmatic] for the raised
blood pressure. Labour was augmented with amniotomy and syntocinon after an epidural.
The persistent tachycardia was attributed to nifedepine /epidural although the possibility
of venous thromboembolism was considered. An ECG done showed only sinus
tachycardia and arterial blood gasses were normal. We proceeded to an emergency
caesarean section in view of poor progress[cervical dilatation arrested at 5 cms for
7hours in spite of syntocinon],persistent maternal tachycardia and pre-ecclampsia,
initially under an epidural block which was converted to a general anaesthetic post skin
incision as the patient had complained of pain. Patient had a normal recovery post
reversal of GA[54 minutes from induction] after an uneventful C/S. However 17 minutes
post reversal patient was unresponsive ,with decerebrate posturing and a brady arrest.
She was resuscitated, intubated and shifted to critical care. Supportive management was
initiated with ventilatory assistance for 22 days.She did not require blood products or
inotropes. CTPA done was supportive of amniotic fluid embolism while CT brain done
on the day of arrest and repeated on day 2 were normal. A 2D echo raised suspicion of
an ASD but a trans oesophageal echo showed only a prominent chian network[which is
associated with a patent foramen ovale].An MRI done on day3 showed evidence of
scattered infarction involving mainly the corpus callosum, frontal lobes and water shed
areas of the brain. Clinical picture showed steady improvement progressing from
quadriparesis and weak speech on day 25 to almost full recovery by day 60 with residual
defects at time of report being short term memory loss and 3-4/5 power in lower limbs

Discussion
Brady arrest with cerebrovascular insult in the immediate post caesarean section period is
rare. This case presents an acute diagnostic dilemma as none of the classic features of the
differential diagnosis considered [AFE,PTE,Paradoxical embolism, atypical presentation
of ecclampsia] were present. A detailed history revealed that the patient was born
prematurely at 26 weeks gestation and suffered from chlamydial pneumonia,severe
bronchopulmonary dysplasia ,patent ductus arteriosus and intraventricular haemorrhage.
Whether these events could have contributed to opening of an intracardiac
communication between the arterial and venous circulations is a matter of debate[Kozelj
et al.1999].The presence of only mild coagulopathy was another interesting
observation.[PT 17.2(N),PTT 44.7 N range(25.5 -38.5),platelet count 164] and could
point to the relatively small size of the embolus[Nagar etal.2005].Inspite of absence of a
clear diagnosis treatment available is only supportive with anticoagulation and
ventilatory/rehabilitation support. The near complete recovery that the patient had
supports the widely held view that primary determinant of outcome will be number of
emboli reaching cerebral ,coronary and pulmonary vascular beds regardless of how
aggressive therapy may be .[Noble and St-Amand1993]
References

Kozelj M. Novak-Antolic Z. Grad A. Peternel P. Patent foramen ovale as a potential
cause of paradoxical embolism in the postpartum period. European Journal of
Obstetrics, Gynecology, & Reproductive Biology. 84(1):55-7, 1999 May

M. Nagar, A. Gratrix, H. O’Beirne, S. Enright Survival following amniotic fluid
embolism and cardiac arrest complicated by sub-capsular liver haematoma.
International Journal of Obstetric Anesthesia, Volume 14, Issue 1, Pages 62-65 ,2005 Jan


Noble WH. St-Amand J. Amniotic fluid embolus. [Review] [53 refs] [Case Reports.
Journal Article. Review] Canadian Journal of Anaesthesia. 40(10):971-80, 1993 Oct