Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942008000400010
Brazilian Journal of Anesthesiology
Clinical Information

Embolia amniótica durante parto normal sob analgesia: relato de caso

Amniotic fluid embolism during vaginal delivery under analgesia: case report

José Fernando Amaral Meletti; Reinaldo Vargas Bastos de Miranda

http://dx.doi.org/10.1590/S0034-70942008000400010 Braz J Anesthesiol, vol.58, n4, p.397-402, 2008
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Resumo

JUSTIFICATIVA E OBJETIVOS: A embolia amniótica é rara, sendo quadro clínico de início súbito e elevada morbidade. O objetivo deste trabalho foi apresentar um caso de embolia amniótica em paciente primigesta, submetida à analgesia para parto normal. RELATO DO CASO: Gestante de 38 anos, bolsa rota e 5 cm de dilatação do colo uterino. Apresentava-se com muita dor, agitação, sudorese, taquissistolia e venóclise com Ringer com lactato associado a 5 UI de ocitocina em gotejamento lento, pressão arterial (PA) de 110 × 70 mmHg, freqüência cardíaca (FC) 115 bpm, em ritmo sinusal e SpO2 de 98%. Optou-se por técnica combinada, empregando-se 2,5 mg de bupivacaína pesada e 20 µg de fentanil no espaço subaracnóideo e cateter no espaço peridural. Após 20 minutos do início da analgesia a paciente referiu prurido súbito e intenso, apresentou agitação, vômito e palidez, FC 160 bpm, taquipnéia, SpO2 80% e PA inaudível. Administrou-se solução fisiológica a 0,9% (500 mL) associada à hidrocortisona, efedrina (50 mg) e oxigênio sob máscara facial com fluxo de 10 L.min-1. Nesse momento, a PA era 60 × 30 mmHg, a FC 150 bpm e a SpO2 92%. Como a PA tendia a diminuir, foi administrado um total de 7 mg de metaraminol, divididos em várias doses. Após o parto vaginal, a paciente foi encaminhada à UTI com PA 90 × 60 mmHg, FC 110 bpm e taquipnéia. Duas horas após apresentou sangramento e hipotensão arterial, sendo diagnosticado coagulação intravascular disseminada (CIVD), tratada com cristalóides, concentrado de hemácias e plasma fresco congelado. Alta da UTI no terceiro dia de pós-operatório. CONCLUSÕES: Em decorrência da dramaticidade, gravidade e instalação abrupta do quadro, a rapidez e objetividade de medidas para manter sinais vitais são fundamentais e decisivos para a sobrevida das gestantes. Alerta-se para a importância de monitoração durante a analgesia de parto.

Palavras-chave

CIRURGIA, Obstétrica, COMPLICAÇÕES, COMPLICAÇÕES

Abstract

BACKGROUND AND OBJECTIVES: Amniotic fluid embolism is a rare occurrence; it has a sudden onset and high morbidity. The objective of this report was to present a case of amniotic fluid embolism in a primipara undergoing analgesia for vaginal delivery. CASE REPORT: This is a 38-year old pregnant woman with amniotic sac ruptured, cervix with 5-cm dilation, complaining of severe pain; the patient was agitated, diaphoretic, and with tachysystoly. After venipuncture, Ringer's lactate with 5 IU of oxytocin was infused slowly, blood pressure (BP) 110 × 70 mmHg, heart rate (HR) 115 bpm with sinus rhythm, and SpO2 98%. It was decided to use a combined technique: 2.5 mg of heavy bupivacaine and 20 µg of fentanyl were administered in the subarachnoid space and a catheter was inserted into the epidural space. Twenty minutes after the institution of analgesia, the patient complained of sudden onset of severe pruritus, she was agitated, with nausea and vomiting, pale, HR 160 bpm, tachypneic, SpO2 80%, and BP could not be detected. Normal saline (500 mL) associated with hydrocortisone, ephedrine (50 mg), and oxygen with a face mask at 10 L.min-1 were administered. At that moment, she presented BP 60 × 30 mmHg, HR 150 bpm, and SpO2 92%. Since BP tended to decrease, a total of 7 mg of metaraminol were administered divided in several doses. After vaginal delivery, the patient was transferred to the ICU with BP 90 × 60 mmHg, HR 110, and tachypnea. Two hours later, she developed bleeding and hypotension; disseminated intravascular coagulation (DIC) was diagnosed and the patient treated with crystalloid solutions, packed red blood cells and fresh frozen plasma. She was discharged from the ICU in the 3rd postoperative day (PO). CONCLUSIONS: Due to the dramatic presentation, severity, and fast installation of the symptoms, the speed and objectivity of the measures instituted to maintain vital signs are fundamental and decisive for survival of pregnant patients. We alert for the importance of monitoring during labor analgesia.

Keywords

COMPLICATIONS, COMPLICATIONS, SURGERY, Obstetric

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