Recordia Kennedy’s first three deliveries
in 1991, 1994 and 1996 were as uneventful
as birth can be in terms of her own health.
“And I have always been a healthy person,”
says Kennedy, age 41, just five days after
she nearly died during her fourth delivery,
due to the rare obstetric emergency known
as amniotic fluid embolism (AFE), or
anaphylactoid syndrome of pregnancy.
“A combination of maternal fetal medicine
(MFM), great obstetrical nursing and
phenomenal medical care saved her life,”
says Washington University physician and
Barnes-Jewish Hospital Women and Infants
Medical Director George Macones, MD.
Macones points to excellent teamwork, a
timely forceps delivery and the use of
an unusual combination of resuscitative
medications as some of the causes of the
unexpected recovery for mother and baby.
While Kennedy has asthma and had
a placenta previa with this pregnancy
that resolved in early January 2012, she
seemed healthy on Feb. 26, according to
Angela Zangara, BSN, RN, her bedside
nurse that day. Kennedy was progressing
in labor, with an epidural infusing. The
fetal heart tracing was NICHD Category
II, and she was approaching the second
stage of labor quietly, without pain.
Then, “She called out, thinking the baby
was ready to deliver,” says Zangara,
who, along with Barnes-Jewish Hospital
resident physician Julianna Verticchio,
MD, checked Kennedy’s cervix. “She was
eight [cm],” Zangara says, “so we sat her
back up.”
That’s when things started to deteriorate
for Kennedy, Zangara says. “She said, ‘I
feel like I can’t breathe.’ She coughed for
about 10 seconds, like she couldn’t get air
in.” Zangara checked the pulse oximeter
reading. “It went from 98 to 81, and then
she went unresponsive.” Zangara called
out Kennedy’s name multiple times with
no response, then performed a sternal rub
while Verticchio pushed the emergency
code button.
Carolyn Mank, BSN, RN, responded to
the call and, after finding no carotid pulse,
started chest compressions within one
minute. “There was no chaos,” Mank says.
“We can respond with urgency and instinct in
OB because we are so used to working stat.”
Barnes-Jewish Hospital attending
obstetrician and Washington University
maternal fetal medicine fellow Lorie Harper,
MD, was leaving the operating room
following a cesarean section when she
received the obstetric emergency page.
“The patient was pulseless, and
there were no fetal heart tones
when I walked in,” Harper says.
Within two minutes of being at the bedside,
Harper had climbed onto the lower half
of the bed into a kneeling position and
delivered Kennedy’s baby boy using
Simpson-Luikart forceps from a +2 station,
while Zangara applied suprapubic pressure.
“Luckily she was complete by that time,”
Harper says. If she had not been complete,
Harper says, an emergent, bedside cesarean
section would have been indicated.
Mank and others continued chest
compressions. The obstetric anesthesia
team had arrived with Harper and had
successfully intubated Kennedy concurrent
with delivery. “I heard the baby crying in
the room, and our working differential
was already AFE versus pulmonary
embolism” Harper says.
The acute care team arrived immediately
after delivery, and the full code continued,
with the maternal fetal medicine, obstetric
nursing and anesthesia teams working
together, each maintaining a vital role
in Kennedy’s medical management and
resuscitation. “Everyone knew what their
responsibility was and not only performed
well, but also kept the rest of the team
up to date,” says Tim Nienhaus, RN, the
responding nurse from the acute care team.
Excellent teamwork was
integral to Kennedy’s
successful resuscitation.
“The patient would have died if there had
been three separate tornadoes going on in
that room,” Macones says.
Approximately 30 minutes into the
ACLS-compliant code, when hope for
Kennedy’s successful resuscitation was
dwindling, the anesthesiology team
gave four embolus-specific medicines,
concurrently maintaining the ACLS
algorithm, according to Maryann Otto, MD,
Washington University anesthesiologist at
Barnes-Jewish Hospital. “Within minutes of
receiving those meds she got a pulse back,”
says Otto, who led the team that managed
Kennedy's airway during the code.
According to Otto, AFE occurs when
amniotic debris enters maternal circulation
and causes the release of endogenous
serotonin mediators. Because AFE does not
naturally occur in animals, and scientists
cannot recreate the entire picture of AFE
in laboratory animals, consideration of
treatment for AFE comes from research
done on the chemical mediators of serotonin
involved in pulmonary embolism [PE]. “With
PE, there is the additional component of
mechanical obstruction to consider. With
AFE, there is no mechanical obstruction.
Therefore, the focus of treatment is on the
chemical mediators of serotonin. A sudden
imbalance in these mediators causes a
cascade that leads to extreme pulmonary
vaso- and broncho-constriction,” Otto says.
“This extreme pulmonary hypertension leads
to right-sided heart failure and, quickly, to
cardiac arrest.”
The estimated incidence for AFE is two
per 100,000 deliveries, according to a
population-based cohort study performed
by Knight, et. al., published in 2010 in
Obstetrics and Gynecology. However, the
incidence reported in recent medical
literature ranges from two to 7.7 cases
per 100,000 deliveries. While it is very rare,
it is estimated that AFE caused between
5 and 15 percent of all pregnancy-related
deaths in developed countries between
1999 and 2009, according to an
evidence-based review by Conde-Audelo
and Romero, published in the American
Journal of Obstetrics and Gynecology in 2009.
AFE presents suddenly, with
56 percent of cases occurring
before or during labor and
the remaining 44 percent
occurring within four hours
after delivery.
The reported mortality rate associated
with AFE varies widely. In addition to
finding a 20 percent fatality rate, the Knight
study showed that a greater percentage
of the women who died were from
ethnic-minority groups.
Kennedy was at increased risk for
antenatal AFE related to multiple factors.
There is no documented evidence that
she experienced any of the premonitory
symptoms until just before her cardiac
arrest. Kennedy does not remember the
day of her delivery, and family members
present at the time of her respiratory
depression and cardiac arrest state she
had not mentioned any symptoms until
just prior to losing consciousness.
Clinically, there are two major components
to look for with AFE, says Harper. They
are cardiopulmonary depression or arrest
and disseminated intravascular coagulation
(DIC). There is no diagnostic blood test;
in the moment, the team must use clinical
presentation to diagnose AFE, then treat
accordingly while resuscitating. If the baby
is still in the uterus when AFE occurs, the
obstetric team has less than five minutes
from the moment of cardiac arrest to
maximize the chance for the baby to be
born neurologically intact, says Harper.
Newborn David has done well. He earned
a five-minute Apgar of 9, had an umbilical
arterial blood pH of 7.22 and went home on
day of life 5 instead of 3 or 4, due only to the
need to remain in-hospital with his mother.
Kennedy went on to exhibit all of the
entry criteria for AFE. “Basically, as soon
as she had a pulse again, she was bleeding
from every possible site,” says Mank of the
ensuing DIC. Kennedy was moved to the
medical intensive care unit (MICU). The
obstetric team placed a Bakri balloon in
Kennedy's uterus to help with her DICrelated
bleeding from that site, and her
coagulopathy was managed in cooperation
with the MFM and MICU medical teams.
During her hospital stay, Kennedy
received a total of 23 units of blood
products for acute DIC with, at one point,
an undetectable fibrinogen. Her recovery
has been slow but steady, with a few
complications, including the development
of a deep venous thrombosis (DVT)
during her inpatient hospital stay.
Just 17 days after she nearly died giving
birth, Kennedy returned home to care for
her newborn and three older children.
She has some physical limitations that
are believed by her physicians to be
temporary, but she is still struggling to
speak and walk as well as she used to.
“I’m going to have to try hard just to
keep up,” she says, then looks away.
“She is doing well,” says Margaret Baum,
MD, the obstetrician who cared for
Kennedy prenatally and has treated her
since discharge from the hospital. “I’ve
seen her two or three times; she sees
us for routine medical care. Her gait
and memory are improving,” Baum
says, noting that Kennedy has been
walking independently, though at times
unsteadily, all along. “She’s not on
dialysis, her last creatinine was normal,
and her liver function tests are almost
normal.” According to Baum, Kennedy
also regularly sees an internal medicine
physician for continuing anticoagulation
and monitoring of her renal dysfunction
and the neurological sequelae of
extended resuscitation.
Kennedy says that although
she has strong and steady
family support, the recovery
has been emotionally and
physically difficult.
But this is not the first challenge
that Kennedy, who spent some of her
formative years without a guardian,
has faced. And she is inspired and
determined to recover. “I have a new
baby,” she says. “I will never take life
for granted.”