Experts from across Tufts Medical Center came together to save a new mother’s life after a rare obstetric complication
Angela Gonzalez knew that she would need a C-section for the birth of her fourth child, due to a large fibroid blocking the top of her birth canal. The C-section wasn’t scheduled until the end of June, but when she began experiencing contractions a few days early, Angela headed to Tufts Medical Center Labor and Delivery in the middle of the night. The next morning, Angela’s doctors and nurses delivered a healthy baby boy. What happened next would challenge her medical team in ways they never could have imagined, as they came together in a race against time to save Angela’s life.
Within seconds of the birth of her son, Angela lost consciousness. At first, Obstetric Anesthesiologist Ben Moor, MD, wasn’t overly concerned. Angela’s vital signs remained stable and she had a history of fainting. However, she was intubated and Dr. Moor called Anesthesiologist Pavan Sekhar, MD, with the Critical Care team for support when Angela’s breathing did not begin to improve.
"Her lungs were not functioning completely normally, but at that point we seemed to be in control of the situation," said Dr. Moor. "Then suddenly, without warning, her vital signs crashed, and she went into complete cardiopulmonary collapse. Her heart stopped beating."
Nurses and doctors started CPR, while doctors delivered shock therapy to Angela’s heart. Her pulse returned, but it was very weak. By now, the medical team realized what they were dealing with—a rare obstetric complication called amniotic fluid embolism (AFE). Angela’s life was in grave danger.
“I only have seen a couple of amniotic fluid embolism cases in my 20 years in practice; it is an extremely rare, but feared complication of delivery,” said Michael House, MD, Maternal-Fetal Medicine Physician and Angela’s obstetrician. “The cause of AFE is not well-understood, but it’s hypothesized that, at the time of delivery, amniotic fluid enters the mother’s bloodstream and causes an allergic reaction, resulting in a widespread inflammatory response. The problem strikes like a bolt of lightning.”
As the inflammation rapidly spreads to the lungs, they begin to fail. Without normal blood flow across the lungs, the heart starts failing too, followed by all the other organs in quick succession. In addition to sudden cardiac arrest, the inflammation can cause an abnormal blood clotting condition, called disseminated intravascular coagulation (DIC), throughout the body. DIC occurs when the body responds to the massive inflammation by using up platelets and other coagulations components that form blood clots, resulting in uncontrolled bleeding. The risk of AFE is small—studies have estimated between 2 and 6 cases per 100,000 deliveries. But when AFE does occur, maternal mortality rates are extremely high and the prognosis in those who survive is poor.
“The mortality rate of a severe case of AFE–one that includes both cardiac arrest and DIC in the first hour—is close to 50 percent,” said Dr. House. “And that’s exactly what we were dealing with in Angela’s case.”
Without hesitation, Dr. Sekhar summoned the ECMO team. ECMO is a machine that completely takes over the patient’s heart and lung function when those organs fail, allowing the organs to rest and hopefully recover. Within three minutes, the ECMO team was on site, along with Dr. House, Dr. Moor, Trauma Surgeon Ben Johnson, MD, 3 ICU physicians, a cardiac anesthesiologist, a critical care anesthesiologist, a hematologist, a pediatrician and numerous other doctors, nurses and support staff, all ready to help.
“Advanced prior coordination between the Cardiovascular Intensivist group and Trauma Surgery enables us to provide ECMO response at a moment’s notice, 24/7, anywhere in the Medical Center, but this was the first time I had ever used ECMO in Labor and Delivery,” said Haval Chweich, MD, Critical Care Intensivist and the leader of the ECMO team. “Putting a patient like this on ECMO that quickly is a difficult task. In most cases, patients progress more slowly to the point where ECMO is needed. It’s rare that we encounter an emergent situation like this.”
Once Angela was stabilized on ECMO, Dr. House and Charlotte Lee, MD, Chief Resident for Labor and Delivery, were able to close her abdomen and complete the c-section procedure.
"At that point, I thought we might be out of the woods," said Dr. Moor. "Dr. House and Dr. Chweich had left to talk to the family, and we were preparing to move Angela to the ICU. But suddenly, she started hemorrhaging uncontrollably. As a result of the DIC, her blood was not clotting.”
The obstetric and anesthesia teams worked quickly and diligently to try to stop the bleeding with several different medications and compression devices. Finally, the insertion of 2 Bakri balloons (a device used for the temporary control of postpartum bleeding) was effective at stemming the hemorrhaging. In most cases, just 1 Bakri balloon would be enough.
“This was the critical point,” said Dr. House. “Dr. Lee suggested using 2 balloons. We weren’t sure if the balloons would work. If they failed, we would have had to perform a hysterectomy, which would have been extremely difficult due the large fibroid and the DIC.”
However, the balloons only provided a temporary solution. The team still needed to find and stop the source of her bleeding, but Angela's condition was too unstable to reopen her abdomen for exploratory surgery.
After an intense discussion, the decision was made to move Angela through the hospital, while still on ECMO, to a special procedures suite, where Interventional Radiologist Nathan Frenk, MD, performed an embolization (blocking) of the uterine arteries to stop the bleeding for good. During the 6-hour period from delivery to embolization, the Tufts MC Blood Bank supplied 79 bags of blood products (blood, platelets and clotting factors), which the anesthesiology team transfused into Angela. Her life had been saved for a third time in a matter of hours.
“The infrastructure at Tufts MC was key in saving Angela’s life,” said Dr. Moor. “If 1 team didn’t arrive on time, we would not have been successful. We know and trust each other, and our ability to mobilize quickly and work together efficiently and effectively as one team really made the difference that day.”
“If you don’t have the structure and program already in place, the chance of survival in a situation like this is almost zero,” agreed Dr. Chweich. “Academic medical centers tend to be siloed. Tufts Medical Center is fully integrated and this makes us greater than the sum of our parts. If Angela had delivered in a different setting, she almost certainly would not have survived.”
Angela spent a total of 6 days on ECMO and an additional 10 days as an inpatient at Tufts MC. She required two additional surgical procedures, one to remove blood that had pooled in her belly, and a second to close up the incision from that surgery. Throughout the entire 16 days, including the time she was intubated and on ECMO, Angela was able to do skin-to-skin with her newborn baby, Kaleb, thanks to the efforts of the Neonatology team, which went to great lengths to ensure this valuable bonding time was not lost. After a short stop in rehab, Angela was discharged home in mid-July.
While Angela has a ways to go in her recovery—she is still experiencing some mild memory loss, weakness in one thigh and periodic anxiety—her doctors are optimistic that all the symptoms will continue to improve and she will be back to normal within a couple of months. Kaleb, approaching two months old, is thriving. “He eats a lot!,” said Angela.
And now, even 8 weeks later, Angela’s doctors continue to marvel at how well she is doing and what they were able to accomplish together, as a unified team.
“I have never seen a case as dire as this one result in such a good outcome. It was the most severe and complicated case I have ever seen,” said Dr. House. “The whole team came together incredibly quickly–doctors, nurses, residents, OB, Anesthesiology, the ECMO team, the Blood Bank, Critical Care, Trauma Surgery, Interventional Radiology—it was an extraordinary effort by all.”
“I think Angela’s case exemplifies what sets Tufts Medical Center apart, even within the city of Boston,” said Dr. Moor. “Bigger hospitals may offer similar skills, services and technical expertise, but no one else can match the speed at which we are able to mobilize our critical care infrastructure, and quickly concentrate so much firepower in one place. When I finally was able to catch my breath and take stock of what happened, I was absolutely astonished by what our teams had achieved. It really was quite humbling.”
Looking back on her harrowing experience (most of which she doesn’t remember), Angela says she is extremely grateful for the care she received and is thankful to God and for the doctors, nurses and countless others who all came together to help save her life.
“Everyone was so great to me and my family,” she said. “Kaleb will grow up with a mother, now. They went above and beyond, and I am so very appreciative of everything they did for me.”
