Clinical case study: Rapid deployment of extracorporeal membrane oxygenation and left ventricular unloading seen as crucial to recovery of patient with amniotic fluid embolism, cardiogenic shock and disseminated intravascular coagulation.

Published: November 4, 2025

The patient

A 41-year-old pregnant patient at 38 weeks’ gestation was admitted for elective cesarean section. Her medical history included three pregnancies, two live births, two prior cesarean sections, anterior placenta with polyhydramnios (amniotic fluid index 35), pituitary macroadenoma, gastroesophageal reflux disease (GERD), and headaches. Echocardiogram in 2019 demonstrated an ejection fraction (EF) of 56%. Prenatal course for this pregnancy was otherwise uncomplicated.

The challenge

After induction of anesthesia, a low transverse uterine incision was performed. Due to fetal malposition, a footling breech extraction was required. A viable infant weighing 7 pounds, 9 ounces, with APGAR score of 8 at one minute was delivered.

Immediately following delivery, the patient exhibited snoring respirations and became pulseless. Cardiopulmonary resuscitation was initiated, including chest compressions and advanced resuscitation measures.

• Resuscitative measures included:
  • 7 units packed red blood cells
  • 30 units cryoprecipitate
  • 10 units plasma
  • 3 units platelets
• Cardiac arrest duration: four minutes, followed by return of spontaneous circulation
• Postpartum hemorrhage protocol initiated: Thromboxane A2, methylergometrine, misoprostol (800 milligrams rectal), carboprost

Echocardiography demonstrated a severely dilated right ventricle with EF reduced to 20%, consistent with acute cardiogenic shock secondary to amniotic fluid embolism (AFE). The patient required escalating vasopressor and inotrope support, including dobutamine.

After a subsequent 54-minute cardiac arrest (pulseless electrical activity), the decision was made to activate the cardiogenic shock/extracorporeal membrane oxygenation (ECMO) team. The patient was transferred to Norton Audubon Hospital for high-risk peripheral venoarterial (VA) ECMO cannulation.

The providers

The solution

The patient was cannulated for VA ECMO (SCAI E shock) by Mohammad F. Mathbout, M.D., interventional cardiologist with Norton Heart & Vascular Institute. An Impella CP was placed for left ventricular (LV) unloading.

Hospital course

• ECMO duration: Six days
• Complications:
  • Intra-abdominal hemorrhage secondary to cesarean section and DIC
  • Emergent hysterectomy on post-cannulation day 1 (estimated blood loss: 4 liters)
  • Acute kidney injury requiring continuous renal replacement therapy
  • Bilateral cerebral watershed infarcts (cerebral hemispheres and cerebellum)

The result

At the time of transfer, the patient’s EF had recovered to 59%, marking a significant improvement from her immediate postoperative EF of 20%. She survived a highly lethal condition — amniotic fluid embolism complicated by cardiogenic shock, DIC, and cardiac arrest — through rapid recognition, aggressive resuscitation and early initiation of VA ECMO with LV unloading.

Amniotic fluid embolism is a rare but catastrophic obstetric emergency with maternal mortality rates historically reported between 20% and 60%. The classic presentation includes sudden cardiovascular collapse, hypoxemia, coagulopathy and DIC.

Despite complications of hemorrhage, renal injury and neurologic insults, the patient demonstrated meaningful cardiac and neurologic recovery, ultimately surviving to rehabilitation and maternal-infant bonding.

This case highlights the critical role of multidisciplinary coordination and advanced mechanical circulatory support in managing catastrophic maternal collapse due to amniotic fluid embolism. ECMO, when rapidly deployed, can provide lifesaving support and a bridge to recovery, even in cases complicated by prolonged arrest and multiorgan dysfunction.

Early recognition of shock, escalation to ECMO and multidisciplinary collaboration were pivotal to survival. The use of VA ECMO with Impella venting provided circulatory support and allowed for myocardial recovery.