2016 FSA Posters

P010: MASSIVE CARDIAC THROMBOSIS AND DISSEMINATED INTRAVASCULAR COAGULOPATHY IN A PATIENT WITH RETAINED DEAD FETUS SYNDROME
Stefanie Vallancourt, DO; University of Florida

Introduction: Disseminated intravascular coagulopathy (DIC) is a disorder of hemostasis resulting in massive activation of the clotting cascade with consumption of platelets and clotting factors in addition to massive thrombolysis, leading to both thrombosis and hemorrhage. This disorder is a rare but well-known complication of retained products of an intrauterine fetal demise.

Case Presentation: A 30-year-old woman at 24 weeks gestation presented to the ED with acute onset shortness of breath, chest pain, and palpitations. Work-up was consistent with new onset heart failure (elevated BNP, bilateral interstitial edema, pleural effusions, and cardiomegaly on chest radiograph and CT scan, echocardiography showed left ventricular systolic dysfunction with ejection fraction of 30-35%). Two days prior to admission, the patient was diagnosed with intrauterine fetal demise with ultrasound imaging consistent with 14 week-sized fetus. The patient was also a known carrier of Duchenne Muscular Dystrophy and Fragile X syndrome. MRI was performed and showed macerated products of conception and concern for placenta accreta. She was admitted for cardiac stabilization and scheduled for a D&E with possible hysterectomy.

Once in the operating room, general endotracheal anesthesia was established. Large-bore intravenous access was obtained in addition to invasive blood pressure monitoring. D&E was performed with a large amount of blood loss associated with hemodynamic instability requiring resuscitation with fluids, blood products, and vasoactive medications. Because of continued bleeding and the inability to separate the placenta from the uterus, the procedure was converted to a laparotomy for hysterectomy. A transesophageal echocardiography (TEE) probe was inserted and showed global hypokinesis and left ventricle dilation with an LVEF of <25%. The patient continued to bleed despite the uterus being removed and significant resuscitation efforts. Lab results at this time were consistent with DIC. The patient became significantly hypotensive and TEE revealed a large amount of sludge filling the left ventricle and the patient suffered profound cardiac collapse.  ACLS protocol was initiated and multiple consults were made to colleagues regarding management. Despite these efforts, the patient died. Autopsy revealed blood clots in all four cardiac chambers, diffuse hemorrhage and petechiae both intra-alveolar and on the surface of both lungs, and a large amount of blood in the pleural and peritoneal cavities consistent with DIC from retained dead fetus syndrome.

Discussion: This case presents intraoperative death from a large cardiac thrombus associated with DIC in the setting of retained dead fetus syndrome in a patient with carrier status for Duchenne Muscular Dystrophy and new onset dilated cardiomyopathy. The cause of death in this patient is likely multifactorial from the above-mentioned circumstances.

DIC is a disruption of hemostasis resulting in massive activation of the clotting cascade resulting in the generation of thrombin and fibrin resulting in widespread thrombosis, leading to consumption of platelets and coagulation factors and excessive thrombolysis. Although it is a rare cause of DIC, retention of dead fetal products is a known risk factor for the development of this disorder.