Intraoperative Collapse During First-Trimester Abortion: Hyperleukocytosis Crisis, Thrombotic Pulmonary Embolism, or Amniotic Fluid Embolism?

BACKGROUND: Hyperleukocytosis in patients with hematologic malignancies poses significant perioperative risks, including leukostasis, coagulopathy, tumor lysis syndrome and hyperinflammatory syndrome. Additionally, pregnancy and hyperleukocytosis predispose patients to a hypercoagulable state, increasing the risk of thrombosis. On the other hand, amniotic fluid embolism (AFE) is a rare but serious complication of pregnancy. Although distinct in etiology, thrombotic pulmonary embolism (PE), AFE, and hyperleukocytosis crisis can present with a strikingly similar clinical picture of pulmonary hypertension and respiratory failure, posing a significant diagnostic challenge in the perioperative setting.

CASE PRESENTATION: An 18-year-old female with chronic phase chronic myeloid leukemia and hyperleukocytosis (WBC >100×109/L) underwent medical termination of pregnancy followed by emergency dilation and curettage. Intraoperatively, she developed acute hypoxemia, hypotension, and cardiac arrest. Resuscitation was successful, but she exhibited severe pulmonary hypertension, respiratory failure and DIC. The initial diagnosis of large thrombotic pulmonary and AFE was ultimately reconsidered in favor of a hyperleukocytosis crisis, based on three key observations: pulmonary angiography revealed no central, lobar, or segmental filling defects, the resolution of pulmonary hypertension closely paralleled a reduction in leukocyte count two weeks later, and there was an absence of uterine atony and massive uterine bleeding despite profound DIC. Though histopathological confirmation is lacking, pulmonary leukostasis remains the most likely explanation for the patient's cardiopulmonary collapse. The patient survived after prolonged intensive care unit care, including mechanical ventilation, renal replacement therapy, and cytoreductive treatment.

CONCLUSION: Anesthesia and surgical interventions in patients with hyperleukocytosis pose a formidable challenge, which could cause life threatening complications and need vigilance care. Given hyperleukocytosis crisis can present with clinical features indistinguishable from thrombotic pulmonary embolism and AFE, recognizing this distinction is critical for guiding appropriate treatment and optimizing perioperative outcomes.