Development of Carbon Dioxide Embolism During Partial Amniotic Carbon Dioxide Insufflation for Fetoscopic Laser Photocoagulation: A Case Report

Partial amniotic carbon dioxide (CO2) insufflation during fetoscopic laser photocoagulation (FLP) can improve surgical visibility. However, this procedure poses risks of gas embolism. A 27-year-old woman underwent FLP for twin-to-twin transfusion syndrome under combined spinal-epidural anesthesia. Owing to turbid amniotic fluid, CO2 was manually insufflated. Due to intraoperative respiratory discomfort, the anesthesia was converted to general anesthesia with endotracheal intubation. After a 15° lateral table tilt, the patient developed sudden hypotension and hypoxia. A waterwheel murmur was heard on auscultation. Urgent transthoracic echocardiography confirmed CO2 bubbles in the right side of the heart with paradoxical migration to the left atrium through a patent foramen ovale. Immediate gas aspiration and head-down positioning led to rapid recovery. The patient was extubated without neurological deficits. Intrauterine CO2 insufflation can cause systemic gas embolism, particularly with manual injection and postural changes. Early diagnosis using point-of-care ultrasonography is crucial for successful management.