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.