Amniotic fluid embolism (AFE):-

AFE is an uncommon potentially catastrophic and unpredictable condition unique to

pregnancy. The confidential enquiry into maternal deaths in the UK for the
triennium 2006-2008 recorded AFE as the fourth most common cause of maternal
death with a rate of 0.57 per 100,000. Incidences vary worldwide and range from 1
in 8000 to 1 in 80,000 deliveries. A recent study in the US revealed an incidence of
approximately 1 in 20,000.

Etiology of AFE is unclear although it is felt that the exposure of amniotic fluid
and/or fetal material to the maternal circulation is the primary catalytic event. Clerk
suggested that a more descriptive term for AFE would be anaphylactoid syndrome
of pregnancy in view of the clinical similarities it shares with anaphylaxis and septic
shock.
Risk factors for AFE include:-
 induction of labor
 advanced maternal age
 forceful uterine contractions
 cesarean section/instrumental delivery
 grand multiparity
 placental previa and placental abruption
 cervical lacerations
 fetal compromise
 eclampsi

Although these factors are associated with AFE a causative factor does not appear to
exist as AFE can occur in any parturient at any stage of pregnancy.

Diagnosis and clinical evaluation:-

AFE predominantly occurs during labor. The classical clinical picture of AFE
involves acute development of severe hypoxia cardiovasclular collapse and
disseminated intravascular coagulation. Other features may include sweating,
shivering, dyspnea, cyanosis, bronchospasm and fetal compromise (bradycadia).

Management:-
Management of AFE predominantly supportive. As AFE presents predominantly
intrapartum or early postpartum most patients will be assessed and managed
initially in the delivery suite or operating room (if delivered by cesarean section) by
the obstetric and anesthetic terms in attendance but early involvement of critical
care staff will be required. The primary focus in the initial management is to
stabilize the patient's cardio-respiratory status.

The main components of critical care management are:-

 Early intubation and administration of 100% oxygen via positive pressure

ventilation are appropriate initial measures.

 Large bore intravenous access and invasive hemodynamic monitoring

(invasive BP and CVP) should be established early to assist resuscitation and
administration of vasopressor/intropic agents as required.

 Early echocardiography is extremely useful to determine the nature of the

cardiac injury (right versus left ventricular failure). Right ventricular failure
can be worsened by high levels of positive end expiratory pressure and
vasopressors and can be managed with milrinone, enoxamone, dobutamine ,
inhaled intric oxide and nebulized prostacyclin.

 If AFE presents antenatally following maternal stabilization the treating team

should consider emergency delivery which will potentially improve both
neonatal prognosis and maternal cardio-respiratory status.

 Associated cardio-respiratory (disseminated intravascular coagulation DIC)

should be anticipated. The blood bank should be informed of the potential
requirement for transfusion of large volumes of blood fresh frozen plasma
platelets and fibrinogen concentrate or cryoprecipitate.

 Large quantities of blood products can result in fluid overload. Although

ECMO may appear to be an ideal approach to a patient in cardiopulmonary
failure excess bleeding may limit its application.
  Management of DIC involves regular clinical assessment and frequent
measurement of serum hemoglobin, platelets count, and coagulation profile
including fibrinogen level to guide transfusion.

 Ongoing care is supportive. Following resolution of the coagulopathy,

thromboprophylaxis should be strongly considered as these patients are at
increased risk of thromboembolic complications.

In the past maternal mortality figures from AFE were as high as 80%. Early
recognition and prompt resuscitative measures have improved outcomes. And
admission to ICU is associated with long term survival. Maternal morbidity rates are
high particularly neurological impairment. Neonatal outcomes are poor with
mortality rates as high as 20-25% and up-to 50% of survivors may have a poor
neurological outcome.