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Amniotic Fluid Embolism Amniotic Fluid Embolism
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- 2. Definition Amniotic Fluid Embolism(AFE) ● is a rare (1:20,000 deliveries) but often lethal complication (86% mortality rate in some series) that can occur during labor, delivery, or cesarean section, or postpartum. ● Anaphylactoid syndrome of pregnancy, an alternate term used has been suggested to emphasize the systemic role of chemical mediators.
- 3. Etiology ● AFE isconsidered an unpredictable and unpreventable event with an unknown cause. ● Reported risk factors for development of AFE include multiparity, advanced maternal age, male fetus, and trauma.
- 4. Epidemiology ● AFE isone of the leading causes of death resulting directly from childbirth, accounting for 5% to 15% of cases worldwide. ● Incidence of amniotic fluid embolism (AFE) is estimated at 1 case per 8,000- 30,000 pregnancies. ● The true incidence is unknown because of inaccurate diagnoses and inconsistent reporting of nonfatal cases. ● No racial or ethnic predilection has been thought to exist. ● According to statistics, it is the most common cause of maternal death in Australia and the second-most common in the USA and the U.K.
- 5. Clinical Presentation ● Patientstypically present with: ○ sudden tachypnea ○ cyanosis ○ shock ○ generalized bleeding ● Three major pathophysiological manifestations are responsible: ○ Acute pulmonary embolism ○ Disseminated Intravascular Coagulation (DIC) ○ Uterine atony
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- 19. Chronology and incidenceof signs and symptoms of AFE Gei AF, Vadhera RB, Hankins GD. Embolism during pregnancy: thrombus, air, and amniotic fluid. Anesthesiol Clin North Am. 2003 Mar;21(1):165-82. doi: 10.1016/s0889-8537(02)00052-4. PMID: 12698839.
- 20. British Journal ofAnesthesiology Highest incidence: ● Hypotension ● Fetal Distress ● ARDs/Pulmonary Edema ● Cardiopulmonary Arrest ● Cyanosis ● Coagulopathy
- 21. Diagnostic Criteria: Cunningham, F.G., et . al. (2014). Williams obstetrics (24th edition.). New York: McGraw-Hill Education.
- 22. MANAGEMENT: EMERGENCY MANAGEMENT ● Multidisciplinaryapproach ● Anticipate possible cardiorespiratory arrest and emergent C-section ● Airway Management and hemodynamic support ● Perform CPR as indicated, Do High Quality CPR ● Control Hemorrhage & Reverse Coagulopathy: ○ Tranexamic Acid (TXA) ○ Institute Massive Transfusion Protocol ● Monitoring: EKG, SpO2, EtCO2 , Urine Output
- 24. MANAGEMENT: Airway andbreathing ● Prepare for need for emergent intubation ● Give 100% O2, high-flow ● Maintain an arterial PO2 > 60 mm Hg (or O2 Sat of 90% and above)
- 25. MANAGEMENT: Hemodynamic Instability ●Establish large volume IV Access ● Support circulation with IV fluid, vasopressors and inotropes ● Anticipate massive hemorrhage and DIC ● Maintaining systolic blood pressure ≥ 90 mm Hg, or MAP ≥65 mmHg , and acceptable peripheral organ perfusion (urine output ≥ 25 mL/hour) ● Consider transfer to intensive care unit
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- 29. MANAGEMENT: Novel Treatment:A-OK Protocol ● Atropine 1 mg ● Ondansetron 8 mg ● Ketorolac 30 mg
- 30. Rezai et al.(2017). Atypical Amniotic Fluid Embolism Managed with a Novel Therapeutic Regimen. Case Rep Obstet Gynecol.
- 31. Limitations ● Limited casestudies ● Inaccurate diagnosis and inconsistent reporting ● No confirmatory laboratory tests ● Difficulty of obtaining human evidence ● Little value from animal studies
- 32. Morgan, G. E.,Mikhail, M. S., & Murray, M. J. (2006). Clinical anesthesiology. New York: Lange Medical Books/McGraw Hill Medical Pub. Division. Cunningham, F. G., et . al. (2014). Williams obstetrics (24th edition.). New York: McGraw-Hill Education. Gist, Richard S. MD* ; Stafford, Irene P. MD† ; Leibowitz, Andrew B. MD* ; Beilin, Yaakov MD*‡ Amniotic Fluid Embolism, Anesthesia & Analgesia: May 2009 - Volume 108 - Issue 5 - p 1599-1602 doi: 10.1213/ane.0b013e31819e43a4 Gei AF, Vadhera RB, Hankins GD. Embolism during pregnancy: thrombus, air, and amniotic fluid. Anesthesiol Clin North Am. 2003 Mar;21(1):165-82. doi: 10.1016/s0889-8537(02)00052-4. PMID: 12698839. Rezai et al. (2017). Atypical Amniotic Fluid Embolism Managed with a Novel Therapeutic Regimen. Case Rep Obstet Gynecol. Stanford Anesthesia Emergency Manual (2016) References:
Editor's Notes
- #2 Life threatening obstetric emergency characterized by sudden cardiorespiratory collapse and disseminated intravascular coagulation ASP is a rare but serious condition that causes a widespread, proinflammatory, anaphylactic-like reaction after amniotic fluid enters the maternal circulation