Amniotic Fluid Embolism

Normally, amniotic fluid does not enter the maternal circulation because it is contained safely within
the uterus, sealed off by the amniotic sac. AFE occurs when the barrier between amniotic fluid and
maternal circulation is broken and fluid abnormally enters the maternal venous system.

Presentation

One of the major factors that makes AFE so devastating is its total unpredictability and there are no
definitive clues, warning signs, or associated conditions that indicate the risk of AFE may be increased. Most
experts agree that AFE, as it is known now, cannot be predicted or prevented . Although most cases occur
after the onset of labor, some incidents have occurred outside of labor.

The condition is rare- about 1 in 80,000 deliveries.

The symptoms generally include:

1) cardiovascular collapse characterized by falling blood pressures and a rising pulse culminating
in cardiac arrest
2) respiratory distress with increasing difficulty in breathing sometimes concluding with a
respiratory arrest
3) disordered blood clotting. The specific medical terms for this condition include coagulopathy and
disseminated intravascular coagulation (DIC).
4)neurological symptoms such as seizures or coma

Once the fluid and fetal cells enter the maternal pulmonary circulation, there will be profound respiratory
failure with deep cyanosis and cardiovascular shock followed by convulsions and profound coma,
however this does occur in two phases detailed below:

First phase
The patient experiences acute shortness of breath and hypotension. This rapidly progresses to
cardiac arrest as the chambers of the heart fail to dilate and there is a reduction of oxygen to the
heart and lungs. Not long after this stage the patient will lapse into a coma

Second phase
Although many women do not survive beyond the first stage, about 40% of the initial survivors will
pass onto the second phase. This is known as the hemorrhagic phase and may be accompanied
by severe shivering, coughing, vomiting, and the sensation of a bad taste in the mouth. This is also
accompanied by excessive bleeding as the blood loses its ability to clot. Collapse of the
cardiovascular system leads to fetal distress and death unless the child is delivered swiftly.
Causes
It is mostly agreed that this condition results from amniotic fluid entering the uterine veins and in order for
this to occur there are three prerequisites:
• Ruptured membranes (a term used to define the rupture of the amniotic sac)
• Ruptured uterine or cervical veins
• A pressure gradient from uterus to vein
There is some evidence that AFE may be associated with abdominal trauma or amniocentesis. A 2006
study showed that the use of drugs to induce labor, such as misoprostol, nearly doubled the risk of
AFE. A maternal age of 35 years or older,caesarean or instrumental vaginal delivery,
polyhydramnios,cervical laceration or uterine rupture, placenta previa or abruption, eclampsia, and fetal
distress were also associated with an increased risk.
Diagnosis
Usually made in autopsy but recently with more awareness of the condition, the features can be recognized
by medical staff and a earlier diagnosis can be made.
Treatment
Despite technological advances in critical care life support, the maternal mortality rate for AFE remains
around 61%; a large percentage of survivors have permanent hypoxia-induced neurological damage. The
fetal mortality rate, although better than the maternal rate, is a dismal 21%, and 50% of the surviving
neonates experience permanent neurological injury.
Management of the clinical symptoms are the only remedies. Therefore, resuscitation of the mother and
stabilization of her condition are the priorities.
In the event of cardiac arrest, the resuscitation team should follow standard Advanced Cardiac Life Support
protocols for obstetric patients.The fetus should be monitored continuously for signs of
compromise.Specific to pregnant women is the importance of positioning. In order to ensure optimal uterine
perfusion throughout the management of AFE, the mother’s hips should be displaced to the left to prevent
the weight of the uterus from compressing the inferior vena cava and compromising blood flow.
Oxygenation
The fetus is very vulnerable to maternal hypoxia,which is initially profound in AFE. Therefore, the first
priority is resuscitation of the mother and administration of oxygen by any means available at
concentrations of 100%.
Circulation
Volume replacement with isotonic crystalloid solution is a first-line therapy for maintaining blood pressure.
Administration of inotropic agents for maintaining cardiac output and blood pressure.
Control of Hemorrhage and Coagulopathy
Administration of blood transfusions and blood components is considered the first line of treatment for
correcting coagulopathy associated with AFE.Blood products include packed red blood cells, fresh-frozen
plasma, platelets, and cryoprecipitate to maintain organ perfusion and urinary output until bleeding due to
disseminated intravascular coagulation resolves.
Another pharmacological intervention is the use of intravenous steroids. Amniotic fluid not only displaces
blood and reduces oxygen and waste exchange but also introduces antigens, cells, and protein aggregates
that trigger inflammation within the bloodstream.In consideration of the potential inflammatory response
and similarities to anaphylaxis, the administration of corticosteroids may be helpful in AFE.
Fetal Considerations
In some instances and in favour of the fetus, AFE does not occur until after delivery. When AFE occurs
before or during delivery, however, the fetus is in grave danger from the onset because of the maternal
cardiopulmonary crisis. As soon as the mother’s condition is stabilized, delivery of the viable infant is
swiftly conducted. If resuscitation of the mother is futile, an emergency bedside cesarean delivery may be
necessary to save the infant.The sooner after maternal cardiopulmonary arrest that the fetus is delivered, the
more favorable is the fetal outcome.Therefore, as difficult as it may be, and even though the mother may be
viewed as the primary patient, prolonged resuscitation efforts are usually stopped so that the fetus can be
saved.