Amniotic fluid embolism: diagnosis and management

Publications & Guidelines, Obstetric Care Consensus,
Diagnosis/definition: 
  • Triad of sudden hypoxia and hypotension, followed in many cases by coagulopathy, all occurring in relation to labor and delivery
  • DDX in any women with sudden cardiovascular collapse or cardiac arrest seizures, severe respiratory difficulty or hypoxia, particularly if such events are followed by a coagulopathy that cannot be otherwise explained
  • DDX (long): myocardial infarction, pulmonary embolism, air embolism, anesthetic complications, anaphylaxis, and eclampsia and sepsis
  • Period of anxiety, change in mental status, agitation, and a sensation of “doom” may precede the event
  • May progress rapidly to cardiac arrest, with pulseless electrical activity (PEA), asystole, ventricular fibrillation, or pulseless ventricular tachycardia
  • DIC is present in up to 83% of cases 
  • Diminished uterine perfusion, uterine atony
Epidemiology/Incidence: 
  • AFE is so rare that there are no risk factors sufficiently established to justify any alteration in standard obstetric care
  • 70% of cases of AFE occur during labor, 11% after a vaginal delivery, and 19% during a cesarean delivery
    Management: 
Screening/Work-up:

• The use of any specific diagnostic laboratory test to either confirm or refute the diagnosis of AFE is not recommended at the present time; AFE remains a clinical diagnosis. (GRADE 1C)

Cardiac Arrest
  • Immediate high quality cardiopulmonary resuscitation  with standard BCLS and ACLS protocols in patients who develop cardiac arrest associated with AFE. (GRADE 1C) 
  • Involvement of a multidisciplinary team including anesthesia, respiratory therapy, critical care, and maternal-fetal medicine should be involved in ongoing care of such women. (Best Practice)
  • Use of vasopressors, anti-arrhythmic agents, and defibrillating doses is not different than those utilized in non- pregnant individuals
  • Preparations for emergent perimortem cesarean should be initiated simultaneously with initiation of CPR – if the cardiac arrest is still ongoing as the instruments become available, proceed with cesarean delivery
  • Following cardiac arrest with AFE, we recommend immediate delivery in the presence of a fetus > 23 weeks of gestation. (GRADE 2C)
Post cardiac arrest management
  • Fluids, vasopressors, and inotropes with the goal is to maintain a mean arterial blood pressure of 65 mmHg
  • Fever may worsen ischemia-reperfusion injury to the brain and should be aggressively treated
  • Hyperoxia will also worsen ischemia-reperfusion injury, and administration of 100% oxygen after survival of cardiac arrest should be avoided
  • The inspired fraction of oxygen should be weaned to maintain a pulse oxymetry value of 94%-98%
  • Serum glucose should be maintained between 140-180 mg/dL with the use of insulin intravenous infusions if needed
Coagulopathy

Coagulopathy may follow cardiovascular collapse with AFE, early assessment of clotting status and early aggressive management of clinical bleeding with standard massive transfusion protocols is recommended (GRADE 1C)

Last Reaffirmed: Aug 1, 2022

Original Article


TAGS:fetal anomalies amniotic fluid embolism
CATEGORIES:Internal Medicine & Medicine Subspecialists Family Medicine OB-GYN, Sub-specialist, Certified Nurse Midwife and Laborist Clinical Guidelines Maternal Medical Complications