Management of Amniotic Fluid Embolism
Amniotic fluid embolism (AFE) is a rare clinical syndrome that occurs intrapartum or immediately postpartum. The exact cause of this syndrome is not known although it is widely suspected that there may be an immune etiology causing an anaphylactoid-like r
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Susan H. Cheng and Marie R. Baldisseri
Case Presentation A 45 year old obese, multiparous (G3P3), African American female with no other past medical history and an uncomplicated prenatal course, presents with twins at 40 weeks gestation. Her prior vaginal deliveries were uncomplicated. She experiences a tumultuous labor of many hours with delivery by Cesarean section because of fetal distress. Shortly after delivery, she suddenly complains of shortness of breath. Her oxygen saturation falls from 98 to 74 %, blood pressure falls to 86/50, and she suffers a generalized seizure. You also note oozing at her IV insertion sites and increased bloody vaginal discharge. Question What diagnosis is suspected? Answer Amniotic Fluid Embolism Syndrome (AFE) is a clinical diagnosis of exclusion, that is rare (estimated between 1.7 and 12 cases per 100,000 deliveries) [1–9] but with high mortality (most recent data estimates 11–43 %) [1–9] and morbidity (especially neurologic injury). It is unpredictable, unpreventable and usually occurs with an abrupt onset during pregnancy or shortly after delivery with a constellation of multi systemic symptoms [10]. She is intubated for airway protection and to improve oxygenation. Ativan is given to control S.H. Cheng (*) • M.R. Baldisseri Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA e-mail: [email protected]
seizure activity. A 500 cc crystalloid bolus results in minimal blood pressure improvement. Stat labs are ordered: ABG with PaO2 of 60, Hgb of 7 (previously 14), platelet of 90, (PT, PTT, INR, D-dimer, fibrinogen levels consistent with DIC). Stat blood transfusion is ordered. Oxygenation improves to 96 % and blood pressure to 118/72. The patient is transferred to the ICU where an arterial line and central venous catheter are placed. Portable chest x-ray is obtained. Norepinephrine infusion is started.
Symptoms
1. Hypoxemia (most common) and respiratory failure 2. Hypotension from cardiogenic shock 3. Disseminated intravascular coagulation 4. Seizures or coma
Risk Factors
1. Precipitous or tumultuous labor [10] 2. Advanced maternal age [6, 7, 11, 12] 3. Cesarean [6–8, 11, 12] and instrumental delivery [10] 4. Placenta previa and abruption [6, 11] 5. Multiparity [12] 6. Multiple birth delivery [8, 11] 7. Cervical lacerations [10] 8. Fetal distress [8, 11] 9. Eclampsia [11] 10. Medical induction of labor [8, 11]
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_88
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Pathophysiology
Management
The precise mechanism is unclear. It is proposed that amniotic fluid enters the maternal circulation through endocervical veins, placental insertion site, or a site of uterine trauma [13]. There is evidence of a biphasic pattern of cardiogenic shock. During the initial phase (15–30 min) there is acute pulmonary hypertension and right heart failure followed by a later phase of left ventricular dysfunction [14]. Hypoxemia is pr
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