Amniotic fluid embolism: analysis of the national registry

An example of prompt and appropriate multidisciplinary management leading to an exceptionally good outcome: a case complicated by amniotic fluid embolism

Amniotic fluid embolism (AFE) is a rare and serious phenomenon; we describe a rare case of AFE occurring after a second trimester surgical termination in a private clinic, which, with prompt transfer and appropriate multidisciplinary management, had an exceptionally good outcome. The patient developed hypotension, respiratory arrest and disseminated intravascular coagulopathy following the procedure but with aggressive management she made a full recovery without any neurological or long-term sequelae.

Respiratory Failure and Mechanical Ventilation in the Pregnant Patient

Fewer than 2% of all peripartal patients need intensive care unit admission. But due to some anatomic and physiologic changes in pregnancy, respiratory failure can be promoted. This article reviews several obstetric and nonobstetric diseases that lead to respiratory failure and the treatment of these. Furthermore, invasive and noninvasive ventilation in pregnancy is discussed and suggestions of medication during ventilation are given.

Acute respiratory failure in pregnancy

Respiratory failure affects up to 0.2% of pregnancies, more commonly in the postpartum period. Altered maternal respiratory physiology affects the assessment and management of these patients. Respiratory failure may result from pregnancy-specific conditions such as preeclampsia, amniotic fluid embolism or peripartum cardiomyopathy. Pregnancy may increase the risk or severity of other conditions, including thromboembolism, asthma, viral pneumonitis, and gastric acid aspiration. Management during pregnancy is similar to the nonpregnant patient. Endotracheal intubation in pregnancy carries an increased risk, due to airway edema and rapid oxygen desaturation following apnea. Few data are available to direct prolonged mechanical ventilation in pregnancy. Chest wall compliance is reduced, perhaps permitting slightly higher airway pressures. Optimizing oxygenation is important, but data on the use of permissive hypercapnia are limited. Delivery of the fetus does not always improve maternal respiratory function, but should be considered if benefit to the fetus is anticipated.

Implementation of an obstetric cell salvage service in a tertiary women's hospital

INTRODUCTION

Intraoperative cell salvage (ICS) is an important aspect of patient blood management programmes. An ICS service was introduced at KK Women's and Children's Hospital, Singapore, from 2 May 2011 to 30 April 2013 to aid in the management of massive obstetric haemorrhage.

METHODS

With support from the Ministry of Health's Healthcare Quality Improvement and Innovation Fund, a workgroup comprising obstetricians, anaesthetists and nursing staff was formed to develop training requirements, clinical guidelines and protocols for implementing ICS using the Haemonetics Cell Saver 5. Pregnant women with an anticipated blood loss of > 1,000 mL during Caesarean delivery, a baseline haemoglobin level of < 10 g/dL, rare blood types and who had refused donor blood were recruited to the service after obtaining informed consent.

RESULTS

A total of 11 women were recruited to the ICS service; the primary indications were placenta praevia and placenta accreta. Median blood loss in these 11 patients was 1,500 (range 400-3,000) mL. In four patients, adequate autologous blood was collected to initiate processing and salvaged, processed blood was successfully reinfused (mean 381.3 [range 223.0-700.0] mL). Median blood loss among these four patients was 2,000 (range 2,000-3,000) mL. No adverse event occurred following autologous transfusion. Mean immediate postoperative haemoglobin level was 8.0 (range 7.1-9.4) g/dL.

CONCLUSION

The implementation of an obstetric ICS service in our institution was successful. Future studies should seek to address the cost-effectiveness of ICS in reducing allogeneic blood utilisation.

From appearance to essence: 10 years review of atypical amniotic fluid embolism

PURPOSE

Amniotic fluid embolism (AFE) is an unpredictable and unpreventable complication of maternity. The presentation may range from relatively subtle clinical events to sudden maternal cardiac arrest. However, the neglected diagnosis of non-classical form of AFE (atypical AFE) is very common. The aim of this study was to examine population-based regional data from Suzhou, China. Based on the analysis of all available case reports, we put forward an outline of atypical AFE and investigate whether any variation identified could be ascribed to methodology.

METHODS

Retrospective study from January 2004 to December 2013, 53 cases was identified from the database of Center for Disease Control (CDC) in the city of Suzhou. We investigated the presentations of atypical AFE and maternal characteristics with potential factors underlying AFE. Multiple-regression analysis was used to calculate adjusted odds ratios (ORs) and 95 % confidence intervals (CIs).

RESULTS

The incidence of AFE was 6.91 per 100,000 deliveries (53/766,895). Seventeen deaths occurred, a mortality rate of 32 %. Atypical AFE may as the earlier stage or mild form of AFE, there was no death case in the study with timely remedy. The atypical AFE appear is obstetric hemorrhage and/or pulmonary and renal dysfunction postpartum. Hyperfibrinolysis and coagulopathy may the early laboratory findings of atypical AFE. Atypical and classical AFE shared the same risks, such as advanced maternal age, placental abnormalities, operative deliveries, eclampsia, cervical lacerations, and induction of labor.

CONCLUSION

Staying alert to premonitory symptoms of AFE is critical to turn it to a remediable disease. Patient complaints such as breathlessness, chest pain, feeling cold, distress, panic, a feeling of nausea, and vomiting should elicit close attention. The management of a suspected episode of amniotic fluid embolism is generally considered to be supportive. Hysterectomy must be performed if there is further progression of symptoms. Due to advances in acute care, mortality has decreased in recent years, highlighting the importance of early detection and treatment.

Acute postpartum pulmonary edema in a 23-year-old woman 5 days after cesarean delivery

The presentation of acute dyspnea after pregnancy is rare, but should bring a number of important conditions to the mind of the attending physician. Pulmonary embolism, amniotic fluid embolism, pneumonia, aspiration and pulmonary edema are some of the potentially devastating causes that must be considered. The percentage of pregnancies that are complicated by acute pulmonary edema has been estimated to be 0.08%. The most common contributing factors include the administration of tocolytic agents, underlying cardiac disease, iatrogenic fluid overload and preeclampsia. No matter what the underlying pathology, prompt administration of appropriate resuscitation is always the first priority. Only after the patient has been stabilized can attention be turned to diagnosis and specific treatment. This case examines one such presentation and reviews some of the diagnostic possibilities.

Protein S deficiency present in a pregnant woman with dyspnea, abdominal pains, restlessness, agitation and hypofibrinogenemia

Hypofibrinogenemia is rare in pulmonary thromboembolism. A pregnant woman with dyspnea, abdominal pain, restlessness, agitation and protein S deficiency exhibited normal blood oxygenation and high D-dimer (370 μg/mL) and undetectable fibrinogen levels in the blood. The pathogenesis responsible for present findings may have some features similar to amniotic fluid embolism.

Unresponsive primipara after rupture of membranes

Amniotic fluid embolism, also called anaphylactoid syndrome of pregnancy, is a rare but severe problem in obstetrics. It occurs in 8/100,000 births and the maternal mortality is up to 90%. We report the case of a patient with amniotic fluid embolism who was transferred to our hospital. The initial presentation was an unresponsive patient after spontaneous rupture of the membranes. The massive hypotension and coagulopathy as well as fetal bradycardia of 60 bpm led, after stabilisation of the mother, to an emergency caesarean section. The neonate expired hours later, despite neonatological intensive care. During the operation, we had to deal with massive bleeding due to the coagulopathy. Through interdisciplinary teamwork including Bakri postpartum balloon insertion through the obstetrics team, uterine artery embolism by the interventional radiologists and transfusion of blood products, the maternal life was saved and the patient was discharged 9 days after admission.

Amniotic fluid embolism pathophysiology suggests the new diagnostic armamentarium: β-tryptase and complement fractions C3-C4 are the indispensable working tools

Amniotic fluid embolism (AFE) is an uncommon obstetric condition involving pregnant women during labor or in the initial stages after delivery. Its incidence is estimated to be around 5.5 cases per 100,000 deliveries. Therefore, this paper investigated the pathophysiological mechanism, which underlies AFE, in order to evaluate the role of immune response in the development of this still enigmatic clinical entity. The following databases (from 1956 to September 2014) Medline, Cochrane Central, Scopus, Web of Science and Science Direct were used, searching the following key words: AFE, pathophysiology, immune/inflammatory response, complement and anaphylaxis. The main key word "AFE" was searched singularly and associated individually to each of the other keywords. Of the 146 sources found, only 19 were considered appropriate for the purpose of this paper. The clinical course is characterized by a rapid onset of symptoms, which include: acute hypotension and/or cardiac arrest, acute hypoxia (with dyspnoea, cyanosis and/or respiratory arrest), coagulopathies (disseminated intravascular coagulation and/or severe hemorrhage), coma and seizures. The pathology still determines a significant morbidity and mortality and potential permanent neurological sequelae for surviving patients. At this moment, numerous aspects involving the pathophysiology and clinical development are still not understood and several hypotheses have been formulated, in particular the possible role of anaphylaxis and complement. Moreover, the detection of serum tryptase and complement components and the evaluation of fetal antigens can explain several aspects of immune response.

Ischemic stroke related to an amniotic fluid embolism during labor

We report a young woman who survived multiple cerebral infarctions related to an amniotic fluid embolism (AFE) during labor. To our knowledge, an embolic stroke due to the coexistence of an AFE and patent foramen ovale (PFO) has not been reported. We describe the patient's clinical and radiological features and discuss the stroke mechanism in relation to our AFE hypothesis. A 32-year-old woman presented to the emergency room after experiencing convulsions during labor (blood pressure, 64/28mmHg; oxygen saturation, 67%). She was in a stupor, and her response to painful stimuli on the right side was weaker than on the left side. Acute stroke was considered as a possible cause. Additionally, an AFE was suspected due to cardiopulmonary arrest during labor. Brain MRI revealed multiple territory embolic infarctions. The transcranial Doppler with bubble study demonstrated a right-to-left shunt during the Valsalva maneuver. A transesophageal echocardiogram revealed a PFO with a right-to-left shunt. The elevated intrathoracic pressure during labor may have caused blood to flow backward through the heart, shunting blood from the right side to the left through the PFO. In cases such as this, an amniotic fluid embolus may travel directly from the venous to the arterial circulation via the PFO, leading to multiple cerebral infarctions.

Successful resuscitation of amniotic fluid embolism applying a new classification and management strategy

Amniotic fluid embolism (AFE) is a rare but life-threatening maternal emergency caused by the entry of amniotic fluid contents into the maternal circulation. The clinical manifestations of AFE are heterogeneous, leading to misdiagnosis or treatment delay. Kanayama and colleagues distinguished the cardiopulmonary collapse type (or classic type) from the disseminated intravascular coagulation (DIC) type of AFE on the basis of the presence of uterine atony and DIC in the latter prior to cardiopulmonary failure. We report a case of DIC-type AFE successfully treated by blood volume replacement and coagulation therapy. The patient was scheduled for elective cesarean delivery because of a previous cesarean section and moyamoya disease. Delivery was uneventful, but massive vaginal bleeding without clotting and ensuing hypovolemic shock occurred 4 h later. She was transferred to the operating room for emergency laparotomy, but sustained a cardiac arrest. The patient was successfully resuscitated and a hysterectomy performed. During surgery, the patient received fresh frozen plasma, platelets, fibrinogen, and antithrombin concentrate. In cardiopulmonary collapse type AFE, cardiopulmonary resuscitation without delay is important. In the present case of DIC-type AFE, however, early supplementation of clotting factors and platelets was critical for patient survival.

Thromboelastography as a part of management of amniotic fluid embolism

Amniotic fluid embolism (AFE) is an obstetrical catastrophe characterized by acute hypotension, hypoxia, and coagulopathy occurring during labor, cesarean section, post-delivery, or during amniocentesis. Thromboelastography (TEG) is a bedside test of global homeostasis and has seldom been used to study coagulation in AFE despite increasing popularity in other diseases. We report TEG usage as part of a treatment for patients with AFE.

Neurocritical care complications of pregnancy and puerperum

Neurocritical care complications of pregnancy and puerperum such as preeclampsia/eclampsia, hemolysis, elevated liver enzymes, low platelets syndrome, thrombotic thrombocytopenic purpura, seizures, ischemic and hemorrhagic stroke, postpartum angiopathy, cerebral sinus thrombosis, amniotic fluid emboli, choriocarcinoma, and acute fatty liver of pregnancy are rare but can be devastating. These conditions can present a challenge to physicians because pregnancy is a unique physiologic state, most therapeutic options available in the intensive care unit were not studied in pregnant patients, and in many situations, physicians need to deliver care to both the mother and the fetus, simultaneously. Timely recognition and management of critical neurologic complications of pregnancy/puerperum can be life saving for both the mother and fetus.

Survival after an amniotic fluid embolism following the use of sodium bicarbonate

Amniotic fluid embolism (AFE) is a rare and potentially fatal complication of pregnancy. In this case report, we highlight the successful use of sodium bicarbonate in a patient with an AFE. We present a case of a 38-year-old mother admitted for an elective caesarean section. Following the delivery of her baby, the mother suffered a cardiac arrest. Following a protracted resuscitation, transoesophageal echocardiography demonstrated evidence of acute pulmonary hypertension, with an empty left ventricle and an over-distended right ventricle. In view of these findings and no improvement noted from on-going resuscitation, sodium bicarbonate was infused as a pulmonary vasodilator. Almost instantaneous return of spontaneous circulation was noted, with normalisation of cardiac parameters. We propose that in patients suspected with AFE and who have been unresponsive to advance cardiac life support measures, and where right ventricular failure is present with acidosis and/or hypercarbia, the use of sodium bicarbonate should be considered.

Incidence, diagnosis and pathophysiology of amniotic fluid embolism

Amniotic fluid embolism (AFE) is a rare clinical entity, sometimes fatal. A review was conducted to describe the frequency, diagnosis and pathophysiology of AFE. The reported incidences ranged from 1.9 cases per 100,000 maternities (UK) to 6.1 per 100,000 maternities (Australia), which can vary considerably, depending on the period, region of study and the definition. Although the development of amniotic fluid-specific markers would have an impact on early diagnosis, definition of AFE based on these markers is not widely accepted. To date, immunological mechanisms, amniotic fluid-dependent anaphylactic reaction and complement activation, have been proposed as potential pathogenetic and pathophysiological mechanisms. Immune cell activation induced through complement activation may be associated with the mechanism that immediately initiates maternal death, only in susceptible individuals. This review will focus on advances in the field of AFE biology and discuss the prevalence, diagnosis and pathophysiology of AFE.

Amniotic fluid embolism: an interdisciplinary challenge: epidemiology, diagnosis and treatment

BACKGROUND

Amniotic fluid embolism (AFE) is a life-threatening obstetric complication that arises in 2 to 8 of every 100 000 deliveries. With a mortality of 11% to 44%, it is among the leading direct causes of maternal death. This entity is an interdisciplinary challenge because of its presentation with sudden cardiac arrest without any immediately obvious cause, the lack of specific diagnostic tests, the difficulty of establishing the diagnosis and excluding competing diagnoses, and the complex treatment required, including cardio - pulmonary resuscitation.

METHOD

We selectively reviewed pertinent literature published from 2000 to May 2013 that was retrieved by a PubMed search.

RESULTS

The identified risk factors for AFE are maternal age 35 and above (odds ratio [OR] 1.86), Cesarean section (OR 12.4), placenta previa (OR 10.5), and multiple pregnancy (OR 8.5). AFE is diagnosed on clinical grounds after the exclusion of other causes of acute cardiovascular decompensation during delivery, such as pulmonary thromboembolism or myocardial infarction. Its main clinical features are severe hypotension, arrhythmia, cardiac arrest, pulmonary and neurological manifestations, and profuse bleeding because of disseminated intravascular coagulation and/or hyperfibrinolysis. Its treatment requires immediate, optimal interdisciplinary cooperation. Low-level evidence favors treating women suffering from AFE by securing the airway, adequate oxygenation, circulatory support, and correction of hemostatic disturbances. The sudden, unexplained death of a pregnant woman necessitates a forensic autopsy. The histological or immunohistochemical demonstration of formed amniotic fluid components in the pulmonary bloodflow establishes the diagnosis of AFE.

CONCLUSION

AFE has become more common in recent years, for unclear reasons. Rapid diagnosis and immediate interdisciplinary treatment are essential for a good outcome. Establishing evidence-based recommendations for intervention is an important goal for the near future.

Amniotic fluid embolism: the known and not known

Amniotic fluid embolism was first recognized in 1926, in a Brazilian journal case report, on the basis of large amounts of fetal material in the maternal pulmonary vasculature at autopsy. The first English language description appeared in 1941 and consisted of eight parturients dying suddenly in which, once again, fetal material was seen in the pulmonary vasculature. A control group of 34 pregnant women dying of other recognized causes did not have fetal material in their lungs. The incidence of recognized, serious illness is on the order of two to eight per 100,000, with a mortality rate ranging from 13% to 35%. The diagnosis rests largely on one or more of four clinical signs: circulatory collapse, respiratory distress, coagulopathy, and seizures/ coma. The only confirmatory laboratory test remains autopsy findings although serum tests for fetal antigen, insulin-like growth factor binding protein-1, and complement are currently being investigated. One of the paradoxes of diagnosis is that fetal material in the pulmonary circulation at autopsy is specific for amniotic fluid embolism, while the same finding in the living is not. The mechanism of disease remains uncertain although the best available evidence suggests that complement activation might have a role. In contrast, mast cell degranulation probably is not a mechanism, so amniotic fluid embolism is not an anaphylaxis or anaphylactoid reaction as has been occasionally suggested. Perhaps the greatest unknown is not why 1 in 50,000 pregnant women develop what appears to be an immune response to their fetus, but rather why the other 49,999 do not?

Amniotic fluid embolism--investigation of fatal cases in Slovakia in the years 2005-2010 compared with fatal cases in the United Kingdom

BACKGROUND

Amniotic fluid embolism (AFE) is a rare, often severe complication of pregnancy. The clinical diagnosis is difficult to establish and is one of exclusion. The aim of this study was to investigate 6 fatal cases of AFE in Slovakia and compare the incidence, risk factors, course, management and neonatal outcomes with fatal cases of AFE in the United Kingdom (UK).

MATERIALS AND METHODS

Data on fatal cases of AFE in Slovakia were analysed and compared with fatal cases in the UK in the years 2005-2010.

RESULTS

The incidence in Slovakia was significantly higher than in the UK from 2005-2010 (RR 5.03, 95% CI 1.98-12.75, P=0.003). However, 5/6 deaths occurred in 2009 coinciding with the H1N1 flu virus pandemic in Slovakia. There were no significant differences in the characteristics of women who died, with the exception of gestational age at delivery; significantly higher in Slovakia (median 41 versus 39 weeks, P=0.01). In Slovakia most of the cases occurred after delivery, 83.3%, compared with 52.9% in the UK. There were no significant differences in clinical signs, use of recombinant factor VIIa or performance of obstetric hysterectomy. In Slovakia 83.3% and in the UK 94.7% of infants survived, but 20% and 27.8% had some long-term sequelae.

CONCLUSION

AFE is now the leading cause of maternal deaths in Slovakia. However, we found no significant differences in the possible risk factors, course, management or outcomes between Slovakia and the UK. This analysis is limited by study power; we propose that establishment of a national register of cases of AFE in Slovakia would help further investigate and monitor mortality from this condition.

Pulmonary embolism and amniotic fluid embolism in pregnancy

Amniotic fluid embolism and pulmonary embolism are 2 of the most common causes of maternal mortality in the developed world. Symptoms of pulmonary embolism include tachycardia, tachypnea, and shortness of breath, all of which are common complaints in pregnancy. Heightened awareness leads to rapid diagnosis and institution of therapy. Amniotic fluid embolism is associated with maternal collapse. There are currently no proven therapies, although rapid initiation of supportive care may decrease the risk of mortality.

Incidence, risk factors, and consequences of amniotic fluid embolism

BACKGROUND

Amniotic fluid embolism (AFE) is a rare but serious cause of maternal mortality whose aetiology remains obscure. Previous population-based studies have reported associations with labour induction and caesarean delivery.

METHODS

We updated a previous analysis based on the US Nationwide Inpatient Sample from 1999 to 2008. We adapted a diagnostic validation algorithm to minimise false-positive diagnoses, along with statistical methods that account for the stratified random sampling design.

RESULTS

Of the 8 571 209 deliveries recorded in the database, 276 met our case definition of AFE, of which 62 (22.9% of the 274 with known vital status) were fatal. Significant associations with AFE were observed for medical induction {adjusted odds ratio [aOR] = 1.7 [95% confidence interval (CI) 1.2, 2.5]}, caesarean delivery [aOR = 15.0; 95% CI 9.4, 23.9], instrumental vaginal delivery [aOR = 6.6; 95% CI 4.0, 11.1], and cervical/uterine trauma [aOR = 7.4; 95% CI 3.6, 14.9]. AFE was associated with increases in risk of stillbirth, hysterectomy, maternal death, and prolonged maternal length of delivery hospital stay.

CONCLUSIONS

AFE remains an extremely serious obstetric complication with high risks of maternal and fetal mortality. The increased risks of AFE associated with labour induction and caesarean delivery have implications for elective use of these interventions.

Amniotic fluid embolism

Amniotic fluid embolism (AFE) is an unpredictable and as-of-yet unpreventable complication of maternity. With its low incidence it is unlikely that any given practitioner will be confronted with a case of AFE. However, this rare occurrence carries a high probability of serious sequelae including cardiac arrest, ARDS, coagulopathy with massive hemorrhage, encephalopathy, seizures, and both maternal and infant mortality. In this review the current state of medical knowledge about AFE is outlined including its incidence, risk factors, diagnosis, pathophysiology, and clinical manifestations. Special attention is paid to the modern aggressive supportive care that resulted in an overall reduction in the still alarmingly high mortality rate of this devastating entity. The key factors for successful management and resolution of this disease process continue to be sharp vigilance, a high level of clinical suspicion, and rapid all-out resuscitative efforts on the part of all clinicians involved in the medical care of the parturient.

The use of therapeutic hypothermia in the management of amniotic fluid embolism

Background:

Amniotic fluid embolism (AFE) is a rare peripartum obstetric emergency where patients seldom survive neurologically intact. The exact pathophysiology is not completely understood and treatment remains mainly supportive.

Case:

A 34-year-old African American woman gravida 1, para 0-0-0-0 at 38 weeks and four days induced for chronic hypertension with superimposed preeclampsia experienced an AFE during labour. Supportive treatment included early use of therapeutic hypothermia resulting in a normal neurological outcome.

Conclusion:

This case demonstrates the timely use of therapeutic hypothermia in a patient surviving an AFE and suffering no neurological sequelae. Therapeutic hypothermia should be considered in the supportive treatment of AFE.

Amniotic fluid embolism: 10-year retrospective study in a level III maternity hospital

OBJECTIVE

To provide updated data on amniotic fluid embolism (AFE) based on our population over a 10 year period, and to propose steps for improving current practice.

STUDY DESIGN

Retrospective study carried out in the Department of Gynaecology and Obstetrics at the Strasbourg University Teaching Hospital between 1 January 2000 and 31 December 2010. Dossiers of patients with AFE were identified using medical information system programme (MISP) coding and cross-checked with the pathology reports (hysterectomy, post-mortem examination).

RESULTS

Eleven dossiers were found (0.28/1000). Eight cases (73%) of AFE occurred during labour, two (18%) in the post-partum period and one (9%) outside of parturition. Induction was initiated in four patients (45%) and labour sustained with oxytocin in 9 patients (90%). Acute circulatory collapse with cardio-respiratory arrest (CRA) was the herald symptom of AFE in 2 patients, and secondary cardio-respiratory arrest occurred rapidly in 6 patients (55%) following a relatively non-indicative prodromal phase. Disseminated intravascular coagulopathy (DIC) was observed in 10 cases (91%) and massive transfusion was necessary in all patients. Seven haemostatic hysterectomies (63%) were performed, with secondary arterial embolisation in 2 cases (22%). Although all patients presented a clinical picture of AFE, confirmation through histology or laboratory test results was forthcoming in only 7 cases (63%). Three patients died (27%). When AFE occurred during labour, 8 fetuses (75%) received intensive care support. In all, 11 newborns survived (85%). Their pH was less than 7.00 in 3 cases (27%) and 4 fetuses (36%) had an Apgar score of less than 5 at 5 minutes of life.

CONCLUSION

AFE is a rare but extremely serious disease. Some risk factors for AFE have been identified but they do not allow its occurrence to be predicted. The diagnosis may be supported by specific laboratory test results but only a post-mortem examination provides a pathognomonic diagnosis: unfortunately it is always retrospective. Obstetrical and intensive care management is complex and must be adapted to the situation bearing in mind the significant risk of haemorrhage and DIC. Hysterectomy must be performed if there is the least doubt.

[Amniotic fluid embolism: an update]

Amniotic fluid embolism (AFE) results from the passage of fœtal and amniotic fragments into the maternal circulation, occurring mostly within minutes before or after delivery. Although maternal and fœtal mortality of AFE remains high (about 40%), AFE should no longer be considered as having an ineluctable fatal course. Diagnosis is often made upon clinical presentation but histological confirmation is difficult owing favorable outcome and because an autopsy has not been performed. Identification of squamous cells in the maternal circulation could not confirm the diagnosis because of their possible maternal origin. High plasma level of insulin-like growth factor-binding protein-1 (IGFBP-1) has recently been identified as a biomarker of amniotic fluid passage into the maternal circulation and might therefore be used to confirm the diagnosis when lung tissue histology is not available. Treatment of AFE remains supportive with a special focus on correction of the coagulopathy and search for acute core pulmonale. In this later case, physicians should consider initiating an extracorporeal life support when facing a patient with refractory shock. Finally, caution is needed with the use of recombinant factor VIIa in this context.

Usefulness of the bispectral index during cardiopulmonary resuscitation -A case report-

The usefulness of using the bispectral index (BIS) for monitoring during cardiopulmonary resuscitation (CPR) is not clearly understood. However, BIS has been a popular anesthetic monitoring device used during operations. The case presented is of a pregnant woman going into cardiac arrest due to an amniotic fluid embolism during a Cesarean section. CPR was performed, but neither the return of spontaneous circulation (ROSC) nor the return of consciousness was achieved, despite 50 min of effective CPR. However, CPR was continued based on BIS. ROSC was achieved, and an alert consciousness state was reached 1 day postoperation. This finding suggests that BIS be used as a basic monitoring device during CPR and that it may help in deciding to continue CPR.

Fatal amniotic fluid embolism with typical pathohistological, histochemical and clinical features

Despite the decrease in maternal mortality rate, amniotic fluid embolism (AFE) is still one of the most feared complications of pregnancy due to the high rate of mortality in Japan. The authors present a fatal case of a healthy 39-year-old woman who died during delivery after a normal 40-week second pregnancy. Shortly after the arrival at hospital, an abrupt drop of foetal heart rate was observed, followed by deterioration of consciousness and cardiac arrest of the patient. Prompt cardiopulmonary resuscitation (CPR) was performed but the patient died about an hour and a half after her arrival at hospital. Forensic autopsy confirmed the pathohistological diagnosis of amniotic fluid embolism supported by histochemical analysis results and excluded other possible causes of death. This paper stresses the fundamental importance of autopsy in an unexpected maternal death in conjunction with the significance of data accumulation on maternal death.

Complications in late pregnancy

Complications of late pregnancy are managed infrequently in the emergency department and, thus, can pose a challenge when the emergency physician encounters acute presentations. An expert understanding of the anatomic and physiologic changes and possible complications of late pregnancy is vital to ensure proper evaluation and care for both mother and fetus. This article focuses on the late pregnancy issues that the emergency physician will face, from the bleeding and instability of abruptio placentae to the wide spectrum of complications and management strategies encountered with preterm labor.