Incidence and risk factors of amniotic fluid embolisms: a population-based study on 3 million births in the United States

A retrospective analysis of the incidence and risk factors for amniotic fluid embolism in cesarean deliveries

BACKGROUND

Amniotic-fluid embolism (AFE) is a rare occurrence but life-threatening disease that can occur in process of delivery and postnatal women. The topic of cesarean section surgery and its associated risk factors has been neglected due to the infrequent occurrence of AFE. However, AFE significantly contribute to maternal morbidity and mortality.

PURPOSES

We aim to examine the correlation between clinical issues, prenatal complications, comorbidities, medical perioperative complications, and cesarean section surgery of AFE in the US, utilizing a Nationwide Inpatient Sample (NIS) database.

METHODS

This study conducted a retrospective cohort analysis on cesarean deliveries in the United States using data from the NIS of the Healthcare Cost and Utilization Project (HCUP) to examine the incidence and risk factors of AFE during cesarean section surgery. The analysis included the period from January 1, 2010, to December 31, 2019. We employed a multivariable logistic regression to evaluate the main outcome, which encompassed the clinical, prenatal, comorbidity, and medical perioperative AFE undergoing cesarean deliveries.

RESULTS

We identified AFE in 269 out of the 2,462,005 women whose cesarean deliveries we investigated, with an incidence rate of 0.0113%. In the AFE group, the median patient age at the cohort level was 32 years (IQR, 27-36 years). The in-hospital mortality rate for patients with AFE following cesarean delivery was significantly higher than for those without AFE (14.9% vs. 0.0%, P < 0.001). In univariable analysis, P < 0.05 served as the initial selection criterion. A multivariable analysis revealed that AFE at the time of cesarean deliveries was significantly correlated with chronic blood loss anemia, coagulopathy, congestive heart failure, other neurological disorders, fluid and electrolyte disorders, weight loss, pulmonary circulation disorders, abruptio placentae, and polyhydramnios.

CONCLUSION

This contemporaneous, nationwide investigation verified the incidence of cesarean deliveries by AFE and corroborated previously identified risk factors for AFE. Although the absolute risk of AFE is minimal, clinicians should be aware of the identified risk factors, such as chronic blood loss anemia, coagulopathy, and polyhydramnios, to enhance preparedness and optimize patient counseling, particularly in high-risk cases.

Extracorporeal Membrane Oxygenation in Amniotic Fluid Embolism: A Systematic Review of Case Reports

Amniotic fluid embolism (AFE) is an obstetric complication that can result in acute circulatory failure during and after labor. The effectiveness of extracorporeal membrane oxygenation (ECMO) in AFE patients has not been established, especially in the context of coagulopathy. This review aims to evaluate the efficacy of ECMO support in AFE patients. We conducted a systematic review of case reports following the Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Quality assessment was performed using a standardized tool. Out of 141 studies screened, 33 studies included 79 AFE patients. The median age was 34 years, and the median gestational age was 37.5 weeks. The majority of AFE cases occurred during cesarean section delivery (55.2%), followed by labor before fetal delivery (26.7%). Extracorporeal membrane oxygenation configurations included venoarterial ECMO (81.3%) and extracorporeal cardiopulmonary resuscitation (CPR, 10.7%). The maternal survival rate was 72%, with 21.2% experiencing minor neurological sequelae and 5.8% having major neurological sequelae. Rescue ECMO to support circulation has demonstrated both safety and efficacy in managing AFE. We suggest early activation of local or mobile ECMO as soon as an AFE diagnosis is established. Further studies are needed to assess the benefits and implications of early ECMO support in AFE patients.

Amniotic Fluid Embolism After Cervical Ripening

Amniotic fluid embolism (AFE) is a rare condition that can have catastrophic maternal and infant consequences. It can lead to rapid multisystem failure and is responsible for a significant portion of maternal deaths. The diagnosis is frequently made late in the pathological process, and the treatment is mainly supportive and infant delivery. It cannot be prevented. Whether cervical ripening and labor induction are risk factors is controversial. A 31-year-old woman who was undergoing cervical ripening and induction of labor at 38 weeks gestation for medication-controlled gestational diabetes (A2GDM) was admitted for delivery. She received five doses of 25 µg vaginal misoprostol serially and, ultimately, a Foley catheter cervical balloon. After approximately 24 hours, she had the sudden onset of unexpected persistent fetal bradycardia. Her cervix was 4 cm at the time of the fetal distress. When she arrived in the operating room, she was hypoxic and difficult to awaken. An emergency cesarean delivery was performed under general endotracheal anesthesia. Immediately after the delivery of a profoundly depressed and acidotic infant with an umbilical cord pH of 6.84, she became hypotensive, requiring vasopressors. After diffuse intravascular coagulation was diagnosed, treatment for AFE was implemented. AFE has a high mortality rate, and the length of time needed to identify the condition and the availability of specialty resources are two elements that can affect the outcome. Newer alternative treatments, such as the supportive "A-OK" (atropine, ondansetron, and ketorolac administration) protocol for AFE, are discussed. Ultimately, both mother and baby survived and, at the six-month check, are doing well with no sequelae.

Early recognition and mobilization of resources in managing amniotic fluid embolism for a high-risk obstetric patient: A case report

A 33-year-old woman, gravida 3 para 2, at 39 weeks of gestation, undergoing induction of labor, had a seizure. She was transferred to the operating room and underwent a cesarean delivery for non-reassuring fetal status. An amniotic fluid embolism (AFE) was suspected given her cardiovascular collapse, disseminated intravascular coagulation, and early right heart failure. Early mobilization of resources (e.g., blood bank, gynecology oncology, extracorporeal membrane oxygenation) was necessary as the hospital was in a stand-alone building. Biomarkers were sent during the acute event. The creation of an AFE order set is discussed.

Anesthetic Considerations and Outcomes in Amniotic Fluid Embolism: A Retrospective Study over a 15-Year Period

(1) Background: A rare and unexpected consequence of childbirth, labor, or the immediate postpartum period is amniotic fluid embolism (AFE). This study aims to identify AFE cases during or immediately after birth from anesthetic management perspectives. Secondary goals include assessing patient clinical features, obstetric care techniques, birth outcomes, and case survival. (2) Methods: A retrospective observational study assessed AFE patients hospitalized in three Romanian clinical institutions from October 2007 to April 2023. Based on the Society of Maternal-Fetal Medicine (SMFM) criteria, we diagnosed 11 AFE patients. (3) Results: AFE occurred in eight cases (73%) during peripartum, two (18%) within 30 min after placental delivery, and 1 (9%) during a scheduled cesarean surgery. Only one of six cardiorespiratory arrest patients responded to external cardiac massage, while the other five (83%) needed defibrillation. The patients received, on average, five units of red blood cells, six of fresh frozen plasma, and two of activated platelets. Six patients (55%) received factor VIIa infusions. Maternal mortality was 36.3%. Six neonates (75%) needed neonatal resuscitation, and two (25%) died on the second and third days. (4) Conclusions: AFE management necessitates a multidisciplinary approach and the incorporation of advanced life support techniques to optimize outcomes for both the mother and newborn.

Acute Respiratory Failure in Pregnancy

Respiratory failure may affect up to 1 in 500 pregnancies, due to pregnancy-specific conditions, conditions aggravated by the pregnant state, or other causes. Management during pregnancy is influenced by altered maternal physiology, and the presence of a fetus influencing imaging, and drug therapy choices. Few studies have addressed the approach to invasive mechanical ventilatory management in pregnancy. Hypoxemia is likely harmful to the fetus, but precise targets are unknown. Hypocapnia reduces uteroplacental circulation, and some degree of hypercapnia may be tolerated in pregnancy. Delivery of the fetus may be considered to improve maternal respiratory status but improvement does not always occur.

Amniotic fluid embolism: a reappraisal

OBJECTIVES

Using cases from our own experience and from the published literature on amniotic fluid embolism (AFE), we seek to improve on existing criteria for diagnosis and discern associated risk factors. Additionally, we propose a novel theory of pathophysiology.

METHODS

This retrospective case review includes eight cases of AFE from two hospital systems and 21 from the published literature. All cases were evaluated using the modified criteria for research reporting of AFE by Clark et al. in Am J Obstet Gynecol, 2016;215:408-12 as well as our proposed criteria for diagnosis. Additional clinical and demographic characteristics potentially correlated with a risk of AFE were included and analyzed using descriptive analysis.

RESULTS

The incidence of AFE was 2.9 per 100,000 births, with five maternal deaths in 29 cases (17.2 %) in our series. None of the cases met Clark's criteria while all met our criteria. 62.1 % of patients were over the age of 32 years and two out of 29 women (6.9 %) conceived through in-vitro fertilization. 6.5 % of cases were complicated by fetal death. Placenta previa occurred in 13.8 %. 86.2 % of women had cesarean sections of which 52.0 % had no acute maternal indication.

CONCLUSIONS

Our criteria identify more patients with AFE than others with a low likelihood of false positives. Clinical and demographic associations in our review are consistent with those previously reported. A possible relationship between cesarean birth and risk of AFE was identified using our criteria. Additionally, we propose a new hypothesis of pathophysiology.

Amniotic fluid embolism: A case report of good outcome with timely intensive multidisciplinary team involvement

OBJECTIVE

Amniotic fluid embolism is one of the most serious pregnancy complications. It can cause sudden maternal collapse with high mortality and morbidity. We present a case report regarding the important of prompt decision making and multidisciplinary team work for management of amniotic fluid embolism to yield favorable maternal and neonatal outcome.

CASE REPORT

This is a 35-year-old, gravida 2, para 1, woman underwent labor induction at gestational age of 37 + 6 weeks due to elective induction. She had sudden facial cyanosis and shortness of breath right after artificial rupture of membrane. Prompt decision of urgent cesarean section, aggressive and timely massive blood transfusion and multidisciplinary team work had spared patient from extracorporeal membrane oxygenation placement and prolonged hospitalization. A male infant was born with Apgar score 3' -> 5' with estimate body weight of 2958 gm; he was hospitalized for 10 days and no other complications was found at follow up pediatric outpatient clinic.

CONCLUSION

One of the most dreadful, but rare pregnancy complications is amniotic fluid embolism (AFE). It can cause serious maternal and neonatal morbidity and mortality. Rapid recognition and multidisciplinary team management are essential to maternal and neonatal prognosis.

Nontrombotic Pulmonary Embolism: Different Etiology, Same Significant Consequences

Nontrombotic pulmonary embolism represents the embolization of different types of materials (cells, organisms, gas, foreign material) into pulmonary circulation. The disease is uncommon, and clinical presentation together with laboratory findings are nonspecific. Its pathology is usually misdiagnosed based on imaging findings as pulmonary thromboembolism, but the correct diagnosis is essential because different therapeutic approaches are required. In this context, knowledge of the risk factors associated with nontrombotic pulmonary embolism and specific clinical symptoms is fundamental. Our objective was to discuss the specific features of the most common etiologies of nontrombotic pulmonary embolism, gas, fat, amniotic fluid, sepsis and tumors, to provide assistance for a rapid and correct diagnosis. Because the most common etiologies are iatrogenic, knowledge of the risk factors could be an important tool for prevention or rapid treatment if the disease develops during different procedures. The diagnosis of nontrombotic pulmonary embolisms represent a laborious challenge, and endeavors should be made to prevent development and increase awareness of this disease.

Placental mesenchymal dysplasia complicated with sudden fetal demise and amniotic fluid embolism: a case report

BACKGROUND

Placenta mesenchymal dysplasia (PMD) is a rare placental anomaly associated with various fetal and maternal complications. Whether close ultrasound surveillance can prevent intrauterine fetal demise (IUFD) in patients with PMD is still under investigation. Amniotic fluid embolism (AFE) is a rare, lethal, and unpredictable maternal complication that has never been described in association with PMD. Here, we report a case of PMD, in which the fetus eventually demised in utero despite weekly color Doppler monitoring, and the mother subsequently encountered AFE during delivery.

CASE PRESENTATION

A 43-year-old woman who had received three frozen embryo transfer, was found to have a singleton pregnancy with an enlarged multi-cystic placenta at 8 weeks' gestation. Fetal growth restriction (FGR) was noted since the 21^stweek. The fetus eventually demised in-utero at 25 weeks despite weekly color Doppler surveillance. Cesarean section was performed under general anesthesia due to placenta previa totalis and antepartum hemorrhage. During surgery, the patient experienced a sudden blood pressure drop and desaturation followed by profound coagulopathy. AFE was suspected. After administration of inotropic agents and massive blood transfusion, the patient eventually survived AFE. PMD was confirmed after pathological examination of the placenta.

CONCLUSIONS

While FGR can be monitored by color Doppler, our case echoed previous reports that IUFD may be unpreventable even under intensive surveillance in PMD cases. Although AFE is usually considered unpredictable, PMD can result in cumulative risk factors contributing to AFE. Whether a specific link exists between the pathophysiology of PMD and AFE requires further investigation.

Association of Pregnancy Characteristics and Maternal Mortality With Amniotic Fluid Embolism

IMPORTANCE

Amniotic fluid embolism (AFE) is an uncommon pregnancy complication but is associated with high maternal mortality. Because of the rarity of AFE, associated risks factors and maternal outcomes have been relatively understudied.

OBJECTIVE

To examine the clinical, pregnancy, and delivery characteristics and the maternal outcomes related to AFE in a recent period in the US.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study examined hospital deliveries from January 1, 2016, to December 31, 2019, from the Healthcare Cost and Utilization Project's National Inpatient Sample.

MAIN OUTCOMES AND MEASURES

The primary outcome was clinical, pregnancy, and delivery characteristics of AFE, assessed with a multivariable binary logistic regression model. The coprimary outcome was failure to rescue, defined as maternal mortality after AFE. Associations with other severe maternal morbidity indicators and failure to rescue per clinical and pregnancy characteristics were also assessed.

RESULTS

A total of 14 684 135 deliveries were examined, with AFE diagnosed in 880 women, corresponding to an incidence rate of 6.0 per 100 000 deliveries. The cohort-level median patient age was 29 years (IQR, 25-33 years). In a multivariable analysis, (1) patient factors of older age, Asian and Black race, Western US region, pregestational hypertension, asthma, illicit substance use, and grand multiparity; (2) pregnancy factors of placental accreta spectrum (PAS), placental abruption, uterine rupture, polyhydramnios, chorioamnionitis, preeclampsia, fetal growth restriction, and fetal demise; and (3) delivery factors of early gestational age, cervical ripening, cesarean delivery, operative delivery, and manual removal were associated with AFE. Among these characteristics, PAS had the largest association with AFE (adjusted odds ratio [aOR], 10.01; 95% CI, 7.03-14.24). When stratified by the PAS subtypes, more severe forms of PAS had a greater association with AFE (aOR for increta and percreta, 17.35; 95% CI, 10.21-28.48; and aOR for accreta, 7.62; 95% CI, 4.83-12.01). Patients who had AFE were more likely to have coagulopathy (aOR, 24.68; 95% CI, 19.38-31.44), cardiac arrest (aOR, 24.56; 95% CI, 17.84-33.81), and adult respiratory distress syndrome (aOR, 10.72; 95% CI, 8.09-14.20). The failure-to-rescue rate after AFE was 17.0% overall. However, the failure-to-rescue rate exceeded 30% when AFE co-occurred with other severe maternal morbidity indicators: 45.8% for AFE, cardiac arrest, and coagulopathy; 43.2% for AFE, shock, and cardiac rhythm conversion; and 38.6% for AFE, cardiac arrest, coagulopathy, and shock. The failure-to-rescue rate after AFE also exceeded 30% when AFE occurred in the setting of placental pathology: 42.9% for AFE and PAS and 31.3% for AFE and placental abruption.

CONCLUSIONS AND RELEVANCE

This contemporaneous, national-level analysis validated previously known risk factors for AFE and confirmed the dismal outcomes of pregnancy complicated by AFE. The association between PAS and AFE, which was not previously reported, warrants further investigation.

A case report of early application of veno-arterial extracorporeal membrane oxygenation in amniotic fluid embolism

RATIONALE

Amniotic fluid embolism (AFE) is a rare obstetrical complication and is a leading cause of maternal death in developed countries. Despite the development of supportive therapeutic measures, the mortality rate remains high.

PATIENT CONCERNS

A 38-year-old nulliparous pregnant woman, who underwent in vitro fertilization-embryo transfer, was admitted for labor at 37 weeks' gestation. Approximately 30 minutes after delivery of the placenta, the puerpera developed postpartum hemorrhage with uterine atony. Soon after, the patient experienced hypotension, repeated cardiac arrest, refectory hypoxia, and disseminated intravascular coagulopathy.

DIAGNOSIS

AFE is diagnosed clinically. The pregnant woman in this case fulfilled the diagnostic criteria for AFE: acute hypotension, cardiac arrest, acute hypoxia, and coagulation disorders within approximately 30 minutes after delivery of the placenta.

INTERVENTIONS

The patient was intubated, connected to a ventilator, and was administered a high dose of vasoactive drugs to maintain blood pressure and underwent an emergency hysterectomy. Considering the risk for recurrent cardiac arrest and severe refractory hypoxia, venoarterial extracorporeal membrane oxygenation was initiated and discontinued as soon as cardiac function was restored based on serial bedside ultrasound assessment.

OUTCOMES

The patient stabilized on day 7 in the intensive care unit and was transferred to the obstetrics ward and, 1 week later, was discharged with no complications. Two months later, follow-up revealed that the patient was in good condition.

LESSON

Serial bedside ultrasound was crucial for assessing cardiac function and optimal weaning. Timely application of venoarterial extracorporeal membrane oxygenation and weaning was significant to avoid the occurrence of complications and improve long-term outcomes.

Cardiac Arrest during Cesarean Section - A Case Report and Review of the Differential Diagnosis

AIM

According to the World Health Organization, approximately 810 pregnant women die every day as a consequence of peripartum complications. A large proportion of deaths happen in developing countries. Peripartum cardiac arrest is a rare event that must be treated immediately. It is important to consider the differential diagnoses in order to save lives.

METHODS

In this review, we discuss a differential diagnosis of cardiac arrest according to the BEAU-CHOPS scheme of the American Heart Association in the relation to the case report of our 40-year-old G5/P3 patient who went into cardiac arrest during cesarean delivery.

RESULTS

Typical differentials for cardiac arrest during labor are bleeding, embolism, anesthetic complications, cardiovascular diseases, eclampsia, and sepsis. All of them were considered and ruled out in this patient. In the end, we suspect that physiological cardio-inhibitory reflexes triggered by sudden profound hypovolemia after placental separation along with the patient's risk factors, especially obesity and maternal age, and the administration of spinal anesthesia all potentially contributed to the cardiac arrest.

CONCLUSIONS

This review highlights that the cardiac arrest during labor can be triggered by the multifactorial etiology, but firstly the typical differential diagnosis needs to be excluded.

Amniotic fluid embolism - implementation of international diagnosis criteria and subsequent pregnancy recurrence risk

OBJECTIVES

An international diagnostic criterion for amniotic fluid embolism (AFE) diagnosis has recently been published. Data regarding subsequent pregnancies is scarce. We sought to implement recent diagnostic criteria and detail subsequent pregnancies in survivors.

METHODS

A case series of all suspected AFE cases at a tertiary medical center between 2003 and 2018 is presented. Cases meeting the diagnostic criteria for AFE were included. Clinical presentation, treatment, and outcomes described. Pregnancy outcomes in subsequent pregnancies in AFE survivors detailed.

RESULTS

Between 2003 and 2018 14 women were clinically suspected with AFE and 12 of them (85.71%) met the diagnostic criteria for AFE. Three cases occurred during midtrimester dilation and evacuation procedures, and the remaining occurred in the antepartum period. Of the antepartum cases, mode of delivery was cesarean delivery or vacuum extraction for expedited delivery due to presentation of AFE in 8/9 cases (88.88%). Clinical presentation included cardiovascular collapse, respiratory distress and disseminated intravascular coagulopathy (DIC). Heart failure of varying severity was diagnosed in 75% (9/12) cases. Composite maternal morbidity was 5/12 (41.66%), without cases of maternal mortality. 11 subsequent pregnancies occurred in four AFE survivors. Pregnant women were followed by a high-risk pregnancy specialist and multidisciplinary team if pregnancy continued beyond the early second trimester. Six pregnancies resulted in a term delivery. No recurrences of AFE were documented.

CONCLUSIONS

Use of a diagnostic criterion for diagnosis of AFE results in a more precise diagnosis of AFE. Nevertheless, the accuracy of clinical diagnosis is still high. Subsequent pregnancies were not associated with AFE recurrence.

Consumptive Coagulopathy Involving Amniotic Fluid Embolism: The Importance of Earlier Assessments for Interventions in Critical Care

Supplemental Digital Content is available in the text.

Objectives:

Amniotic fluid embolism is a rare disease that induces fatal coagulopathy; however, due to its rarity, it has not yet been examined in detail. The strict diagnostic criteria by Clark for amniotic fluid embolism include severe coagulopathy complicated by cardiopulmonary insufficiency, whereas the Japanese criteria also include postpartum hemorrhage or Disseminated Intravascular Coagulation in clinical practice. Amniotic fluid embolism cases with preceding consumptive coagulopathy may exist and are potential clinical targets for earlier assessments and interventions among amniotic fluid embolism cases fulfilling the Japanese, but not Clark criteria. The present study was performed to compare coagulopathy in the earlier stage between the amniotic fluid embolism patients diagnosed by Clark criteria (Clark group, n = 6), those by the Japanese criteria (Non-Clark group, n = 10), and peripartum controls and identify optimal clinical markers for earlier assessments of amniotic fluid embolism-related consumptive coagulopathy.

Design:

Retrospective case-control study.

Setting:

A single university-based center. Our amniotic fluid embolism registry program has accumulated clinical information and blood samples since 2003.

Patients:

Amniotic fluid embolism patients in the Clark and Non-Clark groups between 2009 and 2017 and peripartum controls.

Interventions:

None.

Measurements and Main Results:

Clinical information was collected on hemoglobin levels, platelet counts, and coagulation- and fibrinolysis-related variables. Fibrinolytic parameters were also measured and compared among the three groups before blood transfusion. Fibrinogen levels in all patients in the Clark group and most in the Non-Clark group decreased earlier than hemoglobin levels, which was consistent with the high hemoglobin/fibrinogen ratio and, thus, is a promising clinical marker for the earlier assessment of amniotic fluid embolism-related consumptive coagulopathy.

Conclusions:

Earlier evaluations of consumptive coagulopathy and hyperfibrinolysis using the hemoglobin/fibrinogen ratio following preemptive treatment may reduce the occurrence or prevent the aggravation of severe coagulopathy in amniotic fluid embolism patients.

Fibrinogen may aid in the early differentiation between amniotic fluid embolism and postpartum haemorrhage: a retrospective chart review

This study aimed to determine whether blood loss and fibrinogen can differentiate amniotic fluid embolism (AFE) from postpartum haemorrhage (PPH). This retrospective case–control study included nine patients with clinical AFE (“AFE group”) and 78 patients with PPH managed at our tertiary care perinatal centre between January 2014 and March 2016. Patients meeting the Japanese diagnostic criteria for AFE were stratified into cardiopulmonary collapse-type AFE and disseminated intravascular coagulation (DIC)-type AFE groups. The relationship between blood loss and fibrinogen at onset was examined to compare DIC severity. Vital signs at onset were not significantly different. The AFE group had significantly less blood loss at onset (1506 mL vs 1843 mL, P = 0.0163), significantly more blood loss 2 h post-onset (3304 mL vs 1996 mL, P < 0.0001) and more severe coagulopathy and fibrinolysis. The blood loss/fibrinogen (B/F) ratio at onset was significantly higher in the DIC-type AFE group (23.15 ± 8.07 vs 6.28 ± 3.35 mL dL/mg, P < 0.0001). AFE was complicated by catastrophic DIC irrespective of blood loss at onset. Fibrinogen exhibited the strongest correlation among test findings at onset. The B/F ratio may help differentiate PPH from DIC-type AFE and diagnose clinical AFE, facilitating optimal replacement of coagulation factors during the early stages.

Disseminated intravascular coagulation type of amniotic fluid embolism: a challenging case report with favorable outcome

Amniotic fluid embolism (AFE) is an unforeseeable, life-threatening complication of pregnancy and child birth. Although rare in an absolute sense, most contemporary series of maternal deaths from developed countries report AFE as a leading cause of mortality in the pregnant population. It has a heterogeneous presentation. This clinical heterogeneity makes the diagnosis of AFE difficult based on a beam of clinical and para-clinical arguments. Rapid diagnosis and immediate interdisciplinary treatment are essential for a good outcome. The present is a case of AFE with a disseminated intravascular coagulation (DIC) and a cardiorespiratory collapse following a vaginal delivery.

Contribution of blood detection of insulin-like growth factor binding protein-1 for the diagnosis of amniotic-fluid embolism: a retrospective multicentre cohort study

OBJECTIVE

To assess the contribution of maternal blood detection of IGFBP-1 for the diagnosis of amniotic-fluid embolism in clinical daily practice.

DESIGN

A retrospective multicentre cohort study.

SETTING

Three tertiary care obstetric units in France.

SAMPLE

Data of 86 women for whom amniotic-fluid embolism had been suspected and maternal serum detection of IGFBP-1 had been performed between 2011 and 2019 were analysed.

METHODS

The criteria defined by the United Kingdom Obstetric Surveillance System (UKOSS) were used for the retrospective diagnosis of amniotic-fluid embolism. The more structured definition proposed by the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation (SMFM) was also used as secondary endpoint.

MAIN OUTCOME MEASURES

Agreements between biological and clinical assessments were tested. The performance of blood detection of IGFBP-1 for the diagnosis of amniotic-fluid embolism according to the UKOSS criteria, and to the SMFM definition, was also assessed.

RESULTS

There was only slight agreement between clinical and laboratory diagnosis of amniotic-fluid embolism (Cohen's Kappa coefficient: 0.04). Blood detection of IGFBP-1 had a sensitivity of 16%, a specificity of 88%, a positive and a negative likelihood ratio of 1.3 and 0.95, respectively, and a positive and a negative predictive value of 58 and 50%, respectively, for the diagnosis of amniotic-fluid embolism based on the UKOSS criteria. The use of the more structured SMFM definition of amniotic-fluid embolism did not substantially change the results.

CONCLUSION

These results question the usefulness of blood detection of IGFBP-1 for the early diagnosis of amniotic-fluid embolism in daily clinical practice.

TWEETABLE ABSTRACT

This retrospective multicentre study questions the contribution of IGFBP-1 detection for the diagnosis of AFE.

Summary of clinically diagnosed amniotic fluid embolism cases in Korea and disagreement with 4 criteria proposed for research purpose

OBJECTIVE

This study aimed 1) to investigate the clinical characteristics of amniotic fluid embolism (AFE) cases clinically diagnosed by maternal fetal medicine (MFM) specialists in Korea, 2) to check the disagreement with 4 recently proposed criteria by the Society for Maternal-Fetal Medicine (SMFM) for research purpose, and 3) to compare maternal outcomes between cases satisfying all 4 criteria and cases with at least 1 missing criterion.

METHODS

This study included 12 patients clinically diagnosed with AFE from 7 referral hospitals in Korea. We collected information, including maternal age, symptoms of AFE, the amount of transfusion, and maternal mortality.

RESULTS

The median maternal age was 33 years (range, 28-40 years). Regarding symptoms, cardiovascular arrest, hypotension, respiratory compromise, clinical coagulopathy, and neurologic signs were observed in 41.7%, 83.3%, 83.3%, 100%, and 66.7% of the cases, respectively. Among the 12 cases, 5 women died and 2 suffered severe neurologic disability, showing an intact survival rate of 41.7%. Disagreement with all 4 criteria proposed by the SMFM was found in 66.7% of the cases, due to the lack of criteria for disseminated intravascular coagulation or strict onset time (<30 minutes after delivery). There was no difference in maternal mortality and the amount of transfusion between cases satisfying all 4 criteria and cases with at least 1 missing criterion.

CONCLUSION

Two-thirds of clinically confirmed AFE cases did not satisfy all 4 criteria proposed by the SMFM, despite similar rates of maternal mortality with cases satisfying all 4 criteria. Our study suggests that there may be some discrepancy between the clinical diagnosis of AFE and the recent diagnostic criteria proposed by the SMFM for research purpose.

Amniotic fluid embolism: A rare cause of maternal collapse-A case report

High index of suspicion of amniotic fluid embolism should be considered in any intrapartum or postpartum collapse where the obvious cause of collapse is not identified.

Using a cervical ripening balloon to penetrate the placenta and quickly reduce bleeding by pressing against the placenta during pregnancy termination for patients with placenta previa in the second trimester: Two cases report

INTRODUCTION

The clinical treatment is complicated for patients with placenta previa who must terminate pregnancy due to fetal malformation, death, or inevitable abortion in the second trimester. It is difficult to manage excessive bleeding during pregnancy termination; and those patients face risks of removing the uterus, infection and other complications.

PATIENT CONCERNS

Two patients had placenta previa in the second trimester. Both cases had to terminate pregnancy. Case 1 patient had intrauterine fetal death. Case 2 patient had life-threatening vaginal bleeding. Both patients had bleeding and their cervix was not mature during vaginal delivery.

DIAGNOSIS

After hospitalization, placenta previa was confirmed by magnetic resonance imaging for case 1 patient. Placenta previa was confirmed by ultrasound examination for case 2 patient. Both patients had to terminate pregnancy.

INTERVENTIONS

We designed a new procedure using a cervical ripening balloon to reduce the risks during pregnancy termination for patients with placenta previa. A cervical ripening balloon was inserted through the placenta and placed between the fetus and placenta; external force was applied to keep the cervical ripening balloon pressing against the placenta that covers the cervical os. The cervical ripening balloon dilated the cervix, quickly reduced bleeding, and induced vaginal delivery during pregnancy termination for patients with placenta previa. This method was applied to 2 patients with placenta previa who must terminate pregnancy.

OUTCOMES

Using the new method, both patients had a successful pregnancy termination and vaginal delivery with minimal bleeding. Total time from the balloon placement to the end of the delivery was about 3 hours. The procedure only used a cervical ripening balloon without uterine artery embolization needed. The fetus was delivered through the vagina; and the uterus was fully retained. There was no postpartum infection.

CONCLUSION

This new method using a cervical ripening balloon could be a quick and effective way to reduce the risks during pregnancy termination for patients with placenta previa. It is especially helpful in emergency situations with minimal requirements of personnel and equipment. Our study showed great potential of this new utilization of a cervical ripening balloon, and is worthy of further research.

Amniotic fluid embolism and management of coagulopathy: A case report with successful outcome

Amniotic fluid embolism (AFE) is a rare and potentially catastrophic condition unique to pregnancy. Presentation may range from subtle clinical events to sudden and fatal maternal cardiorespiratory arrest, with a reported incidence of 2–6 in 100,000 deliveries and mortality of 15–60%. Management should include immediate high-grade resuscitation for AFE presenting as cardiac arrest, involvement of multidisciplinary team, provision of adequate ventilator and circulatory support, treatment of coagulopathy precipitated by AFE, and immediate delivery of the foetus in cases of cardiac arrest. The following case report involves a patient with suspected AFE post-induction of labour with favourable maternal and neonatal outcome in our local setting. The management of coagulopathy in AFE is further discussed, including use of massive transfusion protocols, pharmacological agents and recombinant factor VIIa.

Amniotic fluid embolism syndrome: analysis of the Unites States International Registry

BACKGROUND

Incidence, risk factors, and perinatal morbidity and mortality rates related to amniotic fluid embolism remain a challenge to evaluate, given the presence of differing international diagnostic criteria, the lack of a gold standard diagnostic test, and a significant overlap with other causes of obstetric morbidity and mortality.

OBJECTIVE

The aims of this study were (1) to analyze the clinical features and outcomes of women using the largest United States-based contemporary international amniotic fluid embolism registry, and (2) to investigate differences in demographic and obstetric variables, clinical presentation, and outcomes between women with typical versus atypical amniotic fluid embolism, using previously published and validated criteria for the research reporting of amniotic fluid embolism.

MATERIALS AND METHODS

The AFE Registry is an international database established at Baylor College of Medicine (Houston, TX) in partnership with the Amniotic Fluid Embolism Foundation (Vista, CA) and the Perinatology Research Branch of the Division of Intramural Research of the NICHD/NIH/DHHS (Detroit, MI). Charts submitted to the registry between August 2013 and September 2017 were reviewed, and cases were categorized into typical, atypical, non-amniotic fluid embolism, and indeterminate, using the previously published and validated criteria for the research reporting of AFE. Demographic and clinical variables, as well as outcomes for patients with typical and atypical AFE, were recorded and compared. Student t tests, χ2 tests, and analysis of variance tables were used to compare the groups, as appropriate, using SAS/STAT software, version 9.4.

RESULTS

A total of 129 charts were available for review. Of these, 46% (59/129) represented typical amniotic fluid embolism and 12% (15/129) atypical amniotic fluid embolism, 21% (27/129) were non-amniotic fluid embolism cases with a clear alternative diagnosis, and 22% (28/129) had an uncertain diagnosis. Of the 27 women misclassified as an amniotic fluid embolism with an alternative diagnosis, the most common actual diagnosis was hypovolemic shock secondary to postpartum hemorrhage. Ten percent (6/59) of the women with typical amniotic fluid embolism had a pregnancy complicated by placenta previa, and 8% (5/61) had undergone in vitro fertilization to achieve pregnancy. In all, 66% (49/74) of the women with amniotic fluid embolism reported a history of atopy or latex, medication, or food allergy, compared to 34% of the obstetric population delivered at our hospital over the study period (P < .05).

CONCLUSION

Our data represent a series of women with amniotic fluid embolism whose diagnosis has been validated by detailed chart review, using recently published and validated criteria for research reporting of amniotic fluid embolism. Although no definitive risk factors were identified, a high rate of placenta previa, reported allergy, and conceptions achieved through in vitro fertilization was observed.

Extracorporeal Therapies for Amniotic Fluid Embolism

BACKGROUND

Amniotic fluid embolism (AFE) is a catastrophic disease with significant mortality. Because the cardiopulmonary dysfunction associated with AFE is self-limited, the disease could be well suited to the use of extracorporeal therapies.

CASE

A woman progressed into cardiac arrest immediately after an elective cesarean delivery. Owing to severe hypoxemia and hypotension, AFE was suspected and peripheral venoarterial extracorporeal membrane oxygenation was quickly initiated. Subsequent evolution was complicated by intrabdominal bleeding, which required massive transfusion and multiple surgeries. The patient recovered well, with a healthy newborn. We have identified 19 similar cases in the literature and present their outcomes as a series.

CONCLUSION

Extracorporeal therapies can support severely ill women affected by AFE and could be considered even in the presence of disseminated intravascular coagulation and bleeding.

Amniotic fluid embolism: A puzzling and dangerous obstetric problem

In a Perspective, Sarka Lisonkova and Michael Kramer discuss the accompanying study by Kathryn Fitzpatrick and co-authors on management of amniotic fluid embolism.

Risk factors, management, and outcomes of amniotic fluid embolism: A multicountry, population-based cohort and nested case-control study

BACKGROUND

Amniotic fluid embolism (AFE) remains one of the principal reported causes of direct maternal mortality in high-income countries. However, obtaining robust information about the condition is challenging because of its rarity and its difficulty to diagnose. This study aimed to pool data from multiple countries in order to describe risk factors, management, and outcomes of AFE and to explore the impact on the findings of considering United Kingdom, international, and United States AFE case definitions.

METHODS AND FINDINGS

A population-based cohort and nested case-control study was conducted using the International Network of Obstetric Survey Systems (INOSS). Secondary data on women with AFE (n = 99-218, depending on case definition) collected prospectively in population-based studies conducted in Australia, France, the Netherlands, Slovakia, and the UK were pooled along with secondary data on a sample of control women (n = 4,938) collected in Australia and the UK. Risk factors for AFE were investigated by comparing the women with AFE in Australia and the UK with the control women identified in these countries using logistic regression. Factors associated with poor maternal outcomes (fatality and composite of fatality or permanent neurological injury) amongst women with AFE from each of the countries were investigated using logistic regression or Wilcoxon rank-sum test. The estimated incidence of AFE ranged from 0.8-1.8 per 100,000 maternities, and the proportion of women with AFE who died or had permanent neurological injury ranged from 30%-41%, depending on the case definition. However, applying different case definitions did not materially alter findings regarding risk factors for AFE and factors associated with poor maternal outcomes amongst women with AFE. Using the most liberal case definition (UK) and adjusting for the severity of presentation when appropriate, women who died were more likely than those who survived to present with cardiac arrest (89% versus 40%, adjusted odds ratio [aOR] 10.58, 95% confidence interval [CI] 3.93-28.48, p < 0.001) and less likely to have a source of concentrated fibrinogen (40% versus 56%, aOR 0.44, 95% CI 0.21-0.92, p = 0.029) or platelets given (24% versus 49%, aOR 0.23, 95% CI 0.10-0.52, p < 0.001). They also had a lower dose of tranexamic acid (median dose 0.7 g versus 2 g, p = 0.035) and were less likely to have had an obstetrician and/or anaesthetist present at the time of the AFE (61% versus 75%, aOR 0.38, 95% CI 0.16-0.90, p = 0.027). Limitations of the study include limited statistical power to examine factors associated with poor maternal outcome and the potential for residual confounding or confounding by indication.

CONCLUSIONS

The findings of our study suggest that when an AFE is suspected, initial supportive obstetric care is important, but having an obstetrician and/or anaesthetist present at the time of the AFE event and use of interventions to correct coagulopathy, including the administration of an adequate dose of tranexamic acid, may be important to improve maternal outcome. Future research should focus on early detection of the coagulation deficiencies seen in AFE alongside the role of tranexamic acid and other coagulopathy management strategies.

Resuscitation of the Pregnant Patient

Many health care providers lack familiarity with maternal physiologic changes and the distinctive underlying etiology of cardiac arrest in pregnancy. Knowledge of what changes are expected in pregnancy and an understanding of how to adapt clinical practice is essential for the care of the pregnant woman in the emergency department. Amniotic fluid embolism should be recognized as a rare cause of cardiac arrest in pregnancy, characterized by the triad of cardiovascular collapse, hypoxic respiratory failure, and coagulopathy. Cardiopulmonary resuscitation should follow standard AHA ACLS guidelines. Resuscitative hysterotomy may be attempted to restore perfusion to both mother and fetus.

Amniotic fluid embolism and spontaneous hepatic rupture during uncomplicated pregnancy: a case report and literature review

Amniotic fluid embolism (AFE) and spontaneous hepatic rupture both are extremely rare complications of pregnancy that can be fatal to mother and/or child. AFE is characterized by a sudden collapse of the cardiovascular system, a change in mental status, and disseminated intravascular coagulation (DIC), occurring immediately during labor, delivery, or postpartum, caused by the inflow of amniotic components into the maternal circulation. Spontaneous hepatic rupture during pregnancy which is most often occurs alongside hypertensive disorders, eclampsia, or HELLP syndrome. We report on the case of a 28-year-old woman (G3P2) who is suffering from AFE and spontaneous hepatic rupture, without history of hypertensive disorders, preeclampsia/eclampsia, or HELLP syndrome, and she died suddenly after delivering of a severe asphyxial neonate within 1 h with postpartum of hepatic rupture and massive hemorrhage. The lack of typical clinical signs and symptoms resulted to the difficulty of early diagnosis. If AFE and hepatic rupture is highly suspected in a pregnant patient, a collaborative multidisciplinary approach is mandatory. Pregnancy women is simultaneously complicated in amniotic fluid embolism and spontaneous hepatic rupture, similar cases are infrequent in the literature, which is reviewed in this report, explore the pathophysiological changes, we hope that can be helpful for the prevention, diagnosis and treatment of similar cases.

Beyond Pulmonary Embolism; Nonthrombotic Pulmonary Embolism as Diagnostic Challenges

Nonthrombotic pulmonary embolism (NTPE) is less well understood and is encountered less frequently than pulmonary embolism from venous thrombosis. NTPE results from embolization of nonthrombotic material to the pulmonary vasculature originating from many different cell types as well as nonbiologic or foreign materials. For many radiologists NTPE is a challenging diagnosis, presenting nonspecific or unusual imaging findings in the setting of few or unusual clinical signs. The aim of this paper is to review the pathophysiology of diverse causes of NTPE, which should aid radiologists to better understand and, more importantly, diagnose these infrequent events.

A Systematic Review of the Causes and Management of Nonthrombotic Embolic Stroke of Tissue Origin

Introduction

Various bodily tissues have been reported to enter the arterial circulation and embolize to the brain resulting in ischemic stroke. Most frequently nonthrombotic embolic stroke (NTES) of tissue origin is iatrogenic or related to an underlying disease process. With the increase in elective surgery and intravascular procedures, NTES may increase in prevalence.

Aim

To compile a summary of the background, incidence, presentation, and treatment of NTES of tissue origin, by conducting a systematic review of the current literature.

Summary of Review

We searched EMBASE and MEDLINE for articles on NTES of tissue origin published in English with no restriction on publication date (search date June 2017). 800 articles were identified and screened and 159 articles were ultimately reviewed in full text and included in qualitative analysis. Articles deemed relevant were assessed by a second reviewer to confirm compatibility with the inclusion criteria. References of included articles were reviewed for relevant publications. We categorized the pathology of the emboli into the following groups: amniotic fluid (4 publications), tumour (60 publications), fat (43 publications), cholesterol (19 publications), and intravascular debris (12 publications). We then summarized the available literature on each cause of NTES.

Conclusions

NTES of tissue origin is an uncommon but important diagnosis to consider particularly in younger stroke patients and in certain clinical settings. Treatment for NTES is currently anecdotal and based on small case series. Embolectomy may emerge as the therapy of choice due to the longer treatment timeframe and heterogeneity of the emboli.

[Nonthrombotic pulmonary embolisms]

The term nonthrombotic pulmonary embolism (NTPE) is defined as embolization of pulmonary arteries caused by foreign bodies (e. g. detached catheter fragments), biological substances (e. g. septic thrombus) or exogenous substances (e. g. gas). The frequency of NTPE is underestimated. Symptoms can cover the spectrum from undetectable to sudden death. In addition to mechanical obstruction of the pulmonary arteries, some NTPEs trigger an inflammatory cascade that causes deterioration of vascular, pulmonary and cardiac function. Radiological imaging in combination with the medical history of patients is sufficient to identify most NTPEs with certainty. The aim of this article is to make readers aware of the symptoms, frequency, relevance, classification, pathophysiology, laboratory findings and radiological findings of the most frequent forms of NTPE. The spectrum of forms presented here includes pulmonary embolisms due to foreign bodies (intravascular, intracorporeal and extracorporeal), amniotic fluid, endogenous tissue, fat, tumors, septic thrombi, hydatids, cement, metallic mercury, gas, silicone and particles.

Atypical Amniotic Fluid Embolism Managed with a Novel Therapeutic Regimen

Amniotic fluid embolism (AFE) is the second leading cause of maternal mortality in the USA with an incidence of 1 : 15,200 births. The case fatality rate and perinatal mortality associated with AFE are 13–30% and 9–44%, respectively. This rare but devastating complication can be difficult to diagnose as many of the early signs and symptoms are nonspecific. Compounding this diagnostic challenge is a lack of effective treatment regimens which to date are mostly supportive. We present the case of a 26-year-old woman who suffered from suspected AFE and was successfully treated with the novel regimen of Atropine, Ondansetron, and Ketorolac (A-OK). The authors acknowledge that this case does not meet the new criteria proposed, by Clark in 2016, but feel that it is important to share this case report, due to dramatic patient response to the provided supportive therapy presented in this case report. We hope this case report will prompt further research into this novel approach to treating AFE with Atropine, Ondansetron, and Ketorolac.

Anesthetic management of amniotic fluid embolism -- a multi-center, retrospective, cohort study

INTRODUCTION

Amniotic fluid embolism (AFE) is a rare and potentially lethal obstetric complication, commonly occurring during labor, delivery, or immediately postpartum. There is a paucity of data regarding incidence, risk factors, and clinical management. Our primary objective in this study was to evaluate clinical presentation of AFE and delineate anesthesia management of these cases.

METHODS

This 10 years retrospective multi-center cohort study was performed in five tertiary university-affiliated medical centers, between the years 2005 and 2015. All documented cases of AFE identified according to the ICD guidelines were reviewed manually to determine eligibility for AFE according to Clark's criteria. All cases confirming Clark's diagnosis were included in the cohort.

RESULTS

Throughout the study period, 20 cases of AFE were identified, with an incidence of 4.1 per 100,000 births. Average age at presentation was 35 ± 5 years. Seventy percent of cases presented during vaginal delivery, 20% occurred throughout a cesarean delivery, and 10% occurred during a dilation and evacuation procedure. The most common presenting symptom was sudden loss of consciousness in 12 parturients (66.7%), fetal bradycardia in 11 parturients (55%), and shortness of breath in 10 parturients (50%). Perimortem cesarean section was performed in 55% of cases, although only one case was performed in the delivery suite, while all others were performed in the operating room. Echocardiography was performed in 60% of the cases and all were pathological. Furthermore, 20% of cases were connected to an extracorporeal membrane oxygenation machine. There was a 15% mortality rate of 15%. A further 15% suffered major neurological disability, 25% suffered minor neurological morbidity, and 45% survived without severe complications.

CONCLUSION

AFE is associated with significant maternal morbidity. This study highlights the importance of providing advanced training for the delivery suite staff for cases of maternal cardiovascular collapse secondary to AFE and increasing awareness for this rare and devastating obstetric condition.

Amniotic fluid embolism mortality rate

AIM

The objective of this study was to determine the mortality rate of amniotic fluid embolism (AFE) using population-based studies and case series.

METHODS

A literature search was conducted using the two key words: 'amniotic fluid embolism (AFE)' AND 'mortality rate'. Thirteen population-based studies were evaluated, as well as 36 case series including at least two patients.

RESULTS

The mortality rate from population-based studies varied from 11% to 44%. When nine population-based studies with over 17 000 000 live births were aggregated, the maternal mortality rate was 20.4%. In contrast, the mortality rate of AFE in case series varies from 0% to 100% with numerous rates in between.

CONCLUSION

The AFE mortality rate in population-based studies varied from 11% to 44% with the best available evidence supporting an overall mortality rate of 20.4%. Data from case series should no longer be used as a basis for describing the lethality of AFE.

Necessity of preoperative activated partial thromboplastin time test as a predictor for surgical hemorrhage in obstetric and gynecological patients in China

BACKGROUND

On an international scale, the necessity of preoperative coagulation screen remains controversial, yet in China, coagulation screen is still a routine test before surgery required by the Ministry of Health of China.

METHODS

A retrospective review of 26,807 patients >18y presenting with problems related to the areas of gynecology and obstetrics from March 2013 to July 2015 was performed, and the rate of major bleeding and the amount of blood lost during surgery were compared among groups of patients grouped according to the values of preoperative APTT, the departments the patients belonged to, or the measures for intervention.

RESULTS

Groups with increased APTT had higher rates of major bleeding (9.80% & 26.14% vs 2.77%, P<0.001) and more blood loss (862.9 and 1455.6ml vs 194.0ml, P<0.001). And the same conclusion could be induced in both the obstetric and gynecological patients when they were taken into account separately. For obstetric patients, once those with high bleeding risks, e.g., placental abruption, placental implantation, or preoperative massive hemorrhage were excluded, groups with increased APTT would no longer demonstrated the higher rate of major bleeding (0.91% & 2.38% vs 0%, P=0.409 & 0.833) and would even have a lower amount of blood loss (202.76 and 228.09ml vs 322.13ml, P=0.003 and 0.027). In increased APTT patients without bleeding or bleeding tendency, FFP intervention would not make a difference in the rate of major bleeding (7.69% vs 8.37%, P=0.203) and the amount of blood loss (271.35ml vs 306.63, P=0.865).

CONCLUSION

For Chinese patients from the Obstetrics and Gynecology Departments, APTT is a good screen test to predict surgical hemorrhage.

Maternal, Labor, Delivery, and Perinatal Outcomes Associated with Placental Abruption: A Systematic Review

Objective Risk factors for placental abruption have changed, but there has not been an updated systematic review investigating outcomes. Methods We searched PubMed, EMBASE, Web of Science, SCOPUS, and CINAHL for publications from January 1, 2005 through December 31, 2016. We reviewed English-language publications reporting estimated incidence and/or risk factors for maternal, labor, delivery, and perinatal outcomes associated with abruption. We excluded case studies, conference abstracts, and studies that lacked a referent/comparison group or did not clearly characterize placental abruption. Results A total of 123 studies were included. Abruption was associated with elevated risk of cesarean delivery, postpartum hemorrhage and transfusion, preterm birth, intrauterine growth restriction or low birth weight, perinatal mortality, and cerebral palsy. Additional maternal outcomes included relaparotomy, hysterectomy, sepsis, amniotic fluid embolism, venous thromboembolism, acute kidney injury, and maternal intensive care unit admission. Additional perinatal outcomes included acidosis, encephalopathy, severe respiratory disorders, necrotizing enterocolitis, acute kidney injury, need for resuscitation, chronic lung disease, infant death, and epilepsy. Conclusion Few studies examined outcomes beyond the initial birth period, but there is evidence that both mother and child are at risk of additional adverse outcomes. There was also considerable variation in, or absence of, the reporting of abruption definitions.

Amniotic Fluid Embolism. Is a New Pregnancy Possible? Case Report

Amniotic fluid embolism (AFE) is a rare but potentially catastrophic clinical condition, characterized by a combination of signs and symptoms that reflect respiratory distress, cardiovascular collapse and disseminated intravascular coagulation (DIC). Its pathogenesis is still unclear. More recently, the traditional view of obstruction of pulmonary capillary vessels by amniotic fluid emboli as the main explanation for the etiology has been ruled out, and immunologic factors and the activation of the inflammatory cascade took on an important role. Amniotic fluid embolism has an unpredictable character, its diagnosis is exclusively clinical, and the treatment consists mainly of cardiovascular support and administration of blood products to correct the DIC. No diagnostic test is recommended until now, though multiple blood markers are currently being studied. The authors present a case report of a woman who had survived AFE in her previous pregnancy and had a subsequent pregnancy without recurrence, providing one more clinical testimony of the low risks for the pregnancy after AFE.

Amniotic fluid embolism: diagnosis and management

OBJECTIVE

We sought to provide evidence-based guidelines regarding the diagnosis and management of amniotic fluid embolism.

STUDY DESIGN

A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and the Cochrane Library. The search was restricted to English-language articles published from 1966 through March 2015. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion. Evidence reports and published guidelines were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used for defining the strength of recommendations and rating quality of the evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence.

RESULTS AND RECOMMENDATIONS

We recommend the following: (1) we recommend consideration of amniotic fluid embolism in the differential diagnosis of sudden cardiorespiratory collapse in the laboring or recently delivered woman (GRADE 1C); (2) we do not recommend the use of any specific diagnostic laboratory test to either confirm or refute the diagnosis of amniotic fluid embolism; at the present time, amniotic fluid embolism remains a clinical diagnosis (GRADE 1C); (3) we recommend the provision of immediate high-quality cardiopulmonary resuscitation with standard basic cardiac life support and advanced cardiac life support protocols in patients who develop cardiac arrest associated with amniotic fluid embolism (GRADE 1C); (4) we recommend that a multidisciplinary team including anesthesia, respiratory therapy, critical care, and maternal-fetal medicine should be involved in the ongoing care of women with AFE (Best Practice); (5) following cardiac arrest with amniotic fluid embolism, we recommend immediate delivery in the presence of a fetus ≥23 weeks of gestation (GRADE 2C); (6) we recommend the provision of adequate oxygenation and ventilation and, when indicated by hemodynamic status, the use of vasopressors and inotropic agents in the initial management of amniotic fluid embolism. Excessive fluid administration should be avoided (GRADE 1C); and (7) because coagulopathy may follow cardiovascular collapse with amniotic fluid embolism, we recommend the early assessment of clotting status and early aggressive management of clinical bleeding with standard massive transfusion protocols (GRADE 1C).

Severe placental abruption: clinical definition and associations with maternal complications

BACKGROUND

Placental abruption traditionally is defined as the premature separation of the implanted placenta before the delivery of the fetus. The existing clinical criteria of severity rely exclusively on fetal (fetal distress or fetal death) and maternal complications without consideration of neonatal or preterm delivery-related complications. However, two-thirds of abruption cases are accompanied by fetal or neonatal complications, including preterm delivery. A clinically meaningful classification for abruption therefore should include not only maternal complications but also adverse fetal and neonatal outcomes that include intrauterine growth restriction and preterm delivery.

OBJECTIVES

The purpose of this study was to define severe placental abruption and to compare serious maternal morbidity profiles of such cases with all other cases of abruption (ie, mild abruption) and nonabruption cases.

STUDY DESIGN

We performed a retrospective cohort analysis using the Premier database of hospitalizations that resulted in singleton births in the United States between 2006 and 2012 (n = 27,796,465). Severe abruption was defined as abruption accompanied by at least 1 of the following events: maternal (disseminated intravascular coagulation, hypovolemic shock, blood transfusion, hysterectomy, renal failure, or in-hospital death), fetal (nonreassuring fetal status, intrauterine growth restriction, or fetal death), or neonatal (neonatal death, preterm delivery or small for gestational age) complications. Abruption cases that did not qualify as being severe were classified as mild abruption cases. The morbidity profile included amniotic fluid embolism, pulmonary edema, acute respiratory or heart failure, acute myocardial infarction, cardiomyopathy, puerperal cerebrovascular disorders, or coma. Associations were expressed as rate ratios with 95% confidence intervals that were derived from fitting log-linear Poisson regression models.

RESULTS

The overall prevalence rate of abruption was 9.6 per 1000, of which two-thirds of cases were classified as being severe (6.5 per 1000). Serious maternal complications occurred in 15.4, 33.3, and 141.7 per 10,000 among nonabruption cases and mild and severe abruption cases, respectively. In comparison with no abruption, the rate ratio for serious maternal complications were 1.52 (95% confidence interval, 1.35-1.72) and 4.29 (95% confidence interval, 4.11-4.47) in women with mild and severe placental abruption, respectively. Rate ratios for the individual complications were 2- to 7-fold higher among severe abruption cases. Furthermore, the rate ratios for serious maternal complications among severe abruption cases compared with mild abruption cases was 3.47 (95% confidence interval, 3.05-3.95). This association was considerably stronger for virtually all maternal complications among cases with severe abruption compared with mild abruption. Annual rates of mild and severe abruption were fairly constant during the study period. Although the maternal complication rate among non-abruption births was stable from 2006-2012, the rate of complications among mild abruption cases dropped from 2006-2008 and then leveled off thereafter. In contrast, the rate of serious complications among severe abruption cases remained fairly stable from 2006-2010 and increased sharply thereafter.

CONCLUSIONS

Severe abruption was associated with a distinctively higher morbidity risk profile compared with the other 2 groups. The clinical characteristics and morbidity profile of mild abruption were more similar to those of women without an abruption. These findings suggest that the definition of severe placental abruption based on the proposed specific criteria is clinically relevant and may facilitate epidemiologic and genetic research.