Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies

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.

Amniotic fluid embolism: A case-series

Amniotic fluid embolism (AFE) is a rare but potentially catastrophic pregnancy complication. This is a 10-year retrospective study on women with AFE from 2014 to 2023. Cases that met Clark's criteria or in whom a clinical diagnosis was made after exclusion of other causes were included. Information on clinical characteristics, treatment, complications and outcomes were collected and analysed. Four cases of AFE were identified. Two met Clark's criteria and presented with cardiac arrest requiring extracorporeal membrane oxygenation, of which one had cognitive and functional impairment. Two women had atypical AFE, one with disseminated intravascular coagulation (DIC)-type AFE who did not survive, and another who had paradoxical intracranial emboli from a patent foramen ovale, who had full recovery. All had coagulopathy and postpartum haemorrhage. Early recognition and initiation of cardiovascular support is crucial in AFE. DIC and haemorrhage should be treated aggressively. Survival and good outcomes of AFE are possible.

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.

Analysis of Modified ISTH DIC Score in Cases of Abruptio Placentae and Its Correlation with Severity of Abruptio Placentae

Background

Disseminated intravascular coagulation (DIC) is a potentially fatal condition which is always secondary to an underlying disorder with abruption being the most common cause in obstetrics.Our study analysed the modified International Society of Thrombosis and Haemostasis DIC score for prediction of DIC in cases of abruptio placentae. Additionally, we correlated the score with severity of abruption to optimize its use in limited resource settings.

Methods

This was a prospective observational study of 126 participants admitted in Netaji Subhash Chandra Bose Medical College and Hospital, with the diagnosis of Abruptio Placentae and period of gestation more than 28 weeks. Modified ISTH DIC score calculated. A value > 26 suggested high probability of DIC. Resultant score of each participant was correlated with degree of abruption adapted from Page classification of severity of placental abruption.

Results

In present study, 47 participants (37.3%) with abruptio placentae had high probability of DIC and all of them needed blood/blood product transfusion. Out of these 47 participants, 38 participants (80.85%) had Grade 3 abruption;while 9 participants(19.15%) had Grade 2 abruption. Association between grade of abruption and modified ISTH DIC score was found to be statistically significant (p value 0.001).

Conclusion

Anticipation and early prediction of disseminated intravascular coagulation is crucial for timely management of participants at risk. Present prospective study concludes that Modified ISTH DIC Score should be used for early prediction of DIC in cases of abruptio placentae; especially in cases with Grade 2 and Grade 3 abruption; to reduce overall maternal morbidity and mortality.

Mortality Following Childbirth in Ontario: A 20-Year Analysis of Temporal Trends and Causes

OBJECTIVES

Maternal death during or after pregnancy is often preventable and accurate surveillance is key to prevention. We examined the number and causes of maternal death in Ontario over 20 years.

METHODS

Retrospective cohort study including all hospital livebirths and stillbirths from 2002-2022 in the Canadian Institute for Health Information Discharge Abstracts (for hospitalizations) and National Ambulatory Care System (for emergency department encounters) linked to the Better Outcomes and Registry and Network births. Death was ascertained from childbirth to 365 days thereafter; all deaths were reviewed by at least 3 clinicians.

RESULTS

There were 485 deaths among 2 764 214 live and stillbirths over 20 years-a maternal mortality ratio (MMR) of 17.5 per 100 000 (95% CI 16.0-19.2). There were 222 (45.8%) early deaths within 42 days of birth (MMR of 8.0 per 100 000; 95% CI 7.0-9.2), and 263 (54.2%) late deaths from 43 to 365 days after birth (MMR 9.5 per 100 000; 95% CI 8.4-10.7). Death was pregnancy-related in 169/485 cases (34.8%). Early death causes were predominantly hemorrhage, infection, preeclampsia, and pulmonary embolism. The top causes of 263 late deaths were cancer, injury, and cardiac arrest, or unknown.

CONCLUSIONS

Most deaths within 1 year of childbirth are not related to obstetrical factors; however, pregnancy complications factor in early deaths. Causes of early and late deaths differ, but examining late deaths is equally important to identify factors not regularly examined in maternal mortality. As death in early pregnancy or outside hospitals is not reported, mortality is likely higher.

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.

Postpartum acute myometritis suppresses expression of contraction-associated proteins in the gravid uterus

Uterine atony is a major contributor to postpartum hemorrhage. We previously proposed the novel histological concept of postpartum acute myometritis (PAM) to elucidate the pathophysiology of uterine atony. This concept involves the infiltration of macrophages and neutrophils, as well as mast cell and complement activation in the myometrium. However, the pathological mechanism underlying uterine atony in the context of PAM remains unclear. Herein, we focused on uterine contraction-associated proteins (CAPs) including connexin 43 (Cx43), oxytocin receptors (OXR), prostaglandin receptors EP1, EP3, FP, and protease-activated receptor (PAR)-1. This follow-up study aimed to compare CAP expression between PAM and control groups. We selected 38 PAM subjects from the cases enrolled in our amniotic fluid embolism registry between 2011 and 2018. Control tissues from 10 parturients were collected during cesarean section. We stained the myometrial tissues with the following CAP markers, inflammatory cell markers, and other markers: Cx43, OXR, EP1, EP3, FP, PAR-1, C5a receptor, tryptase, neutrophil elastase, CD68, β-actin, and Na+/K+-ATPase. The immunostaining-positive areas of Cx43, OXR, EP1, EP3, and FP standardized by β-actin in the PAM tissue were significantly smaller than in the control group, whereas those of PAR-1 and Na+/K+-ATPase increased significantly in the PAM group. The Cx43- and OXR-positive areas correlated negatively with the immunostaining-positive cell numbers of CD68 and tryptase with halo, respectively. PAM may impair individual and synchronized myocyte contraction, leading to uterine atony refractory to uterotonics. Further cell-based studies are needed to elucidate the molecular mechanism by which inflammatory cells suppress CAP expression.

Resuscitative endovascular balloon occlusion of the aorta: A novel approach for treating amniotic fluid embolism with disseminated intravascular coagulopathy-A report of two cases

We present two critical cases of life-threatening postpartum hemorrhage (PPH) due to amniotic fluid embolism (AFE) complicated by disseminated intravascular coagulopathy (DIC). These cases are the first to show the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for patient survival. In Case 1, the patient, experiencing critical conditions with severe PPH and DIC despite conventional treatments, including rapid blood transfusion and fibrinogen concentrate, was air-transferred to our hospital, where REBOA was promptly employed before hysterectomy was completed. Case 2 involved an ambulance-transferred patient with massive PPH and DIC despite conventional treatments. Prehospital REBOA was performed to prevent cardiac arrest during transfer, and hysterectomy was performed in the hospital. Given the rapid deterioration associated with AFE, REBOA can serve as a bridge until complete hemostasis to maintain vital signs and control bleeding in patients unresponsive to standard therapies before hemostatic interventions or during transfer.

Breaking Barriers in the Management of Amniotic Fluid Embolism With Interventional Radiology: A Case Report

Amniotic fluid embolism (AFE) is a rare obstetric emergency with a high mortality rate despite treatment. The pathogenesis likely involves inflammatory cytokines reacting to amniotic fluid in the bloodstream, causing rapid multi-organ failure and coagulopathy. Prompt recognition and supportive, multidisciplinary treatment are vital for enhancing patient outcomes. This report presents the case of a 27-year-old female with acute decompensation due to AFE. Our patient was scheduled for cesarean delivery due to high-risk placental anomalies and began demonstrating signs of AFE and severe hemorrhage shortly after delivery. She was transferred to our tertiary care center and was treated with coil embolization of the hemorrhaging uterine, iliac, and epigastric arteries, ultimately stabilizing her and saving her life. This case highlights the successful management of AFE with interventional radiological (IR) techniques.

Probable acute fatty liver of pregnancy presenting with dyspnoea and ground-glass opacities

We present the case of a postpartum woman presenting with acute dyspnoea and hypoxia. She was found to have liver enzyme derangement with evidence of synthetic dysfunction. Computed tomography of her chest showed ground-glass opacities. The causes of this phenomenon are discussed, including the difficulties in differentiating amniotic fluid embolism and acute fatty liver in pregnancy. Pulmonary fat embolism is also considered as a differential diagnosis.

A Case of Consumptive Coagulopathy Before Cardiopulmonary Failure in Amniotic Fluid Embolism and Review of Literature: A Perspective of the Latent Onset and Progression of Coagulopathy

Amniotic fluid embolism (AFE) induces cardiopulmonary insufficiency with consumptive coagulopathy. Previous studies reported that refractory coagulopathy has already advanced at the onset of maternal cardiovascular and/or respiratory symptoms. However, when the consumption of coagulation factors starts during the clinical course, AFE remains to be elucidated. We report an intrapartum AFE case of consumptive coagulopathy before dyspnea with hypotension developing during urgent cesarean delivery that was revealed by non-reassuring fetal heart rate tracing. The patient, a 42-year-old multiparous parturient, underwent induced labor after a premature rupture of membranes in week 39 of pregnancy. Coagulation screening was initially within the normal range. Fetal heart rate monitoring demonstrated bradycardia coincided with uterine tachysystole after three hours, which required urgent cesarean section with preoperative blood screening. The hemoglobin level was maintained at 129 g/L; however, the fibrinogen value reduced to 1.79 g/L with D-dimer elevation over 60 µg/mL. Ninety minutes later, she developed dyspnea with hypotension at suturing hysterotomy. At the end of surgery, her fibrinogen further decreased to below 0.3 g/L with prolonged prothrombin time. After vigorous intensive care, she was discharged without sequelae. Consumptive coagulopathy may initiate and progress before apparent cardiopulmonary symptoms in some AFE cases. Non-reassuring fetal heart rate tracing concomitant with abrupt uterine tachysystole and/or hypertonus may be an earlier time point for the detection and intervention of AFE-related coagulopathy.

Amniotic Fluid Embolism Coagulopathy Guided by the Point-of-Care Quantra QStat® Hemostasis System: A Case Report

Amniotic fluid embolism (AFE) is a rare pregnancy complication associated with high maternal mortality that occurs during labor or in the early postpartum period. The diagnosis of AFE is challenging because signs and symptoms are common to other obstetric complications. Early identification and management of profound coagulopathy associated with AFE is essential to improve patient survival. We present a case of a 31-year-old woman with placenta previa and clinical suspicion of AFE after cesarean section. Immediately after delivery, the parturient presented hypotension, hypoxia, coagulopathy, and severe postpartum hemorrhage. We hereby discuss the role of the most recently developed point-of-care viscoelastic testing device, the Quantra QStat® system (Stago Group Company; HemoSonics LLC, Durham, NC), for early detection of acute obstetric coagulopathy and guided hemostatic treatment.

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.

Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review

BACKGROUND

Cardiopulmonary collapse is a catastrophic event in cesarean section, which leads to adverse outcomes for both the mother and the fetus. Pulmonary embolism is one of the rare etiologies of this entity. We herein reported the successful management of acute embolism pulmonary associated with cesarean delivery on a healthy pregnant woman at our tertiary referral hospital.

CASE PRESENTATION

A full-term pregnant woman hospitalized for planned cesarean delivery due to placenta previa without cardiorespiratory diseases. She was scheduled uneventfully for a planned cesarean section. After placental delivery, the patient spontaneously fell into cardiopulmonary collapse and her vital signs deteriorated rapidly. The obstetricians promptly completed the cesarean section and performed all procedures to prevent the PPH and preserve the uterus. At the same time, the anesthesiologists continued to carry out advanced heart-lung resuscitation in order to control her vital signs. After surgery, the multidisciplinary team assessed the patient and found a thrombus in her pulmonary circulation. Therefore, the patient was managed with therapeutic anticoagulation. The patient recovered in good clinical condition and was discharged after 2 weeks without any complications.

CONCLUSIONS

The diagnosis of acute pulmonary embolism is extremely difficult due to uncommon occurrence, sudden onset, and non-specific presentation. Awareness of this life-threatening pathology during cesarean delivery should be raised. Interdisciplinary assessment must be essentially established in this life-threatening condition. After the whole conventional management, uterine conservation may be acceptable where applicable. Further data is required to encourage this finding.

Comparative analysis of hyperfibrinolysis with activated coagulation between amniotic fluid embolism and severe placental abruption

Amniotic fluid embolism (AFE) and placental abruption (PA) are typical obstetric diseases associated with disseminated intravascular coagulation (DIC). AFE is more likely to be complicated with enhanced fibrinolysis than PA. AFE may have an additional mechanism activating fibrinolytic cascade. We aimed to compare the coagulation/fibrinolysis factors among AFE, PA, and peripartum controls. We assessed AFE cases registered in the Japanese AFE Registry, and PA cases complicated with DIC (severe PA) and peripartum controls recruited at our hospital. The following factors in plasma were compared: prothrombin fragment 1 + 2 (PF1 + 2), plasmin α2-plasmin inhibitor complex (PIC), tissue factor (TF), tissue plasminogen activator (tPA), annexin A2 (AnnA2), total thrombin activatable fibrinolysis inhibitor (TAFI) including its activated form (TAFIa), and plasminogen activator inhibitor-type 1 (PAI-1). PF1 + 2 and PIC were markedly increased in both AFE (n = 27) and severe PA (n = 12) compared to controls (n = 23), without significant difference between those disease groups; however, PIC in AFE showed a tendency to elevate relative to PF1 + 2, compared with severe PA. AFE had significantly increased tPA and decreased total TAFI levels compared with severe PA and controls, which might be associated with further plasmin production in AFE and underlie its specific fibrinolytic activation pathway.

Early Prediction of Hypertensive Diseases of Pregnancy by Using Combined Screening Methods in a Rural Population

INTRODUCTION

The most frequent medical issue during pregnancy is hypertension, which can complicate up to 10% to 15% of pregnancies worldwide. An estimated 14% of all maternal fatalities worldwide are thought to be caused by hypertensive disease of pregnancy, one of the main causes of maternal and fetal morbidity and mortality. Despite the fact that maternal mortality is substantially lower in high-income countries than in low- and middle-income countries, hypertension is still one of the leading causes of maternal death globally. Maternal mortality associated with hypertension fluctuated between 0.08 and 0.42 per 100,000 births between 2009 and 2015. In India, the estimated overall pooled prevalence of HDP was determined to be one out of 11 women, or 11% (95% CI, 5%-17%). Despite various government programs, there is still a high prevalence of hypertension, which calls for stakeholders and healthcare professionals to focus on providing both therapeutic and preventive care. The best solution is to concentrate more on the early detection of pregnancy-related hypertension and to guarantee its universal application so that proper care can be carried out to prevent maternal and fetal morbidity.

AIM

To estimate the predictive value of the combination of maternal characteristics, i.e., mean arterial pressure (MAP), biophysical evaluation (uterine artery Doppler), and biochemical markers (pregnancy-associated plasma protein A (PAPP-A)), in the first trimester of pregnancy for hypertensive diseases of pregnancy.

METHODOLOGY

It was a prospective observational study of longitudinal variety that took over 18 months in a tertiary care rural hospital. The number of women admitted to the hospital for labor care during 2019 was 5261. A total of 513 were diagnosed with hypertensive illnesses during pregnancy. At a prevalence rate of 10%, we calculated a sample size of 350 to achieve a sensitivity of 85% with an absolute error of 12.5% at a 95% CI. Maternal histories, such as age, education, socio-economic status, gravidity, and BMI, were taken along with three parameters, i.e., MAP, which was significant above 90 mmHg, uterine artery Doppler, which was taken significant above 1.69, and serum PAPP-A, which was significant at less than 0.69 ml/IU.

OBSERVATION AND RESULTS

We have found that the following are associated with the prediction of hypertension: among the maternal characteristics are advanced age >35 years, presence of body edema, and urine proteins along with MAP, uterine artery pulsatility index (UtA-PI), and PAPP-A are significant. The predictive accuracy of the combination of MAP, UtA-PI, and PAPP-A is also significant. We also found that there is a significant increase in cesarean sections and NICU admissions in hypertensive patients.

CONCLUSION

A combination of screening parameters, including MAP, UtA-PI, and PAPP-A, to predict early hypertensive disease of pregnancy is developed and tested.

Massive platelet-rich thrombus formation in small pulmonary vessels in amniotic fluid embolism: An autopsy study

OBJECTIVE

To identify pulmonary/uterine thrombus formation in amniotic fluid embolism (AFE).

DESIGN

Retrospective, observational.

SETTING

Nationwide.

POPULATION

Eleven autopsy cases of AFE and control cases.

METHODS

We assessed pulmonary and uterine thrombus formation and thrombus area in AFE and pulmonary thromboembolism (PTE) as a control. The area of platelet glycoprotein IIb/IIIa, fibrin, neutrophil elastase, citrullinated histone H3 (a neutrophil extracellular trap marker) and mast cell chymase immunopositivity was measured in 90 pulmonary emboli, 15 uterine thrombi and 14 PTE.

MAIN OUTCOME MEASURES

Pathological evidence of thrombus formation and its components in AFE.

RESULTS

Amniotic fluid embolism lung showed massive thrombus formation, with or without amniotic emboli in small pulmonary arteries and capillaries. The median pulmonary thrombus size in AFE (median, 0.012 mm2 ; P < 0.0001) was significantly smaller than that of uterine thrombus in AFE (0.61 mm2 ) or PTE (29 mm2 ). The median area of glycoprotein IIb/IIIa immunopositivity in pulmonary thrombi in AFE (39%; P < 0.01) was significantly larger than that of uterine thrombi in AFE (23%) and PTE (15%). The median area of fibrin (0%; P < 0.001) and citrullinated histone H3 (0%; P < 0.01) immunopositivity in pulmonary thrombi in AFE was significantly smaller than in uterine thrombi (fibrin: 26%; citrullinated histone H3: 1.1%) and PTE (fibrin: 42%; citrullinated histone H3: 0.4%). No mast cells were identified in pulmonary thrombi.

CONCLUSIONS

Amniotic fluid may induce distinct thrombus formation in the uterus and lung. Pulmonary and uterine thrombi formation may contribute to cardiorespiratory collapse and/or consumptive coagulopathy in AFE.

The Anaphylactoid Syndrome of Pregnancy: Two Autopsy Cases

The anaphylactoid syndrome of pregnancy (ASP) is a rare emergency with significant mortality and morbidity, in which the amniotic fluid and fetal cells enter the maternal circulation leading to respiratory failure, altered mental status, hypotension, and disseminated intravascular coagulation. The term ASP was recently introduced to replace the term amniotic fluid embolism since the clinical manifestations of the entity were more similar to a septic or anaphylactic shock rather than that of an embolic event. Two autopsy cases are described, regarding a 35-year-old gravida 2 para 1 and a 34-year-old gravida 1 para 0, where the cause of death was determined to be ASP.

Amniotic fluid embolism causing multiorgan embolisms and reinforces the need for point-of-care ultrasound

INTRODUCTION

Pregnant patients are at risk of several possible complications during the peripartum period. Amniotic fluid embolism (AFE) is a peripartum complication with high mortality and morbidity. The sudden entry of amniotic fluid into the maternal circulation causes a rapid and dramatic sequence of clinical events called AFE. The reported incidence of AFE after a cesarean section is around 19%, and after a normal delivery, it is 11%. AFE causing multiple embolisms is not reported in the literature, nor is the use of point-of-care ultrasound (POCUS) in the diagnosis of AFE. We report a case of AFE causing pulmonary and ovarian embolisms.

CASE

A 34-year-old pregnant lady had an elective lower section cesarean section (LSCS) for transverse lying and placenta previa under combined spinal and epidural anesthesia. She was gravida 3 para 2 and had regular antenatal check-ups, and she presented for her LSCS at 36 weeks of gestation. Immediately after delivery of the fetus, the patient had convulsions, cardiac arrest, and disseminated intravascular coagulopathy (DIC). Immediately, cardiopulmonary resuscitation started, and the team achieved a return of spontaneous circulation (ROSC) in 3 minutes. DIC was corrected with blood and blood products during this maneuver, and POCUS of the inferior vena cava and heart showed multiple small particles floating, thus confirming the diagnosis of AFE in this patient. The patient was transferred to the intensive care unit (ICU), intubated, and ventilated, necessitating a vasopressor infusion. Computed tomographic pulmonary angiography (CTPA) showed pulmonary embolism and ovarian vein embolism, which were managed with heparin infusion. She was hemodynamically stable and weaned from vasopressors, and the ventilator was then extubated on day 13 of ICU admission. She remained awake and in stable condition. The patient was transferred to the ward and subsequently discharged to go home on the 20^th-day post-delivery.

CONCLUSION

AFE can be quickly diagnosed using clinical manifestations and POCUS, and it can be managed early for better patient outcomes. POCUS will show multiple smaller and a few larger amniotic fluid emboli in the heart and vena cava. These larger AFE emboli can migrate and cause multiple embolisms, requiring systemic anticoagulation.

Neurological Complications in Pregnancy and the Puerperium: Methodology for a Clinical Diagnosis

Neurological complications in pregnancy and the puerperium deserve particular attention from specialists due to the worsening of the clinical picture for both the mother and the fetus. This narrative review of existing data in the literature aims to analyze the most common "red flag symptoms" attributable to neurological complications such as pre-eclampsia (PE), eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), cerebral vasoconstriction syndrome (RCVS), stroke, CVS thrombosis, pituitary apoplexy, amniotic fluid embolism and cerebral aneurysm rupture, with the aim of providing a rapid diagnostic algorithm useful for the early diagnosis and treatment of these complications. The data were derived through the use of PubMed. The results and conclusions of our review are that neurological complications of a vascular nature in pregnancy and the puerperium are conditions that are often difficult to diagnose and manage clinically. For the obstetrics specialist who is faced with these situations, it is always important to have a guide in mind in order to be able to unravel the difficulties of clinical reasoning and promptly arrive at a diagnostic hypothesis.

Amniotic Fluid Embolism: a comparison of two classification systems in a retrospective 8-year analysis from two tertiary hospitals

OBJECTIVE

Amniotic fluid embolism (AFE) is a rare life-threatening complication in obstetrics, but the diagnosis lacks a consensual definition. The objective of this study was to compare two different AFE classification systems by analysing the AFE cases from two university hospitals.

MATERIAL AND METHODS

In this retrospective study, all patients with a strong suspicion of AFE between 2014 and 2021 at two university hospitals, LMU Women's University Hospital Munich, and Women's University Hospital Basel, were included. Patient records were checked for the ICD-10 code O88.1 (AFE). Diagnoses were confirmed through clinical findings and/or autopsy. The presence of the diagnostic criteria of the Society of Maternal Fetal Medicine (SMFM) and the AFE Foundation (AFEF) and of a new framework by Ponzio-Klijanienko et al. from Paris, France, were checked and compared using Chi-square-test.

RESULTS

Within our study period, 38,934 women delivered in the two hospitals. Six patients had a strong suspicion of AFE (0.015%). Only three of six patients (50%) presented with all the four diagnostic criteria of the SMFM/AFEF framework. All six patients met the criteria of the modified "Paris AFE framework".

CONCLUSION

Using the "Paris AFE framework" based exclusively on clinical criteria can help clinicians to diagnose AFE, anticipate the life-threatening condition of the patient and prepare immediately for best clinical care.

Acute obstetric coagulopathy during postpartum hemorrhage is caused by hyperfibrinolysis and dysfibrinogenemia: an observational cohort study

BACKGROUND

Postpartum hemorrhage (PPH) may be exacerbated by hemostatic impairment. Information about PPH-associated coagulopathy is limited, often resulting in treatment strategies based on data derived from trauma studies.

OBJECTIVES

To investigate hemostatic changes associated with PPH.

PATIENTS/METHODS

From a population of 11 279 maternities, 518 (4.6%) women were recruited with PPH ≥ 1000 mL or placental abruption, amniotic fluid embolism, or concealed bleeding. Routine coagulation and viscoelastometric results were collated. Stored plasma samples were used to investigate women with bleeds > 2000 mL or those at increased risk of coagulopathy defined as placenta abruption, amniotic fluid embolism, or need for blood components. Procoagulant factors were assayed and global hemostasis was assessed using thrombin generation. Fibrinolysis was investigated with D-dimer and plasmin/antiplasmin complexes. Dysfibrinogenemia was assessed using the Clauss/antigen ratio.

RESULTS

At 1000 mL blood loss, Clauss fibrinogen was ≤2 g/L in 2.4% of women and 6/27 (22.2%) cases of abruption. Women with very large bleeds (>3000 mL) had evidence of a dilutional coagulopathy, although hemostatic impairment was uncommon. A subgroup of 12 women (1.06/1000 maternities) had a distinct coagulopathy characterized by massive fibrinolysis (plasmin/antiplasmin > 40 000 ng/mL), increased D-dimer, hypofibrinogenemia, dysfibrinogenemia, reduced factor V and factor VIII, and increased activated protein C, termed acute obstetric coagulopathy. It was associated with fetal or neonatal death in 50% of cases and increased maternal morbidity.

CONCLUSIONS

Clinically significant hemostatic impairment is uncommon during PPH, but a subgroup of women have a distinct and severe coagulopathy characterized by hyperfibrinolysis, low fibrinogen, and dysfibrinogenemia associated with poor fetal outcomes.

Diagnosis of unicuspid aortic valve after loss of consciousness during cesarean section: A case report

Loss of consciousness is a rare but potentially serious complication of delivery by cesarean section under spinal anesthesia. Here, we report the case of a pregnant woman with unicuspid aortic valve that was incidentally diagnosed during aortic valve replacement after transient loss of consciousness during cesarean section.

Echocardiography findings in amniotic fluid embolism: a systematic review of the literature

PURPOSE

Amniotic fluid embolism (AFE) is a leading cause of obstetrical cardiac arrest and maternal morbidity. The pathogenesis of hemodynamic collapse is thought to be from right ventricular (RV) failure; however, there is a paucity of data documenting echocardiography findings in this population. We undertook a systematic review of the literature to evaluate the echocardiography findings in patients with AFE.

SOURCES

We retrieved all case reports and case series reporting AFE in Embase and MEDLINE from inception to 20 November 2021. Studies reporting AFE diagnosed by fulfilling at least one of three different proposed AFE criteria and echocardiography findings during hospitalization were included. Patient and echocardiographic data were retrieved, and univariate logistic regression analysis was performed for outcomes of interest. Bias was assessed using the Joanna Briggs Institute clinical appraisal tool for case series.

PRINCIPAL FINDINGS

Eighty publications reporting on 84 patients were included in the final review. Fifty-five out of 82 patients with data (67%) showed RV dysfunction, including 11/82 (13%) with biventricular dysfunction; 14/82 (17%) had normal systolic function. No data on RV or left ventricular function were reported for two patients. The presence of RV dysfunction on echocardiography was associated with cardiac arrest (odds ratio [OR], 3.66; 95% confidence interval [CI], 1.39 to 9.67; P = 0.009), and a composite risk of cardiac arrest, maternal death or use of extracorporeal membrane oxygenation (OR, 3.86; 95% CI, 1.43 to 10.4; P = 0.007). A low risk of bias was observed in 15/84 (18%) cases.

CONCLUSIONS

Right ventricular dysfunction on echocardiography is a common finding in AFE and is associated with a high risk of cardiac arrest. The finding of RV dysfunction on echocardiography may help diagnose AFE and help triage the highest risk patients with AFE.

STUDY REGISTRATION

PROSPERO (CRD42021271323); registered 1 September 2021.

Obstetric Emergencies

Human gestation and birthing result in many deviations from usual physiology that are nonetheless normal to be seen. However, on occasion, certain complications in the obstetric patient can be life-threatening to both mother and fetus. Timely recognition of these disorders and allocation of the appropriate resources are especially important. These conditions often require an intensive care unit admission for closer monitoring and supportive care. They can affect an array of physiological systems and can lead to significant morbidity. Such complications are discussed in greater detail in this article.

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.

Acute respiratory distress and amniotic fluid embolism in pregnancy

Respiratory failure in pregnant and postpartum women is uncommon, but it is one of the leading causes of maternal admission into the intensive care unit and is associated with high mortality. The underlying causes include sequelae of underlying medical conditions, such as congenital heart diseases, but it is more often related to acute respiratory distress syndrome from obstetric complications like pre-eclampsia, effect of treatment like tocolysis, coincidental to pregnancy like transfusion-related acute lung injury, and accidental like amniotic fluid embolism. The pathophysiological mechanisms involved in many of these conditions remain to be clearly established, but maternal inflammatory response and activation of the immune and complement systems appear to play leading roles. Prompt recognition of maternal respiratory distress and related manifestations and aggressive and adequate supportive treatment, especially cardiopulmonary resuscitation, ventilation, maintenance of circulation, and timely termination of the pregnancy, play key roles in achieving survival of both mother and foetus.

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.

Disseminated intravascular coagulation complicating mild or asymptomatic maternal COVID-19

BACKGROUND

Hypercoagulability frequently complicates moderate or severe COVID-19 and can result in venous thromboembolism, arterial thrombosis, or microvascular thrombosis. Disseminated intravascular coagulation, however, is uncommon.

OBJECTIVE

We sought to describe the clinical presentation and outcome in a series of pregnant patients with mild or asymptomatic COVID-19 who had disseminated intravascular coagulation.

STUDY DESIGN

This was a retrospective case series. Cases were solicited via e-mails targeted to obstetrical providers in the Mednax National Medical Group and a restricted maternal-fetal medicine Facebook page. Inclusion criteria were: hospital admission during pregnancy, positive test for SARS-CoV-2 within 2 weeks of admission, and maternal disseminated intravascular coagulation defined as ≥2 of the following: platelet count ≤100,000 per mm3, fibrinogen ≤200 mg/dL, and prothrombin time ≥3 seconds above the upper normal limit. Exclusion criteria were severe COVID-19 requiring ventilation within an hour of diagnosis of coagulopathy or use of anticoagulants at the time of diagnosis. Maternal and newborn records were abstracted and summarized with descriptive statistics.

RESULTS

Inclusion criteria were met in 19 cases from October 2020 through December 2021. Of these, 18 had not received any COVID-19 vaccine, and 1 had unknown vaccination status. Median gestational age on hospital admission was 30 weeks (interquartile range, 29-34 weeks). The main presenting symptom or sign was decreased fetal movement (56%) or nonreassuring fetal heart rate pattern (16%). COVID-19 was asymptomatic in 79% of cases. Two of the 3 defining coagulation abnormalities were found in 89% of cases and all 3 in the remaining 11%. Aspartate aminotransferase was elevated in all cases and ≥2 times the upper normal limit in 69%. Only 2 cases (11%) had signs of preeclampsia other than thrombocytopenia or transaminase elevation. Delivery was performed on the day of admission in 74% and on the next day in the remaining 26%, most often by cesarean delivery (68%) under general anesthesia (62%) because of nonreassuring fetal heart rate pattern (63%). Postpartum hemorrhage occurred in 47% of cases. Blood product transfusions were given in 95% of cases, including cryoprecipitate (89% of cases), fresh/frozen plasma (79%), platelets (68%), and red cells (63%). Placental histopathology was abnormal in 82%, with common findings being histiocytic intervillositis, perivillous fibrin deposition, and infarcts or necrosis. Among the 18 singleton pregnancies and 1 twin pregnancy, there were 13 live newborns (65%) and 7 stillbirths (35%). Among liveborn neonates, 5-minute Apgar score was ≤5 in 54%, and among cases with umbilical cord blood gases, pH ≤7.1 was found in 78% and base deficit ≥10 mEq/L in 75%. Positive COVID-19 tests were found in 62% of liveborn infants.

CONCLUSION

Clinicians should be alert to the possibility of disseminated intravascular coagulation when a COVID-19 patient complains of decreased fetal movement in the early third trimester. If time allows, we recommend evaluation of coagulation studies and ordering of blood products for massive transfusion protocols before cesarean delivery if fetal tracing is nonreassuring.

Post-abortion Complications: A Narrative Review for Emergency Clinicians

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.

Pulmonary Embolism and Amniotic Fluid Embolism

Venous thromboembolism (VTE) as well as other embolic events including amniotic fluid embolism (AFE) remain a leading cause of maternal death in the United States and worldwide. The pregnant patient is at a higher risk of developing VTE including pulmonary embolism. In contrast, AFE is a rare, but catastrophic event that remains incompletely understood. Here the authors review the cause of VTE in pregnancy and look at contemporary and evidence-based practices for the evaluation, diagnosis, and management in pregnancy. Then the cause and diagnostic difficulty of AFE as well as what is known regarding the pathogenesis are reviewed.

Postpartum Hemorrhage Management and Blood Component Therapy

This article serves to highlight both the common nature and severity of postpartum hemorrhage (PPH). Identification of etiologies and management of each is reviewed. In addition, the evaluation and administration of proper blood component therapies and massive transfusion are also explained to help providers become comfortable with early administration and delivery of blood component therapies.

Rotational Thromboelastometry-Guided Venoarterial Extracorporeal Membrane Oxygenation in the Treatment of Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is a rare and often fatal complication of pregnancy that occurs during the puerperium. The low incidence of AFE has resulted in few large studies, which makes evidence-based management of AFE challenging. The use of extracorporeal membrane oxygenation (ECMO) has been reported but is limited by availability and challenges managing anticoagulation. In this report, we detail the case of a 29-year-old female who suffered from an AFE leading to cardiac arrest and disseminated intravascular coagulopathy. She was treated with protocolized A-OK (adenosine, ondansetron, and ketorolac), emergency c-section, cardiopulmonary resuscitation, massive blood transfusion, and rotational thromboelastometry-guided ECMO, allowing her to forgo initial anticoagulation. After a prolonged rehabilitation with initial poor neurological status, she made a complete recovery. In this report, we describe the protocols that contributed to her recovery and detail management of complicated AFE for other clinicians.

Amniotic Fluid Embolism After First-Trimester Abortion

Amniotic fluid embolism (AFE) may be a rare event in pregnancy, especially after a first-trimester medical termination of pregnancy (MTP). A 35-year-old G3P2L2 came to our outpatient department at six weeks of pregnancy for medical termination of pregnancy and bilateral tubal ligation. After around one hour of surgery, she developed respiratory distress with abdominal distension, hypotension, tachycardia and tachypnoea. On laparotomy, we found ascitic fluid, bowels with petechia, and oozing all over the wounds. Finally, within 24 hours of surgery, she expired. Strong clinical suspicion of AFE should prompt a multidisciplinary team including anaesthesia, respiratory therapy, critical care, and maternal-foetal medicine to be involved in the ongoing care of women with AFE.

Amniotic fluid embolism rescued by venoarterial extracorporeal membrane oxygenation

Background

Amniotic fluid embolism (AFE) is a rare but often catastrophic complication of pregnancy that leads to cardiopulmonary dysfunction and severe disseminated intravascular coagulopathy (DIC). Although few case reports have reported successful use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with AFE, concerns can be raised about the increased bleeding risks with that device.

Methods

This study included patients with AFE rescued by VA-ECMO hospitalized in two high ECMO volume centers between August 2008 and February 2021. Clinical characteristics, critical care management, in-intensive care unit (ICU) complications, and hospital outcomes were collected. ICU survivors were assessed for health-related quality of life (HRQL) in May 2021.

Results

During that 13-year study period, VA-ECMO was initiated in 54 parturient women in two high ECMO volume centers. Among that population, 10 patients with AFE [median (range) age 33 (24–40), SAPS II at 69 (56–81)] who fulfilled our diagnosis criteria were treated with VA-ECMO. Pregnancy evolved for 36 (30–41) weeks. Seven patients had a cardiac arrest before ECMO and two were cannulated under cardiopulmonary resuscitation. Pre-ECMO hemodynamic was severely impaired with an inotrope score at 370 (55–1530) μg/kg/min, a severe left ventricular ejection fraction measured at 14 (0–40)%, and lactate at 12 (2–30) mmol/L. 70% of these patients were alive at hospital discharge despite an extreme pre-ECMO severity and massive blood product transfusion. However, HRQL was lower than age-matched controls and still profoundly impaired in the role-physical, bodily pain, and general health components after a median of 44 months follow-up.

Conclusion

In this rare per-delivery complication, our results support the use of VA-ECMO despite intense DIC and ongoing bleeding. Future studies should focus on customized, patient-centered, rehabilitation programs that could lead to improved HRQL in this population.

Successful ECMO-assisted open chest cardiopulmonary resuscitation in a postpartum patient with delayed amniotic fluid embolism

Background

Amniotic fluid embolism (AFE) is a rare but potentially dangerous severe obstetrics complication, which is accompanied by an incidence between 1.9 and 6.1 per 100,000 births.

Case presentation

Here, we report an AFE case after cesarean delivery diagnosed on a cardiac arrest complicated by acute respiratory distress syndrome and coagulopathy. Diagnosis, risk factors and pathophysiology for AFE have been fully discussed, besides, extracorporeal membrane oxygenation in the early management of cardiac arrest was used, describing the indication, efficacy and successful performed of open-chest cardiopulmonary resuscitation for the patient.

Conclusion

In AFE with cute cardiovascular collapse, extracorporeal membrane oxygenation support can be considered as the alternative therapies.

The rare but dangerous amniotic fluid embolish after cesarean delivery was diagnosed.

A cardiac arrest accompanied by acute respiratory distress syndrome and coagulopathy was recorded.

Diagnosis, risk factors and pathophysiology for amniotic fluid embolish in this case were detailly discussed.

Recurrent Cardiac Arrests Due to Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is a rare but devastating complication of pregnancy and is associated with high morbidity and mortality. Identifiable maternal risk factors for AFE include older age, multiparity, cesarean section, and placenta previa, while fetal factors include male gender, fetal distress, and death. AFE presents with respiratory distress, seizure, and circulatory collapse and can be complicated with disseminated intravascular coagulopathy, multiorgan failure, and death. In our case, we present a patient who underwent elective cesarean section for placenta previa, which was complicated by sudden cardiac arrest immediately after delivering the placenta in the operating theatre followed by disseminated intravascular coagulation (DIC). The patient developed massive post-partum hemorrhage secondary to the underlying DIC, which required a massive blood transfusion along with platelets, fresh frozen plasma (FFP), and tranexamic acid. The Society of Maternal-Fetal Medicine proposed criteria for the diagnosis of AFE, which include clinical features and laboratory findings. The presence of a DIC picture is considered to be the hallmark finding that helps to differentiate between AFE and other conditions with similar presentation. Treatment of amniotic fluid embolism depends on early recognition and supportive care.

DIC in Pregnancy - Pathophysiology, Clinical Characteristics, Diagnostic Scores, and Treatments

Obstetrical hemorrhage and especially DIC (disseminated intravascular coagulation) is a leading cause for maternal mortality across the globe, often secondary to underlying maternal and/or fetal complications including placental abruption, amniotic fluid embolism, HELLP syndrome (hemolysis, elevated liver enzymes and low platelets), retained stillbirth and acute fatty liver of pregnancy. Various obstetrical disorders can present with DIC as a complication; thus, increased awareness is key to diagnosing the condition. DIC patients can present to clinicians who may not be experienced in a variety of aspects of thrombosis and hemostasis. Hence, DIC diagnosis is often only entertained when the patient already developed uncontrollable bleeding or multi-organ failure, all of which represent unsalvageable scenarios. Beyond the clinical presentations, the main issue with DIC diagnosis is in relation to coagulation test abnormalities. It is widely believed that in DIC, patients will have prolonged prothrombin time (PT) and partial thromboplastin time (PTT), thrombocytopenia, low fibrinogen, and raised D-dimers. Diagnosis of DIC can be elusive during pregnancy and requires vigilance and knowledge of the physiologic changes during pregnancy. It can be facilitated by using a pregnancy specific DIC score including three components: 1) fibrinogen concentrations; 2) the PT difference - relating to the difference in PT result between the patient's plasma and the laboratory control; and 3) platelet count. At a cutoff of ≥26 points, the pregnancy specific DIC score has 88% sensitivity, 96% specificity, a positive likelihood ratio (LR) of 22, and a negative LR of 0.125. Management of DIC during pregnancy requires a prompt attention to the underlying condition leading to this complication, including the delivery of the patient, and correction of the hemostatic problem that can be guided by point of care testing adjusted for pregnancy.

Nonovert disseminated intravascular coagulation (DIC) in pregnancy: a new scoring system for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion

BACKGROUND

Nonovert disseminated intravascular coagulation (DIC) is a subclinical hemostatic dysfunction that has not yet reached the decompensation stage. The detection of pregnant patients at this stage may assist in the identification of those who will develop severe obstetrical hemorrhage, as it is one of the leading causes for preventable maternal mortality. Currently, nonovert DIC is diagnosed by a scoring system based on nonpregnant patients, originally generated by the International Society on Thrombosis and Hemostasis (ISTH), which does not address the physiologic changes of the hemostatic system during pregnancy.

OBJECTIVES

(1) To develop a pregnancy-specific nonovert DIC score, (2) to determine the diagnostic performance of this score in detecting women at risk for obstetrical hemorrhage requiring blood product transfusion, and (3) to compare it to the existing ISTH nonovert DIC score.

STUDY DESIGN

This retrospective study has longitudinal and cross-sectional components and includes three steps: (1) characterization of the longitudinal changes in the components of modified ISTH nonovert DIC scores, including these parameters - fibrinogen, antithrombin III, protein C, prothrombin time (PT), platelets, thrombin-antithrombin (TAT) complex, and D-dimer - during gestation in a group of normal pregnancies (n = 50); (2) development of a pregnancy-specific nonovert DIC score in a cross-sectional design of high-risk (n = 152) and control (n = 50) pregnancies, based on the predictive performance of each analyte for the detection of women at risk for obstetrical hemorrhage requiring blood product transfusion and a logistic regression model; and (3) comparison between the diagnostic performance of the pregnancy-specific nonovert DIC score and the modified ISTH nonovert DIC score to detect, upon admission, women who are at increased risk for subsequent development of obstetrical hemorrhage requiring blood product transfusion.

RESULTS

(1) The study cohort included 202 patients, of which 21 (10%) had obstetrical hemorrhage that required blood product transfusion and were considered to have nonovert DIC; (2) using the nonpregnant ISTH nonovert DIC score, 92% of the patients had a D-dimer concentration above the 0.5 mg/L threshold, and only 2% were identified to have a low fibrinogen concentration (<100 mg/dL); thus, this scoring system was unable to identify any of the patients with nonovert DIC based on the suggested cutoff of a score of ≥5; (3) the parameters included in the pregnancy-specific nonovert DIC score were selected based on their contribution to the performance of the model for the prediction of women at risk for obstetrical hemorrhage requiring blood product transfusion; as a result, we excluded the PT difference parameter from the score and the TAT complex concentration was added; and (4) a pregnancy-specific nonovert DIC score of ≥3 had a sensitivity of 71.4% and a specificity of 77.9% to identify patients at risk for obstetrical hemorrhage requiring blood product transfusion.

CONCLUSION

We propose (1) a pregnancy-specific nonovert DIC score adjusted for the physiologic changes in the hemostatic system during gestation; and (2) that the pregnancy-specific nonovert DIC score can be a useful tool for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion.

Utilization of point-of-care ultrasound and rotational thromboelastometry (ROTEM) in the diagnosis and management of amniotic fluid embolism presenting as post-partum hemorrhage and cardiac arrest

Objectives

To describe the integration of point-of-care ultrasound (POCUS) and rotational thromboelastometry (ROTEM) in the diagnosis and management of cardiac arrest secondary to amniotic fluid embolism (AFE).

Case presentation

A 29-year-old female presented for induction of labor at 39 weeks. Labor was complicated by hemorrhage and subsequent sinus tachycardia pulseless electrical activity (PEA) arrest. Intra-arrest POCUS demonstrated right ventricular dilation and hypokinesis adding to a presumed hemorrhagic arrest etiology. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated at the bedside following the POCUS findings. ROTEM further clarified the etiology of hemorrhage as disseminated intravascular coagulation (DIC), and in combination with the POCUS findings led to a final diagnosis of amniotic fluid embolism with DIC. The patient was maintained on VA-ECMO without heparin in the setting of DIC. She had a complicated hospital course but was discharged home with her healthy child and no residual physical or neurologic deficits.

Conclusions

In the absence of more specific testing modalities the utilization of rapidly available POCUS in conjunction with ROTEM can impact clinical decision making of cardiovascular resuscitation in patients during labor and delivery by narrowing the differential between pulmonary embolism and AFE.

Effect of cryoprecipitate transfusion therapy in patients with postpartum hemorrhage: a retrospective cohort study

To evaluate the effect of cryoprecipitate (CRYO) transfusion in women referred for postpartum hemorrhage (PPH). This retrospective cohort study included patients with primary PPH referred to Gifu University Hospital between April 2013 and March 2020. We analyzed the effect of CRYO transfusion on fluid balance 24 h after the initial examination using a multivariable linear regression model adjusted for several confounding variables. To evaluate whether outcomes were modified by active bleeding, an interaction term of CRYO*active bleeding was incorporated into the multivariable model. We identified 157 women: 38 in the CRYO group (cases) and 119 in the control group. Fluid balance in the aforementioned period tended to decrease in the CRYO group compared with that in the control group (coefficient - 398.91; 95% CI - 1298.08 to + 500.26; p = 0.382). Active bleeding on contrast-enhanced computed tomography affected the relationship between CRYO transfusion and fluid balance (p = 0.016). Other outcomes, except for the overall transfusion requirement, were not significantly different; however, the interaction effect of active bleeding was significant (p = 0.016). CRYO transfusion may decrease the fluid balance in the first 24 h in PPH patients, especially in those without active bleeding.

A Detailed Review of Critical Care Considerations for the Pregnant Cardiac Patient

Maternal cardiovascular disease is a leading cause of maternal death worldwide and recently, maternal mortality has increased secondary to cardiovascular causes. Maternal admissions to critical care encompass 1%-2% of all critical care admissions, and although not common, the management of the critically ill pregnant patient is complex. Caring for the critically ill pregnant cardiac patient requires integration of pregnancy-associated physiologic changes, understanding pathophysiologic disease states unique to pregnancy, and a multidisciplinary approach to timing around delivery as well as antenatal and postpartum care. Herein we describe cardiorespiratory changes that occur during pregnancy and the differential diagnosis for cardiorespiratory failure in pregnancy. Cardiorespiratory diseases that are either associated or exacerbated by pregnancy are highlighted with emphasis on perturbations secondary to pregnancy and appropriate management strategies. Finally, we describe general management of the pregnant cardiac patient admitted to critical care.