Section 2 Algorithms for Management of the Top Five ‘Direct Killers’
Chapter
Amniotic fluid embolus
7 Derek Tuffnell and Hlupekile Chipeta
Key facts
Definition
Amniotic fluid embolus (AFE) is a rare obstetric
condition that is characterised by one or more
of the following features, in the absence of any
other clear cause:
r Acute fetal compromise.
r Cardiac arrhythmias or arrest.
r Coagulopathy.
r Convulsion.
r Hypotension.
r Maternal haemorrhage.
r Premonitory symptoms, e.g. restlessness,
numbness, agitation, tingling.
r Shortness of breath.
r Excluding women with maternal
haemorrhage as the first presenting feature in
whom there was no evidence of early
coagulopathy or cardiorespiratory
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compromise [1].
Histological amniotic fluid embolus is the
presence of fetal squames or hair in maternal
lungs at postmortem [1].
International variations exist in the definition of AFE
which may account for differences in incidence.
Amniotic fluid embolus is sometimes considered
in two phases. The first phase is characterised by an
almost anaphylactoid reaction with hypotension, dys-
pnoea with or without cardiac arrest. The second phase
is marked by haemorrhage and coagulopathy.
Obstetric and Intrapartum Emergencies, ed. Edwin Chandraharan and Sabaratnam Arulkumaran. Published by Cambridge
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Incidence
r No change in incidence over the last 4 years.
Approximately 2.0 per 100 000 deliveries (95% CI
1.5–2.5) in the UK [1], 3.3 per 100 000 in
Australia [2] and 6.0 per 100 000 singleton
deliveries in Canada [3].
Mortality
Amniotic fluid embolus is the seventh commonest
cause of all maternal deaths [4]. At 0.57 per 100 000
maternities (95% CI 0.33–0.98) it has reduced from
the second to the fourth leading cause of direct mater-
nal deaths in the UK. Maternal case fatality rates are
between 16.5 and 61% in the UK, Australia and the
USA [1, 4]. There is a fall in case mortality rates which
is probably due to high-level supportive care and diag-
nosis of milder cases [5].
Key implications
r Maternal: Pulmonary oedema, acute respiratory
distress syndrome, disseminated intravascular
coagulopathy (DIC), pulmonary embolus,
haemorrhage, right then left cardiac failure,
cerebrovascular events, cardiorespiratory arrest,
death.
r Fetal: Fetal distress, hypoxic ischaemic
encephalopathy (HIE), learning difficulties,
cerebral palsy, intrauterine and neonatal death.
Key pointers
The following risk factors have been identified:
r Maternal age greater than 35 years, odds ratio
(OR) 9.85 (95% CI, 3.57–27.2).

r Induction of labour, OR 3.86 (95% CI, 2.04–7.31).
r Multiple pregnancy, OR 10.9 (95% CI, 2.81–42.7).
r Caesarean delivery, OR 8.84 (95% CI, 3.70-21.1).
Other factors that were previously considered risk fac-
tors are now no longer considered causal [6]:
r Ethnicity – Black and other ethnic minorities.
r Assisted vaginal delivery.
r Placenta praevia.
r Placental abruption.
r Eclampsia.
r r Maintain patency.
Fetal distress.
r r Give high-flow oxygen at a rate of 15 l/minute
Hyperstimulation.
Black or other minority ethnicity is associated with an
increased case fatality rate.
Key symptoms and signs
r Maternal:
r
Symptoms: dyspnoea, loss of consciousness,
cough, wheeze, headache, chest pain.
r
Signs: cyanosis, hypoxia, hypotension,
transient hypertension, cardiac arrhythmia,
cardiopulmonary arrest, seizure, signs of
pulmonary oedema.
r Fetal:
r
Fetal distress, neonate with severe HIE.
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Key actions
r Suspect a diagnosis of AFE in any woman during
labour, after delivery or following surgical
evacuation of the womb with the following
features [7]: maternal haemorrhage, hypotension,
shortness of breath and new-onset respiratory
symptoms, coagulopathy, premonitory symptoms
such as restlessness, agitation, numbness, tingling,
acute fetal compromise, cardiac and/or
arrhythmia, seizures.
A significant number of women present with mater-
nal collapse. Therefore management will consider this
presentation foremost.
Obstetric and Intrapartum Emergencies : A Practical Guide to Management, edited by Edwin Chandraharan, and Sabaratnam Arulkumaran, Cambridge
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Chapter 7: Amniotic fluid embolus
First-line management – resuscitation
Call for help – early
Senior multidisciplinary involvement is important for
a positive prognosis. The team should include obste-
tricians, anaesthetists, intensivists, haematologists and
neonatologists.
Airway
Women are at risk of a compromised airway due to
depressed level of consciousness.
through a face mask with reserve bag.
r Attach a pulse oximeter.
r Consider intubation if still pregnant, respiratory
distress or cardiopulmonary collapse.
r Place into left lateral tilt.
Breathing
Women are at risk of compromised breathing due to
pulmonary oedema.
r Assess breathing (including respiratory rate) and
ventilate if there is evidence of respiratory distress.
r Positive end expiratory pressures may be
necessary to maintain adequate oxygen
saturations.
Circulation
Women are at risk of cardiac arrhythmias, cardiac
arrest, massive haemorrhage and pulmonary embolus
due to sudden fluid shifts and disseminated intravas-
cular coagulation (DIC).
r Assess circulation and blood pressure.
r Start CPR and deliver fetus if cardiac arrest.
r Monitor blood pressure.
r Perform ECG.
r Insert two large-bore intravenous cannulae.
r Consider central monitoring especially if
pulmonary oedema, haemodynamic instability or
peripheral shutdown.
r Send venous blood samples urgently for FBC,
clotting and cross match.
r Perform an arterial blood gas analysis.
r Get a chest X-ray.
49
 Section 2: Algorithms for Management of the Top Five ‘Direct Killers’
Correct hypotension and coagulopathy
r Replace intravascular volume with clear fluids and
blood.
r Liaise early with haematologist to treat DIC with
fresh frozen plasma, cryoprecipitate, platelets or
red blood cells.
r Liaise with intensivists and anaesthetists to
maintain blood pressure with inotropic support.
Deliver fetus
The main aim of early delivery is to facilitate and
improve outcome of maternal resuscitation.
The fetus remains at significant risk of morbid-
ity and demise even with prompt delivery. Outcome
statistics of fetuses and neonates are unlikely to be
accurate due to the small numbers in UK case series
but suggest a ∼50% survival if born to a dead woman
with ∼77% surviving if born to a live woman. Either
way, infants are at significant risk of long-term neuro-
logical deficits [8].
Following delivery, beware of uterine haemorrhage
due to DIC.
r Consider medical treatments for atony including
oxytocics, ergometrine, carboprost and
misoprostol.
r Consider mechanical measures including
bimanual compression, intrauterine tamponading
balloons and brace techniques.
r Consider interventional radiology and uterine
artery embolisation.
r Consider surgical options including internal iliac
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artery ligation and hysterectomy.
r Consider discussion with haematologist for factor
VIIa as well as cryotherapy, FFP and platelets.
Second-line management – diagnosis
and supportive care
Ascertain the diagnosis
With mortality from AFE falling, diagnosis is increas-
ingly clinical. The long list of differential diagnoses
reflects the breadth of symptoms and signs women
present with. These must be excluded before a diagno-
sis is made but treatment of the acutely ill woman must
not be delayed in the quest to find a diagnosis.
Box 7.1 outlines a list of differential diagnoses.
Obstetric and Intrapartum Emergencies : A Practical Guide to Management, edited by Edwin Chandraharan, and Sabaratnam Arulkumaran, Cambridge
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Box 7.1 Differential diagnosis of women with
suspected amniotic fluid embolism [5].
Postpartum haemorrhage
Placental abruption
Uterine rupture
Preeclampsia/HELLP syndrome
Septic shock
Thrombotic embolus
Air embolus
Acute myocardial infarction
Peri-partum cardiomyopathy
Local anaesthetic toxicity
Anaphylaxis
Transfusion reaction
Aspiration of gastric contents
Various investigations should be performed in an
effort to investigate the above differential diagnoses.
Blood tests to perform include clotting, liver and renal
function tests, arterial blood gases. An ECG (with or
without an echocardiogram) may be helpful in show-
ing myocardial problems. A ventilation/perfusion
(V/Q) scan may reveal a perfusion defect. A comput-
erised tomography pulmonary angiography (CTPA)
scan would diagnose intrapulmonary abnormalities.
Zinc coproporphyrin and tryptase levels are not
used routinely in the diagnosis of AFE.
Transfer to intensive care unit
The mainstay of management of AFE remains support-
ive. Rigorous, early supportive therapy saves mothers’
lives.
The purpose of ICU is to monitor observations,
maintain haemodynamic instability and reduce iatro-
genic and disease complications. Options of treat-
ment include diuretics, inotropes and steroids. Plasma
exchange, haemofiltration and extracorporeal mem-
brane oxygenation have been used in treatment.
Disclosure and documentation
At a local level, clear, chronological and contempora-
neous documentation is essential preferably on a high-
dependency chart. Incident reporting is important e.g.
for transfer to the ICU, major postpartum haemor-
rhage, unexpectedly low cord pH and neonatal admis-
sion to NICU.

At a national level, UKOSS and the National Near-
miss Surveillance Programme (UKNeS) are currently
conducting an AFE study looking into incidence, risk
factors, management and maternal and infant out-
comes. Voluntary notification of cases to the database
over a period of 3 years should collect data on an esti-
mated 30 cases.
Key pitfalls
r Failure to suspect AFE in a collapsed or unwell
peripartum woman.
r Failure to seek early input from intensivists,
anaesthetists and haematologists.
r Failure to ensure ABC.
r Failure to consider early delivery of the fetus
principally for maternal resuscitation.
r Failure to correct coagulopathy, stop haemorrhage
and control fluid balance.
r Failure to keep adequate records.
r Failure to report to national registers.
Key pearls
r All staff providing intrapartum care should attend
annual skills and drills training on the
management of maternal collapse.
r Regular fire drills involving maternal collapse on
the labour ward can ensure that a robust system is
in place for the acute management of AFE.
r All staff should be encouraged to report any
maternal collapse through incident forms.
Copyright © 2012. Cambridge University Press. All rights reserved.
Obstetric and Intrapartum Emergencies : A Practical Guide to Management, edited by Edwin Chandraharan, and Sabaratnam Arulkumaran, Cambridge
University Press, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/unisains-trial/detail.action?docID=1042405.
Created from unisains-trial on 2020-03-30 00:22:29.
Chapter 7: Amniotic fluid embolus
References
1. Knight M, Tuffnell D, Brocklehurst P, Spark P,
Kurinczuk JJ, on behalf of the UK Obstetric
Surveillance System. Incidence and risk factors for
amniotic fluid embolism. Obstet Gynecol 2010; 115:
910–917.
2. Roberts C, Algert C, Knight M, Morris J. Amniotic
fluid embolism in an Australian population-based
cohort. Br J Obstet Gynaecol 2010; 117: 1417–1421.
3. Kramer MS, Rouleau J, Baskett TF, Joseph KS;
Maternal Health Study Group of the Canadian
Perinatal Surveillance System. Amniotic-fluid
embolism and medical induction of labour: a
retrospective, population-based cohort study. Lancet
2006; 368: 1444–1448.
4. Centre for Maternal and Child Enquiries (CMACE).
Saving Mothers’ Lives: Reviewing Maternal Deaths to
make Motherhood Safer – 2006–2008. The Eighth
Report on Confidential Enquiries into Maternal Deaths
in the United Kingdom. Br J Obstet Gynaecol 2011; 118
(Suppl. 1): 1–208.
5. Howell C, Grady K, Cox C. Managing Obstetric
Emergencies and Trauma – the MOET Course Manual.
2nd edition. London: RCOG, 2007.
6. Conde-Agudelo A, Romero R. Amniotic fluid
embolism: an evidence-based review. Am J Obstet
Gynecol 2009; 201 (5): 445.e1–13. Erratum in Am J
Obstet Gynecol 2010; 202 (1): 92.
7. Tuffnell D, Knight M, Plaat F. Amniotic fluid
embolism – an update. Anaesthesia 2011; 66 (1): 3–6.
8. Tuffnell DJ. United Kingdom amniotic fluid embolism
register. Br J Obstet Gynaecol 2005; 112: 1625–1629.
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