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Kostelecky N, Loxas M, Multz R, Flanagan ME, Ahrendsen JT, Goldstein J. Amniotic Fluid Embolism: An Illustrated Report and Review of Literature. Am J Forensic Med Pathol 2024:00000433-990000000-00194. [PMID: 39018441 DOI: 10.1097/paf.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Affiliation(s)
- Nicolas Kostelecky
- From the Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Margarita Loxas
- From the Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Rachel Multz
- From the Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Jared T Ahrendsen
- From the Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jeffery Goldstein
- From the Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Yamashita A, Oda T, Aman M, Wakasa T, Gi T, Ide R, Todo Y, Tamura N, Sato Y, Itoh H, Asada Y. Massive platelet-rich thrombus formation in small pulmonary vessels in amniotic fluid embolism: An autopsy study. BJOG 2023; 130:1685-1696. [PMID: 37184040 DOI: 10.1111/1471-0528.17532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 03/24/2023] [Accepted: 04/21/2023] [Indexed: 05/16/2023]
Abstract
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.
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Affiliation(s)
- Atsushi Yamashita
- Department of Pathology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tomoaki Oda
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Murasaki Aman
- Department of Pathology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Pathology, Miyazaki Prefectural Hospital, Miyazaki, Japan
| | - Tomoko Wakasa
- Department of Pathology, Nara Hospital, Kindai University, Ikoma, Japan
| | - Toshihiro Gi
- Department of Pathology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Rui Ide
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yusuke Todo
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoaki Tamura
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuichiro Sato
- Department of Diagnostic Pathology, Faculty of Medicine, Miyazaki University Hospital, University of Miyazaki, Miyazaki, Japan
| | - Hiroaki Itoh
- Department of Obstetrics & Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yujiro Asada
- Department of Pathology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Pathology, Miyazaki Medical Association Hospital, Miyazaki, Japan
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Fibrinogen may aid in the early differentiation between amniotic fluid embolism and postpartum haemorrhage: a retrospective chart review. Sci Rep 2021; 11:8379. [PMID: 33863968 PMCID: PMC8052446 DOI: 10.1038/s41598-021-87685-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 03/31/2021] [Indexed: 12/13/2022] Open
Abstract
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.
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Wakasa T, Ishibashi‐Ueda H, Takeuchi M. Maternal death analysis based on data from the nationwide registration system in Japan (2010-2018). Pathol Int 2021; 71:223-231. [PMID: 33559265 PMCID: PMC8248185 DOI: 10.1111/pin.13076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/19/2021] [Indexed: 12/12/2022]
Abstract
The maternal mortality rate in Japan was 3.5 per 100 000 live births in 2017, similar to that reported in other developed countries. To reduce the number of maternal deaths, a Japanese nationwide registration and analysis system was implemented in 2010. Between January 2010 and April 2018, 367 maternal deaths were reported. Among them, by reviewing 80 autopsy records, the direct obstetric causes of death were identified in 52 women. The major causes of deaths were amniotic fluid embolism and acute pulmonary thromboembolism. The other 26 maternal deaths were associated with indirect obstetric causes including invasive Group A Streptococcus infection, aortic dissection, cerebral stroke and cardiomyopathies. This review highlights the importance of autopsy in maternal deaths. On analyzing 42 autopsy specimens obtained from registered cases of maternal death during 2012-2015, the 36% of causes of death by autopsy were discordant with the clinical diagnosis. Moreover, of the 38% of non-autopsied maternal death, the cause of death could not be clarified from the clinical chart. We emphasized that detailed autopsies are necessary to clarify the precise pathologic evidence related to pregnancy and delivery, especially causes of unexpected death such as amniotic fluid embolism.
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Affiliation(s)
- Tomoko Wakasa
- Department of Diagnostic Pathology, Nara HospitalKindai UniversityNaraJapan
| | | | - Makoto Takeuchi
- Department of PathologyOsaka Women's and Children's HospitalOsakaJapan
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Rudkovskaia AA, Bandyopadhyay D. Intraluminal Arterial Filling Defects Misdiagnosed as Pulmonary Emboli: What Else Could They Be? Clin Chest Med 2019; 39:505-513. [PMID: 30122175 DOI: 10.1016/j.ccm.2018.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary artery filling defects can be observed in various pathologic processes other than pulmonary embolism, for example, nonthrombotic pulmonary embolism with biological and nonbiological materials and intrinsic pulmonary artery lesions. They have also been described in rare conditions, such as fibrosing mediastinitis and congenital absence or stenosis of pulmonary artery, and some pulmonary parenchymal and airway malignancies. Misdiagnosis is common owing to the relative rarity of these conditions. Correct diagnosis is based on the appropriate clinical suspicion considering the unique clinical features, laboratory findings, and additional radiologic clues inferring a pathology other than pulmonary embolism.
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Affiliation(s)
- Anastasiia A Rudkovskaia
- Pulmonary and Critical Care Medicine, Geisinger, 100 North Academy Avenue, Danville, PA 17822-1334, USA.
| | - Debabrata Bandyopadhyay
- Pulmonary and Critical Care Medicine, Geisinger, 100 North Academy Avenue, Danville, PA 17822-1334, USA
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Chen W, Qi J, Shang Y, Ren L, Guo Y. Amniotic fluid embolism and spontaneous hepatic rupture during uncomplicated pregnancy: a case report and literature review. J Matern Fetal Neonatal Med 2018; 33:1759-1766. [PMID: 30394159 DOI: 10.1080/14767058.2018.1526915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Wei Chen
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Jialin Qi
- Department of Pathology, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Yanjie Shang
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Lipin Ren
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Yadong Guo
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
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Koike N, Oi H, Naruse K, Kanayama N, Kobayashi H. Squamous cell carcinoma antigen as a novel candidate marker for amniotic fluid embolism. J Obstet Gynaecol Res 2017; 43:1815-1820. [PMID: 28892217 DOI: 10.1111/jog.13453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/10/2017] [Accepted: 06/17/2017] [Indexed: 11/26/2022]
Abstract
AIM We aimed to evaluate the clinical usefulness of serum squamous cell carcinoma (SCC) antigen for the diagnosis of amniotic fluid embolism (AFE). METHODS Sera and information of 20 patients with AFE (autopsy-proven AFE, four cases; clinical AFE, 16 cases) were obtained from the Japan Amniotic Fluid Embolism Registration Center at Hamamatsu University School of Medicine. As controls, we included 74 gestational-age-matched healthy women who gave birth to healthy newborns during the period from December 2012 to January 2014. Receiver-operator curves (ROC) were used to evaluate the diagnostic performance of SCC levels for prediction of AFE. RESULTS Serum SCC antigen levels in women with autopsy-proven AFE (112.0 ± 169.4 ng/mL, P = 0.001) and clinical AFE (9.5 ± 10.3 ng/mL, P = 0.004) were significantly higher than those in healthy controls with normal delivery (4.4 ± 2.2 ng/mL). On ROC analysis, the optimal cut-off value for SCC antigen levels was 7.15 ng/mL, for which the sensitivity and specificity for AFE prediction was 60.0% and 89.2%, respectively (area under the ROC, 0.785; 95% confidence interval, 0.663-0.908; P < 0.001). CONCLUSION Serum SCC antigen may be a promising predictor of the entry of amniotic fluid into the maternal circulation, potentially serving as a candidate marker for noninvasive diagnosis of AFE.
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Affiliation(s)
- Natsuki Koike
- Department of Obstetrics and Gynecology, Nara Medical University, Nara, Japan
| | - Hidekazu Oi
- Department of Obstetrics and Gynecology, Kindai University Nara Hospital, Ikoma, Japan
| | - Katsuhiko Naruse
- Department of Obstetrics and Gynecology, Nara Medical University, Nara, Japan
| | - Naohiro Kanayama
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroshi Kobayashi
- Department of Obstetrics and Gynecology, Nara Medical University, Nara, Japan
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8
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Benson MD. Amniotic fluid embolism mortality rate. J Obstet Gynaecol Res 2017; 43:1714-1718. [PMID: 28817205 DOI: 10.1111/jog.13445] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 05/29/2017] [Accepted: 06/10/2017] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Michael D Benson
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Nakagami H, Kajihara T, Kamei Y, Ishihara O, Kayano H, Sasaki A, Itakura A. Amniotic components in the uterine vasculature and their role in amniotic fluid embolism. J Obstet Gynaecol Res 2014; 41:870-5. [DOI: 10.1111/jog.12650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 10/23/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Hiroko Nakagami
- Department of Obstetrics and Gynecology; Saitama Medical University; Saitama Japan
| | - Takeshi Kajihara
- Department of Obstetrics and Gynecology; Saitama Medical University; Saitama Japan
| | - Yoshimasa Kamei
- Department of Obstetrics and Gynecology; Saitama Medical University; Saitama Japan
| | - Osamu Ishihara
- Department of Obstetrics and Gynecology; Saitama Medical University; Saitama Japan
| | - Hidekazu Kayano
- Department of Pathology; Saitama Medical University; Saitama Japan
| | - Atsushi Sasaki
- Department of Pathology; Saitama Medical University; Saitama Japan
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology; Juntendo University; Tokyo Japan
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Kanayama N, Tamura N. Amniotic fluid embolism: Pathophysiology and new strategies for management. J Obstet Gynaecol Res 2014; 40:1507-17. [DOI: 10.1111/jog.12428] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 02/08/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Naohiro Kanayama
- Department of Obstetrics and Gynaecology; Hamamatsu University School of Medicine; Hamamatsu Japan
| | - Naoaki Tamura
- Department of Obstetrics and Gynaecology; Hamamatsu University School of Medicine; Hamamatsu Japan
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Furuta N, Yaguchi C, Itoh H, Kanayama N. Immunohistochemical detection of meconium in the fetal lung: report of autopsied cases. Arch Gynecol Obstet 2013; 288:967-9. [DOI: 10.1007/s00404-013-2862-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 04/17/2013] [Indexed: 11/30/2022]
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Legrand M, Rossignol M, Muller F, Payen D. [Amniotic fluid embolism: an update]. ACTA ACUST UNITED AC 2013; 32:189-97. [PMID: 23422343 DOI: 10.1016/j.annfar.2013.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 01/08/2013] [Indexed: 12/14/2022]
Abstract
Amniotic fluid embolism (AFE) results from the passage of fœtal and amniotic fragments into the maternal circulation, occurring mostly within minutes before or after delivery. Although maternal and fœtal mortality of AFE remains high (about 40%), AFE should no longer be considered as having an ineluctable fatal course. Diagnosis is often made upon clinical presentation but histological confirmation is difficult owing favorable outcome and because an autopsy has not been performed. Identification of squamous cells in the maternal circulation could not confirm the diagnosis because of their possible maternal origin. High plasma level of insulin-like growth factor-binding protein-1 (IGFBP-1) has recently been identified as a biomarker of amniotic fluid passage into the maternal circulation and might therefore be used to confirm the diagnosis when lung tissue histology is not available. Treatment of AFE remains supportive with a special focus on correction of the coagulopathy and search for acute core pulmonale. In this later case, physicians should consider initiating an extracorporeal life support when facing a patient with refractory shock. Finally, caution is needed with the use of recombinant factor VIIa in this context.
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Affiliation(s)
- M Legrand
- Département d'anesthésie-réanimation-Smur, EA-3509, université Paris 7, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris, France.
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Falzone E, Ricard JD, Pachy F, Mandelbrot L, Keïta H. [Amniotic fluid embolism: report of the successful outcome of a case with inaugural cardiac arrest and early DIVC complicated by hemoperitoneum of iatrogen origin and bleeding of an hepatic adenoma]. ACTA ACUST UNITED AC 2012; 31:802-5. [PMID: 22925937 DOI: 10.1016/j.annfar.2012.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 07/06/2012] [Indexed: 11/16/2022]
Abstract
Amniotic fluid embolism is a relatively rare clinical entity and with difficult medical recognition. However, it is the second leading cause of maternal mortality. We report here the case of a 32-year-old patient who underwent elective caesarean section complicated by an amniotic fluid embolism with cardiac arrest. The presence of a major disseminated intravascular coagulation favored the occurrence of a retroperitoneal hematoma of iatrogenic origin on attempt of femoral venous catheterization and that of hemoperitoneum on bleeding of an hepatic adenoma. The diagnostic of amniotic fluid embolism was confirmed by the presence of amniotic cells in the bronchoalveolar lavage. The patient survived without sequelae.
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Affiliation(s)
- E Falzone
- Département d'anesthésie-réanimation, HIA Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France.
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Franchitto N, Minville V, Dédouit F, Telmon N, Rougé D. Medical responsibility in the operating room: the example of an amniotic fluid embolism. J Forensic Sci 2012; 57:1120-3. [PMID: 22372588 DOI: 10.1111/j.1556-4029.2012.02098.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Amniotic fluid embolism (AFE) continues to be one of the most feared complications of pregnancy. A healthy 32-year-old woman died during delivery after a normal 39-week third pregnancy. The family filed a complaint with a criminal court as the causes of death appeared unclear. No risk factor associated with AFE was identified. Clinical presentation was typical, including sudden onset of cardiovascular and respiratory symptoms. Autopsy confirmed the histological diagnosis of amniotic embolism and excluded an iatrogenic cause of death or anesthetic malpractice. This article highlights the value of both antemortem records and histological features in establishing the diagnosis of AFE and demonstrates the fundamental importance of autopsy in an unexpected death related directly or indirectly to a medical procedure.
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Affiliation(s)
- Nicolas Franchitto
- Service de Médecine Légale, Centre Hospitalier Universitaire Rangueil, Toulouse, France.
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Naruse K, Noguchi T, Yoshida S, Tsunemi T, Shigetomi H, Oi H, Kobayashi H. Identification of interleukin-6 (IL-6) and squamous cell carcinoma (SCC) as amniotic fluid-specific markers. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ojog.2012.22028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Herbst J, Winskog C, Byard RW. Cardiovascular Conditions and the Evaluation of the Heart in Pregnancy-Associated Autopsies. J Forensic Sci 2010; 55:1528-33. [DOI: 10.1111/j.1556-4029.2010.01489.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Conde-Agudelo A, Romero R. Amniotic fluid embolism: an evidence-based review. Am J Obstet Gynecol 2009; 201:445.e1-13. [PMID: 19879393 PMCID: PMC3401570 DOI: 10.1016/j.ajog.2009.04.052] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 04/10/2009] [Accepted: 04/23/2009] [Indexed: 10/20/2022]
Abstract
We conducted an evidence-based review of information about [corrected] amniotic fluid embolism (AFE). The estimated incidence of AFE is 1:15,200 and 1:53,800 deliveries in North America and Europe, respectively. The case fatality rate and perinatal mortality associated with AFE are 13-30% and 9-44%, respectively. Risk factors associated with an [corrected] increased risk of AFE include advanced maternal age, placental abnormalities, operative deliveries, eclampsia, polyhydramnios, cervical lacerations, [corrected] and uterine rupture. The hemodynamic response in [corrected] AFE is biphasic, with initial pulmonary hypertension and right ventricular failure, followed by left ventricular failure. Promising therapies include selective pulmonary vasodilators and recombinant activated factor VIIa. Important topics for future research are presented.
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Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD and Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD and Detroit, MI
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
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Abstract
Obstetric disorders account for 55% to 80% of admissions to the intensive care unit in the obstetric population. Medical conditions are emerging as the leading cause of maternal mortality, partly because of marked improvement in surgical and obstetric care in the developed world. The rise in maternal mortality related to medical conditions can be explained by multiple factors: improved medical care, women with chronic illnesses reaching childbearing years, older age at time of first pregnancy, improved reproductive technologies, and severe medical conditions exacerbated by the physiologic changes of pregnancy. This article reviews obstetric disorders leading to intensive care unit admissions.
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Affiliation(s)
- Ghada Bourjeily
- Department of Medicine, Pulmonary and Critical Care, Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02905, USA.
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Fineschi V, Riezzo I, Cantatore S, Pomara C, Turillazzi E, Neri M. Complement C3a expression and tryptase degranulation as promising histopathological tests for diagnosing fatal amniotic fluid embolism. Virchows Arch 2009; 454:283-90. [PMID: 19172292 DOI: 10.1007/s00428-009-0730-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Revised: 12/18/2008] [Accepted: 01/06/2009] [Indexed: 11/24/2022]
Abstract
To date, the most recent specific diagnostic investigations for amniotic fluid embolism have been unable to conclusively identify any mechanism of disease other than a physical block to the circulation. We selected eight fatal cases in previously healthy women with uneventful singleton term pregnancies who presented to tertiary care centers in Italy for delivery. Pathologic features were assessed immunohistochemically using anti-fibrinogen, anti-tryptase, anti-C(3a), and anti-cytokeratin antibodies. AE1/AE3 cytokeratin stains proved positive, and tryptase-positive material was documented outside pulmonary mast cells. In all studied cases, expression of complement C(3a) was twofold lower than in the control group, suggesting a possible complement activation in AFE, initiated by fetal antigen leaking into the maternal circulation.
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Affiliation(s)
- Vittorio Fineschi
- Department of Forensic Pathology, University of Foggia, Ospedale Colonnello D'Avanzo, Via degli Aviatori 1, 71100, Foggia, Italy.
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Abstract
Sudden and unexpected natural deaths and nonnatural deaths may result from various pulmonary conditions. Additionally, several nonpulmonary conditions of forensic significance may be complicated by the development of respiratory lesions. Certain situations with pulmonary pathology are particularly likely to be critically scrutinized and may form the basis of allegations of medical negligence, other personal injury liability, or wrongful death.1
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Benson MD. A hypothesis regarding complement activation and amniotic fluid embolism. Med Hypotheses 2007; 68:1019-25. [PMID: 17112682 DOI: 10.1016/j.mehy.2006.09.052] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Accepted: 09/14/2006] [Indexed: 10/23/2022]
Abstract
Amniotic fluid embolism, a rare, sudden and often fatal illness of pregnancy may not be a true embolic event resulting from the physical obstruction of the pulmonary vasculature. The high degree of variability in symptoms, the lack of characteristic findings on radiological exam, the absence of a dose-response effect on symptoms, and the occasional occurrence of coagulopathies are not entirely consistent with a physical block to the circulation as the main mechanism of disease. Alternatively, it might be the result of complement activation initiated by fetal antigen leaking into the maternal circulation. This rare immune response may be initiated by a rare pathological antigen, or by common antigens presented uncommonly--in amount, timing, or frequency of entry into the maternal circulation. Some very early evidence in AFE patients supports this hypothesis but is not conclusive. Complement levels remain well within the normal range during uncomplicated parturition. A prior theory that AFE might be a result of maternal anaphylaxis to fetal antigen has much less evidence to support it. The disseminated intravascular coagulation often seen in this and other serious obstetrical illnesses may be a secondary result of complement activation rather than the direct introduction of pro-coagulants into the maternal circulation although the link between the complement and coagulation pathways, if any, remains poorly defined. Through currently available laboratory testing, both the complement hypothesis and the anaphylaxis mechanism are able to be assessed. Direct measurement of serum complement as well as serum tryptase and urinary histamine are readily obtained tests in community hospitals as well as tertiary care hospitals. If the hypothesis proves true, this investigation may be of profound importance to understanding immune tolerance. Rather, than asking why one pregnant woman in 20,000 develops a violent immune reaction to the fetus, a better question is why do not all pregnant women reject the fetus which is a large collection of foreign antigens?
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Affiliation(s)
- Michael D Benson
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, 101 Bentley Court, Deerfield, IL 60015, USA.
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25
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Tramoni G, Boisson C, Gamerre L, Clement HJ, Bon C, Rudigoz RC, Viale JP. [Amniotic fluid embolism: a review]. ACTA ACUST UNITED AC 2006; 25:599-604. [PMID: 16630704 DOI: 10.1016/j.annfar.2006.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. It is a difficult and somewhat intangible diagnosis that warrants a high index of suspicion by physicians. AFE is an unpredictable, unpreventable, and, for the most part, an untreatable obstetric emergency. Management of this condition includes prompt recognition of the signs and symptoms, aggressive resuscitation efforts, and supportive therapy. Any delays in diagnosis and treatment can result in increased maternal and/or foetal impairment or death. Whereas once the invariable outcome of AFE was death of the mother, today the prognosis is somewhat brighter thanks to increased awareness of the syndrome and advances in intensive care medicine. No laboratory test is specific to attest the diagnosis and autopsy must to be realised in case of maternal death. Although non-specific, the diagnosis of AFE could be supported by the observation of amniotic fluid in the central venous blood as well as in the bronchoalveolar fluid. This easy and quick test will be helpful in decision-making. Prompt and aggressive supportive treatment is required to lessen an otherwise dismal outcome, which may include death and permanent disability. This article provides an account of the protean clinical features, pathogenesis, and principles involved in treatment.
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Affiliation(s)
- G Tramoni
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, 103 Grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France.
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26
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Rault S, Pirrello O, Langer B, Nisand I. [Amniotic fluid embolism: two case reports]. ACTA ACUST UNITED AC 2006; 34:127-30. [PMID: 16458036 DOI: 10.1016/j.gyobfe.2005.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Accepted: 10/17/2005] [Indexed: 11/26/2022]
Abstract
We report two cases of amniotic fluid embolism, confirmed by histological examination. Both patients had an immediate post-partum haemorrhage that required an haemostatic hysterectomy. A typical symptomatology of amniotic fluid embolism revelated the first case. The patient survived without any sequelae. In the second case, amniotic fluid embolism occurred immediately after the delivery. The patient developed an acute respiratory distress with a shock syndrome. Despite haemostatic hysterectomy and resuscitative efforts, she died 6 days later.
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Affiliation(s)
- S Rault
- Département de Gynécologie Obstétrique, Hôpital de Hautepierre, avenue Molière, 67098 Strasbourg cedex, France.
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27
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Abstract
The incidence of amniotic fluid embolism during pregnancy is approximately 1/50,000 and has a mortality rate in excess of 80%. The postmortem diagnosis of amniotic fluid embolism can be challenging for forensic investigators and pathologists. At autopsy, usually signs of disseminated intravascular coagulation suggest an amniotic fluid embolism. A definitive diagnosis of amniotic fluid embolism cannot be made until ancillary studies are performed on the decedent's tissues. We report a case of a 37-year-old G3P2 white female who was 36 weeks gestation when her membranes spontaneously ruptured. She suddenly became breathless, went into cardiogenic shock, and died. The autopsy revealed gross and microscopic findings of amniotic fluid embolism, which was confirmed with ancillary studies consisting of special stains, immunohistochemistry, and a serum tryptase level. The authors hope this case report, including gross and microscopic autopsy findings with procedural and ancillary studies, and review of the literature will help investigators and pathologists in the diagnosis of amniotic fluid embolism.
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Affiliation(s)
- Bradley J Marcus
- Medical University of South Carolina, Charleston, SC 29425, USA.
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28
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Abstract
Pregnancy induces significant physiologic stresses on the pulmonary and cardiovascular systems that may precipitate respiratory compromise. In addition, certain disease states that are unique to the pregnant woman, such as amniotic fluid emboli syndrome, may be associated with respiratory failure. The physiologic changes that affect the pregnant woman are reviewed. Pregnancy-related conditions are discussed as well as how common diseases, such as the acute respiratory distress syndrome, asthma, pneumonia, and AIDS,have to be approached when balancing the needs of the fetus with maternal well-being.
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Affiliation(s)
- Adriana Pereira
- Pulmonary Division, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL 33140, USA
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29
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Dorne R, Pommier C, Boisson C. [About amniotic fluid embolism]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2003; 22:246-7. [PMID: 12747996 DOI: 10.1016/s0750-7658(03)00042-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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30
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Rufforny-Doudenko I, Sipp C, Shehata BM. Pathologic quiz case. A 30-year-old woman with severe disseminated intravascular coagulation during delivery. Arch Pathol Lab Med 2002; 126:869, 870. [PMID: 12125649 DOI: 10.5858/2002-126-0869-pqcayo] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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31
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Aguilera LG, Fernandez C, Plaza A, Gracia J, Gomar C. Fatal amniotic fluid embolism diagnosed histologically. Acta Anaesthesiol Scand 2002; 46:334-7. [PMID: 11939928 DOI: 10.1034/j.1399-6576.2002.t01-1-460319.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Although the mortality of amniotic fluid embolism remains very high, there are more and more reports of patients surviving after prompt and aggressive therapy. However its pathogenesis is controversial, and, in some cases, an anaphylactic reaction to the amniotic fluid rather than the hemodynamic changes following mechanical obstruction by an embolus has been proposed as the underlying pathophysiological mechanism. In this paper we describe a case of amniotic fluid embolism with florid clinical features and a difficult and delayed diagnosis. On autopsy, clear-cut histological changes of amniotic fluid embolism were found.
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Affiliation(s)
- L G Aguilera
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Spain
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32
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Bick RL. Disseminated intravascular coagulation: a review of etiology, pathophysiology, diagnosis, and management: guidelines for care. Clin Appl Thromb Hemost 2002; 8:1-31. [PMID: 11991236 DOI: 10.1177/107602960200800103] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The pathophysiologic mechanisms, clinical, and laboratory manifestations of DIC are complex in part due to interrelationships within the hemostasis system. Only by clearly understanding these extraordinarily complex pathophysiologic interrelationships can the clinician and laboratory scientist appreciate the divergent and wide spectrum of often confusing clinical and laboratory findings in patients with DIC. Many therapeutic decisions to be made are controversial and lack validation. Nevertheless, newer antithrombotic agents, and agents that can block, blunt, or modify cytokine activity and the activity of vasoactive substances appear to be of value. The complexity and variable degree of clinical expression suggests that therapy should be individualized depending on the nature of DIC, age, etiology of DIC, site and severity of hemorrhage or thrombosis and hemodynamics and other appropriate clinical parameters. At present, treatment of the triggering event, low-dose heparin or antithrombin concentrate and wise choice of components when indicated appear to be the most effective modes of therapy.
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Affiliation(s)
- Rodger L Bick
- University of Texas Southwestern Medical Center, Dallas Thrombosis Hemostasis Clinical Center, ThromboCare Laboratories, 75231, USA.
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33
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Capan LM, Miller SM. Monitoring for suspected pulmonary embolism. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2001; 19:673-703. [PMID: 11778377 DOI: 10.1016/s0889-8537(01)80007-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
It is fortunate that serious embolic phenomena are uncommon because, with the exception of neurosurgery in the sitting position and cardiac surgery, thoracic echocardiography and the precordial Doppler device, the most sensitive indicators of embolism, are seldom used. Vigilance is required of the anesthesiologist to recognize the rapid fall in end-tidal PCO2, the usual first indicator of a clinically significant PE. Any sudden deterioration in the patient's vital signs should include embolism in the differential diagnosis, particularly during procedures that carry a high risk of the complication.
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Affiliation(s)
- L M Capan
- Department of Anesthesiology, New York University School of Medicine, Bellevue Hospital Center, New York, New York, USA.
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34
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Fahy KM. Amniotic fluid embolus: a review of the research literature. AUSTRALIAN JOURNAL OF MIDWIFERY : PROFESSIONAL JOURNAL OF THE AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED 2001; 14:9-13. [PMID: 12759986 DOI: 10.1016/s1445-4386(01)80029-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The diagnosis of Amniotic Fluid Embolus (AFE) is often missed clinically leading to the incorrect attribution of a major post-partum haemorrhage, which may accompany AFE, to uterine atony. This paper reviews the research on AFE with particular emphasis on the clinical presentation and diagnosis; both before and after death. It begins by dealing with the difficulty of defining AFE due to confusion about the underlying pathophysiological events. As this paper will demonstrate, the theory that AFE is an embolic event is no longer valid. A description of the clinical manifestations is provided so that these can be explained by the contemporary theory of AFE as an 'anaphylactoid' reaction. Finally, the difficulties of diagnosis, particularly laboratory diagnosis, will be discussed. The research indicates that it is not possible to accurately diagnose AFE, either, pre or post mortem, by any currently available laboratory tests. Because of better diagnosis it is now known that AFE in not uncommon and, if it is diagnosed early, a much higher rate of intact survival can be achieved than was previously thought possible.
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Affiliation(s)
- K M Fahy
- Faculty of Science, University of Southern Queensland.
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35
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Sáinz J, García Lomas M, Sánchez M, Caballero M, Garrido R, Conde J, Robles A. Embolia de líquido amniótico. Caso clínico y revisión del síndrome. ACTA ACUST UNITED AC 2001. [DOI: 10.1016/s0304-5013(01)75623-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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36
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Bick RL. Syndromes of disseminated intravascular coagulation in obstetrics, pregnancy, and gynecology. Objective criteria for diagnosis and management. Hematol Oncol Clin North Am 2000; 14:999-1044. [PMID: 11005032 DOI: 10.1016/s0889-8588(05)70169-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article presents current understanding of the causes, pathophysiology, clinical, and laboratory diagnosis, and management of fulminant and low-grade DIC, as they apply to obstetric, pregnant, and gynecologic patients. General medical complications leading to DIC, which may often be seen in these patients, are also discussed. Considerable attention has been given to interrelationships within the hemostasis system. Only by clearly understanding these pathophysiologic interrelationships can the obstetrician/gynecologist appreciate the divergent and wide spectrum of often confusing clinical and laboratory findings in patients with DIC. Objective clinical and laboratory criteria for diagnosis of DIC have been outlined to eliminate unnecessary confusion and the need to make empiric decisions regarding the diagnosis. Particularly in the obstetric patient, if a condition is observed that is associated with DIC, or if any suspicion of DIC arises from either clinical or laboratory findings, it is imperative to monitor the patient carefully with clinical and laboratory tools to assess any progression to a catastrophic event. In most instances of DIC in obstetric patients, the disease can be ameliorated easily at early stages. Many therapeutic decisions are straightforward, particularly in obstetric and gynecologic patients. For more serious and complicated cases of DIC in these patients, however, efficacy and choices of therapy will remain unclear until more information is published regarding response rates and survival patterns. Also, therapy must be highly individualized according to the nature of DIC, patient's age, origin of DIC, site and severity of hemorrhage or thrombosis, and hemodynamic and other clinical parameters. Finally, many syndromes that are often categorized as organ-specific disorders and are sometimes identified as independent disease entities, such as AFE syndrome, HELLP syndrome, adult shock lung syndrome, eclampsia, and many others, either share common pathophysiology with DIC or are simply a form of DIC. These entities represent the varied modes of clinical expression of DIC and illustrate the diverse clinical and anatomic manifestations of this syndrome.
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Affiliation(s)
- R L Bick
- Department of Medicine, University of Texas Southwestern Medical Center at Dallas, USA.
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37
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Abstract
Amniotic fluid embolism occurs rarely but is one of the leading causes of maternal mortality in the United States. The risk of death associated with this syndrome is 60% to 80% with half of survivors suffering long-term neurologic disability. The pathophysiology of amniotic fluid embolism is poorly understood. A review of the largest case series to date concluded that the physiologic and hematologic manifestations bear a greater resemblance to septic and anaphylactic shock than to any embolic phenomenon. Care of the patient who suffers amniotic fluid embolism is supportive. To date, no therapeutic interventions have been found to improve survival.
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Affiliation(s)
- G J Locksmith
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, USA
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38
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39
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 9-1998. Cardiovascular collapse after vaginal delivery in a patient with a history of cesarean section. N Engl J Med 1998; 338:821-6. [PMID: 9508626 DOI: 10.1056/nejm199803193381208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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