Delayed amniotic fluid embolism following caesarean section under spinal anaesthesia

Defining definitions: a Delphi study to develop a core outcome set for conditions of severe maternal morbidity

OBJECTIVE

Develop a core outcome set of international consensus definitions for severe maternal morbidities.

DESIGN

Electronic Delphi study.

SETTING

International.

POPULATION

Eight expert panels.

METHODS

All 13 high-income countries represented in the International Network of Obstetric Surveillance Systems (INOSS) nominated five experts per condition of morbidity, who submitted possible definitions. From these suggestions, a steering committee distilled critical components: eclampsia: 23, amniotic fluid embolism: 15, pregnancy-related hysterectomy: 11, severe primary postpartum haemorrhage: 19, uterine rupture: 20, abnormally invasive placentation: 12, spontaneous haemoperitoneum in pregnancy: 16, and cardiac arrest in pregnancy: 10. These components were assessed by the expert panel using a 5-point Likert scale, following which a framework for an encompassing definition was constructed. Possible definitions were evaluated in rounds until a rate of agreement of more than 70% was reached. Expert commentaries were used in each round to improve definitions.

MAIN OUTCOME MEASURES

Definitions with a rate of agreement of more than 70%.

RESULTS

The invitation to participate in one or more of eight Delphi processes was accepted by 103 experts from 13 high-income countries. Consensus definitions were developed for all of the conditions.

CONCLUSION

Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process. These should be used in national registrations and international studies, and should be taken up by the Core Outcomes in Women's and Newborn Health initiative.

TWEETABLE ABSTRACT

Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process.

[Recent standards in management of obstetric anesthesia]

The following article contains information not only for the clinical working anaesthesiologist, but also for other specialists involved in obstetric affairs. Besides a synopsis of a German translation of the current "Practice Guidelines for Obstetric Anaesthesia 2016" [1], written by the American Society of Anesthesiologists, the authors provide personal information regarding major topics of obstetric anaesthesia including pre-anaesthesia patient evaluation, equipment and staff at the delivery room, use of general anaesthesia, peridural analgesia, spinal anaesthesia, combined spinal-epidural anaesthesia, single shot spinal anaesthesia, and programmed intermittent epidural bolus.

Practice Guidelines for Obstetric Anesthesia

The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology present an updated report of the Practice Guidelines for Obstetric Anesthesia.

Supplemental Digital Content is available in the text.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Successful recovery from delayed amniotic fluid embolism with prolonged cardiac resuscitation

Amniotic fluid embolisms (AFE) are one of the most fatal complications of pregnancy. We describe a case of AFE that occurred 2 h after vaginal delivery at 41 weeks of gestation. The diagnosis of AFE was made by symptoms of dyspnea, coagulopathy, and severe hypotension. ZnCP-1, the characteristic component of meconium, was elevated in the serum. Cardiac compressions after repeated cardiac arrests were required during the initial 2 h of resuscitation. Primary resuscitation was performed with airway management and aggressive fluid management, including infusion of 33 units of red cell concentrates and 57 units of fresh frozen plasma. The patient recovered without any aftereffects. This case report warrants that AFE should be considered when coagulopathy and dyspnea are observed during the postpartum period.

Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is a rare obstetric catastrophe that occurs suddenly and without warning. AFE is a condition that is poorly understood and often difficult to diagnose, but has a high maternal and neonatal morbidity and mortality. Since it was first described in 1926, the underlying pathophysiology has eluded researchers and clinicians. While a new understanding of the syndrome has emerged with the advent of a national registry in the 1980s, recommendations for diagnostic methods and treatment in the acute phase of the event remain unclear. The purpose of this article is to provide the reader with a historical look at the phenomenon of AFE, a description of its suspected pathophysiology, and recommendations for nursing interventions. A review of data from the national registry and other classic studies are included.

Survival following amniotic fluid embolism and cardiac arrest complicated by sub-capsular liver haematoma

We describe the anaesthetic and intensive care management of a 38-year-old mother with presumed amniotic fluid embolism who suffered cardiorespiratory collapse following delivery of a normal baby by caesarean section. After initial resuscitation, her recovery was complicated by development of disseminated intravascular coagulation and a large sub-capsular hepatic haematoma. We describe the initial resuscitative efforts and subsequent intensive therapy to full neurological recovery and discharge from hospital.

Physical sequelae of caesarean section

The complications and recovery from caesarean section are dominated by the medical condition of the woman pre-operatively. Evidence regarding risks directly attributable to the caesarean section is scanty, and often derived from obstetric practice that differs from the current day. Mortality associated with the procedure is anything up to five times that for vaginal delivery, with emergency caesarean section associated with almost twice the risk of elective procedures. Data regarding placenta praevia and placenta praevia-accreta come from population series where antibiotics were not routinely used for caesarean section, but there is no doubt that previous caesarean section increases the risk of both. Antibiotic and thromboprophylaxis at the time of caesarean section decrease morbidity in the index pregnancy, but can also reasonably be expected to reduce future pregnancy complications.

Amniotic fluid embolus: a review of the literature

PURPOSE

To review the literature since 1979 to determine the natural history, etiology, diagnosis and potential treatment of amniotic fluid embolus (AFE).

SOURCE

English language articles and books published between June 1976 and June 1998 were identified by a computerized medline search using the title or text word amniotic fluid embolus. This same search strategy was repeated and updated to October 1999 by an independent individual using both Medline and Embase. The search was also expanded to include Science Citation Index listing Morgan's 1979 review article. All relevant publications were retrieved and their bibliographies were scanned for additional sources.

PRINCIPAL FINDINGS

Randomized controlled trials are not possible with amniotic fluid emboli. The majority of the literature consists of clinical reports combined with occasional limited reviews. Knowledge obtained from these reports suggests that amniotic fluid emboli present as a spectrum of disease that ranges from a subclinical entity to one that is rapidly fatal. Because cases are sporadic and the diagnosis is often unconfirmed, little progress has been made towards understanding its etiology or defining the risk factors. Present management is empirical and directed towards the maintenance of oxygenation, circulatory support and the correction of coagulopathy.

CONCLUSION

Amniotic fluid embolus continues to be a life-threatening but potentially reversible complication unique to pregnancy. It cannot be predicted nor prevented. Review of the literature reveals that there are no standardized investigational methods or protocols to confirm the diagnosis in suspected cases.

[Evaluation of the blood quality collected by cell-saver during cesarean section]

OBJECTIVE

To determine the quality of blood salvaged and processed during Caesarean section with a cell-saver.

STUDY DESIGN

Laboratory study.

PATIENTS

The study included 20 patients of ASA physical class 1 or 2 undergoing a scheduled Caesarean section.

METHODS

A separate suction device was used from the beginning surgery until the delivery of the fetus, to remove most of the amniotic fluid coming from the surgical field. Thereafter using an Haemolite 2Plus (Haemonetics), the blood was separated and washed with 2 L of normal saline solution. Blood quality was assessed through detection of fetal cells and measuring out of alpha-fetal-protein, tissue factor. A Kleihauer test was also performed.

RESULTS

Cell-saver processing removed most of alpha-fetal-protein and tissue factor while fetal cells were rarely seen. The Kleihauer test could not be performed because of haemolized blood samples. However, the results were very heterogeneous and after washing some salvaged units contained very high concentrations of alpha-fetal-protein or tissue factor.

CONCLUSIONS

These preliminary results show that intra-operative autologous transfusion is not fully safe during Caesarean sections. In addition, there is an immunological risk if a significant part of fetal red blood cells are reinfused into maternal circulation. Therefore, additional studies are needed to better assess this risk.