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Young BK, Florine Magdelijns P, Chervenak JL, Chan M. Amniotic fluid embolism: a reappraisal. J Perinat Med 2024; 52:126-135. [PMID: 38082418 DOI: 10.1515/jpm-2023-0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/20/2023] [Indexed: 02/09/2024]
Abstract
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.
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Affiliation(s)
- Bruce K Young
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York City, USA
- Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York City, USA
| | | | - Judith L Chervenak
- Department of Obstetrics and Gynecology, Bellevue Medical Center, New York City, USA
| | - Michael Chan
- Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York City, USA
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Chuang YC, Peng FS, Tu FC, Chang CY, Lin TY. An intracardiac thrombus as a cause of cardiac arrest during a cesarean delivery. Am J Obstet Gynecol 2022; 227:324-326. [PMID: 35487328 DOI: 10.1016/j.ajog.2022.04.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 11/01/2022]
Affiliation(s)
| | | | - Fung-Chao Tu
- Far Eastern Memorial Hospital, New Taipei, Taiwan
| | | | - Tzu-Yu Lin
- Far Eastern Memorial Hospital, New Taipei, Taiwan.
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McConnell's Sign in a Patient with Amniotic Fluid Embolism and Severe Right Ventricular Dysfunction. CASE (PHILADELPHIA, PA.) 2022; 5:354-357. [PMID: 34993362 PMCID: PMC8713000 DOI: 10.1016/j.case.2021.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
McConnell’s sign may be an early sign of acute RV strain in amniotic fluid embolus. TTE could be considered to facilitate timely diagnosis of amniotic fluid embolus. The presence of RV dysfunction on TTE may help guide hemodynamic therapies.
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Collett LW, Sheehan PV, Gatward JJ. Amniotic fluid embolism with right heart masses presenting as cardiac arrest during labour. Anaesth Intensive Care 2019; 47:193-196. [DOI: 10.1177/0310057x19838726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Thongrong C, Kasemsiri P, Hofmann JP, Bergese SD, Papadimos TJ, Gracias VH, Adolph MD, Stawicki SPA. Amniotic fluid embolism. Int J Crit Illn Inj Sci 2013; 3:51-7. [PMID: 23724386 PMCID: PMC3665120 DOI: 10.4103/2229-5151.109422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Amniotic fluid embolism (AFE) is an unpredictable and as-of-yet unpreventable complication of maternity. With its low incidence it is unlikely that any given practitioner will be confronted with a case of AFE. However, this rare occurrence carries a high probability of serious sequelae including cardiac arrest, ARDS, coagulopathy with massive hemorrhage, encephalopathy, seizures, and both maternal and infant mortality. In this review the current state of medical knowledge about AFE is outlined including its incidence, risk factors, diagnosis, pathophysiology, and clinical manifestations. Special attention is paid to the modern aggressive supportive care that resulted in an overall reduction in the still alarmingly high mortality rate of this devastating entity. The key factors for successful management and resolution of this disease process continue to be sharp vigilance, a high level of clinical suspicion, and rapid all-out resuscitative efforts on the part of all clinicians involved in the medical care of the parturient.
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Affiliation(s)
- Cattleya Thongrong
- Department of Anesthesiology, Division of Trauma, Critical Care and Burn, The Ohio State University College of Medicine, Columbus, USA ; Department of Anesthesiology, Srinagarind Hospital, Faculty of Medicine at the Khon Kaen University, Khon Kaen, Thailand
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Ecker JL, Solt K, Fitzsimons MG, MacGillivray TE. Case records of the Massachusetts General Hospital. Case 40-2012. A 43-year-old woman with cardiorespiratory arrest after a cesarean section. N Engl J Med 2012; 367:2528-36. [PMID: 23268668 DOI: 10.1056/nejmcpc1201413] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jeffrey L Ecker
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, USA
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Kumar S, Wong G, Maysky M, Shulman M, Olenchock S, Falzon-Kirby M, Oo TH. Amniotic fluid embolism complicated by paradoxical embolism and disseminated intravascular coagulation. Am J Crit Care 2010; 19:379-82. [PMID: 19435949 DOI: 10.4037/ajcc2009957] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Amniotic fluid embolism is a rare syndrome with potentially lethal outcomes. Complications include cardiorespiratory failure, disseminated intra-vascular coagulation, seizures, neurological deficits, and death. A 34-year-old woman had amniotic fluid embolism complicated by paradoxical embolism and disseminated intravascular coagulation. Emergency cesarean section followed by cardiopulmonary bypass with removal of the clot from the atria and closure of the patent foramen ovale was performed, resulting in a good outcome for both the mother and the baby. Subsequent treatment with anticoagulants for 6 months was recommended. A literature review revealed that this clinical scenario is rare but can be successfully managed by cardiopulmonary bypass and thromboembolectomy. Data on guidelines for the use of anticoagulation in this situation are limited.
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Affiliation(s)
- Sumeet Kumar
- All authors are on staff at Caritas St Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Glenn Wong
- All authors are on staff at Caritas St Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Michael Maysky
- All authors are on staff at Caritas St Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Mark Shulman
- All authors are on staff at Caritas St Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Stephen Olenchock
- All authors are on staff at Caritas St Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Maria Falzon-Kirby
- All authors are on staff at Caritas St Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Thein H. Oo
- All authors are on staff at Caritas St Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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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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Vellayappan U, Attias MD, Shulman MS. Paradoxical Embolization by Amniotic Fluid Seen on the Transesophageal Echocardiography. Anesth Analg 2009; 108:1110-2. [DOI: 10.1213/ane.0b013e318195b4e3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
INCIDENCE Amniotic fluid embolism is a catastrophic syndrome that occurs during pregnancy or in the immediate postpartum period. Multiple case reports have described the clinical findings and have reported variable success with supportive care. There has been discrepancy with respect to the incidence and mortality of amniotic fluid embolism. One likely explanation for this inconsistency is the lack of sensitive and specific diagnostic studies to definitively identify cases of amniotic fluid embolism, leading to both over- and underreporting. Despite the variation in reported incidence and mortality, amniotic fluid embolism remains a life-threatening condition with significant morbidity and mortality for the pregnant woman. It is the fifth most common cause of maternal mortality in the world. DIAGNOSIS The diagnosis of amniotic fluid embolism continues to be a clinical diagnosis and a diagnosis of exclusion based on the rapid development of a complex constellation of findings with sudden cardiovascular collapse, acute left ventricular failure with pulmonary edema, disseminated intravascular coagulation, and neurologic impairment. Given the significant morbidity and mortality associated with this condition, a high index of suspicion is warranted. Suspected risk factors have included tumultuous labor, trauma, multiparity, increased gestational age, and increased maternal age. However, many patients who develop amniotic fluid embolism have no obvious risk factors. MANAGEMENT Patients with amniotic fluid embolus are best managed using a multidisciplinary approach. There are no pharmacologic or other therapies that prevent or treat the amniotic fluid embolism syndrome, and supportive care typically involves aggressive treatment of multiple types of shock simultaneously. In this article we discuss the clinical presentation of amniotic fluid embolism syndrome as well as current opinions regarding pathophysiology, diagnosis, and management.
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Affiliation(s)
- Jason Moore
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Abstract
PURPOSE OF REVIEW This review will summarize the latest publications on the causes, prevention and treatment of maternal collapse during pregnancy and the postpartum period. It will also explore some future trends particularly in the area of education and team working. RECENT FINDINGS Active management of the third stage of labour has been shown to decrease the incidence of postpartum haemorrhage. Inadequate or prolonged resuscitation following major postpartum haemorrhage can lead to myocardial damage. Guidelines that are followed and the use of drills and simulators may increase effective team working and lead to earlier recognition and treatment of maternal collapse. Some cases of amniotic fluid embolism resemble anaphylaxis and should be treated as such. Important evidence-based guidelines on the management of antithrombolytic prophylaxis and the management of pulmonary embolism have recently been published, which should help clinicians clarify their medical care plans. New resuscitation guidelines in the UK will probably mean that all healthcare workers (including obstetricians and midwives) will need appropriate training every year. SUMMARY Understanding the causes of maternal collapse, its early recognition and prompt resuscitation should decrease both maternal and fetal morbidity and mortality. There is increasing evidence that effective preventative measures and improved multidisciplinary team working may have an important impact on maternal and fetal well-being.
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Affiliation(s)
- James Clarke
- Department of Anaesthesia, St George's Hospital, London, UK.
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