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Plantzas I, Tousia A, Vlachodimitropoulos D, Piagkou M, Goutas N, Tsakotos G, Triantafyllou G, Plantzas E, Sakelliadis E. The Anaphylactoid Syndrome of Pregnancy: Two Autopsy Cases. Cureus 2023; 15:e45145. [PMID: 37842488 PMCID: PMC10570657 DOI: 10.7759/cureus.45145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
The anaphylactoid syndrome of pregnancy (ASP) is a rare emergency with significant mortality and morbidity, in which the amniotic fluid and fetal cells enter the maternal circulation leading to respiratory failure, altered mental status, hypotension, and disseminated intravascular coagulation. The term ASP was recently introduced to replace the term amniotic fluid embolism since the clinical manifestations of the entity were more similar to a septic or anaphylactic shock rather than that of an embolic event. Two autopsy cases are described, regarding a 35-year-old gravida 2 para 1 and a 34-year-old gravida 1 para 0, where the cause of death was determined to be ASP.
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Affiliation(s)
- Ioannis Plantzas
- Forensic Medicine and Toxicology, National and Kapodistrian University of Athens, Athens, GRC
| | - Athina Tousia
- Forensic Medicine and Toxicology, National and Kapodistrian University of Athens, Athens, GRC
| | | | - Maria Piagkou
- Anatomy, National and Kapodistrian University of Athens, Athens, GRC
| | - Nikolaos Goutas
- Forensic Medicine and Toxicology, National and Kapodistrian University of Athens, Athens, GRC
| | - George Tsakotos
- Anatomy, National and Kapodistrian University of Athens, Athens, GRC
| | | | - Evangelos Plantzas
- Forensic Medicine and Toxicology, National and Kapodistrian University of Athens, Athens, GRC
| | - Emmanouil Sakelliadis
- Forensic Medicine and Toxicology, National and Kapodistrian University of Athens, Athens, GRC
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Okada M, Nomura T, Kunihiro Y, Takegami K, Uehara T, Tokurei S. Lung iodine mapping images of acute postpartum dyspnea without pulmonary thromboembolism using dual-energy CT. Acta Radiol 2023; 64:2401-2408. [PMID: 37203191 DOI: 10.1177/02841851231174460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
BACKGROUND Postpartum dyspnea is commonly observed, but its cause is often unknown. PURPOSE To investigate postpartum dyspnea, we compared lung iodine mapping (LIM) using dual-energy computed tomography (DECT) between postpartum women and women suspected of having pulmonary thromboembolism (PTE). MATERIAL AND METHODS In this retrospective study, 109 women of reproductive age (50 postpartum women, 59 women unrelated to pregnancy) underwent DECT between March 2009 and August 2020. Among the postpartum women, 23 patients were excluded due to late-onset dyspnea (n=20: >48 h after delivery) or the presence of PTE (n=3). A total of 86 patients were divided into three groups (27 postpartum women [postpartum group], 19 women with PTE [PTE group], and 40 women without PTE [non-PTE group]). Quantitation was applied to a decreased LIM value (LIM5; defined as <5 HU) and the relative value of LIM5 to whole LIM volume (%LIM5). LIM defects were classified into five patterns (0 = none, 1 = wedge-shaped, 2 = reticular/liner, 3 = diffuse granular/patchy, 4 = massive defects) based on a consensus between two readers. RESULTS There were significant differences in the LIM5 and %LIM5 values among the three groups. The LIM5 and %LIM5 were largest in the PTE group, and postpartum women showed intermediate values between the non-PTE and PTE groups. Wedge-shaped defects were prominent in the PTE group, and diffuse granular/patchy defect was a typical feature in the postpartum group. CONCLUSION Postpartum women with dyspnea showed granular/patchy defects on DECT with a median quantitative value between the PTE and non-PTE groups.
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Affiliation(s)
- Munemasa Okada
- Department of Radiology, National Hospital Organization, Kanmon Medical Center, Shimonoseki, Japan
| | - Takafumi Nomura
- Department of Radiology, Ube-Kohsan Central Hospital, Ube, Japan
| | - Yoshie Kunihiro
- Department of Radiology, Yamaguchi University School of Medicine, Ube, Japan
| | - Kazuki Takegami
- Department of Radiology, Yamaguchi University Hospital, Ube, Japan
| | - Takuya Uehara
- Department of Radiology, Yamaguchi University Hospital, Ube, Japan
| | - Shogo Tokurei
- Department of Radiological Science, Faculty of Health Sciences, Junshin Gakuen University, Fukuoka, Japan
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Shaikh N, Alhammad MF, Nahid S, Umm E A, Fatima I, Ummunnisa F, Yaqoub SA. Amniotic fluid embolism causing multiorgan embolisms and reinforces the need for point-of-care ultrasound. Qatar Med J 2023; 2023:13. [PMID: 37521090 PMCID: PMC10376761 DOI: 10.5339/qmj.2023.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/02/2023] [Indexed: 08/01/2023] Open
Abstract
INTRODUCTION Pregnant patients are at risk of several possible complications during the peripartum period. Amniotic fluid embolism (AFE) is a peripartum complication with high mortality and morbidity. The sudden entry of amniotic fluid into the maternal circulation causes a rapid and dramatic sequence of clinical events called AFE. The reported incidence of AFE after a cesarean section is around 19%, and after a normal delivery, it is 11%. AFE causing multiple embolisms is not reported in the literature, nor is the use of point-of-care ultrasound (POCUS) in the diagnosis of AFE. We report a case of AFE causing pulmonary and ovarian embolisms. CASE A 34-year-old pregnant lady had an elective lower section cesarean section (LSCS) for transverse lying and placenta previa under combined spinal and epidural anesthesia. She was gravida 3 para 2 and had regular antenatal check-ups, and she presented for her LSCS at 36 weeks of gestation. Immediately after delivery of the fetus, the patient had convulsions, cardiac arrest, and disseminated intravascular coagulopathy (DIC). Immediately, cardiopulmonary resuscitation started, and the team achieved a return of spontaneous circulation (ROSC) in 3 minutes. DIC was corrected with blood and blood products during this maneuver, and POCUS of the inferior vena cava and heart showed multiple small particles floating, thus confirming the diagnosis of AFE in this patient. The patient was transferred to the intensive care unit (ICU), intubated, and ventilated, necessitating a vasopressor infusion. Computed tomographic pulmonary angiography (CTPA) showed pulmonary embolism and ovarian vein embolism, which were managed with heparin infusion. She was hemodynamically stable and weaned from vasopressors, and the ventilator was then extubated on day 13 of ICU admission. She remained awake and in stable condition. The patient was transferred to the ward and subsequently discharged to go home on the 20th-day post-delivery. CONCLUSION AFE can be quickly diagnosed using clinical manifestations and POCUS, and it can be managed early for better patient outcomes. POCUS will show multiple smaller and a few larger amniotic fluid emboli in the heart and vena cava. These larger AFE emboli can migrate and cause multiple embolisms, requiring systemic anticoagulation.
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Affiliation(s)
- Nissar Shaikh
- Department of Anesthesia, ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar. E-mail: ORCID ID: https://orcid.org/0000-0002-8241-7939
| | - Muhammad Fras Alhammad
- Department of Anesthesia, ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar. E-mail: ORCID ID: https://orcid.org/0000-0002-8241-7939
| | - Seema Nahid
- Department of Anesthesia, ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar. E-mail: ORCID ID: https://orcid.org/0000-0002-8241-7939
| | - Amara Umm E
- Apollo Medical College Hyderabad, Telangana, India
| | - Ifrah Fatima
- The University of Missouri-Kansas City (UMKC), Missouri, USA
| | | | - Slawa Abu Yaqoub
- Women's Wellness & Research Center, Hamad Medical Corporation, Doha, Qatar
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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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Gara M, Draouil A, Saad AB, Njima M, Ladib A, Cherif O, Jlali A, Grati L. Disseminated intravascular coagulation type of amniotic fluid embolism: a challenging case report with favorable outcome. Pan Afr Med J 2021; 38:325. [PMID: 34285748 PMCID: PMC8265244 DOI: 10.11604/pamj.2021.38.325.23434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 05/26/2020] [Indexed: 12/02/2022] Open
Abstract
Amniotic fluid embolism (AFE) is an unforeseeable, life-threatening complication of pregnancy and child birth. Although rare in an absolute sense, most contemporary series of maternal deaths from developed countries report AFE as a leading cause of mortality in the pregnant population. It has a heterogeneous presentation. This clinical heterogeneity makes the diagnosis of AFE difficult based on a beam of clinical and para-clinical arguments. Rapid diagnosis and immediate interdisciplinary treatment are essential for a good outcome. The present is a case of AFE with a disseminated intravascular coagulation (DIC) and a cardiorespiratory collapse following a vaginal delivery.
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Affiliation(s)
- Mouna Gara
- Anesthesia-Intensive Care Department B, Maternity and Neonatology Teaching Center of Monastir, Monastir, Tunisia
| | - Arij Draouil
- Anesthesia-Intensive Care Department B, Maternity and Neonatology Teaching Center of Monastir, Monastir, Tunisia
| | - Ahmed Ben Saad
- Pulmonology Department, Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Manel Njima
- Department of Pathology, Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Asma Ladib
- Anesthesia-Intensive Care Department B, Maternity and Neonatology Teaching Center of Monastir, Monastir, Tunisia
| | - Ons Cherif
- Department of Gynaecology-Obstetrics, Maternity and Neonatology Teaching Center of Monastir, Monastir, Tunisia
| | - Ali Jlali
- Anesthesia-Intensive Care Department B, Maternity and Neonatology Teaching Center of Monastir, Monastir, Tunisia
| | - Lotfi Grati
- Anesthesia-Intensive Care Department B, Maternity and Neonatology Teaching Center of Monastir, Monastir, Tunisia
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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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7
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Ren F, Huang W, Luo L, Zhou J, Huang D, Tang L. Amniotic fluid and pulmonary emboli in a patient with SLE and a twin gestation. Rheumatology (Oxford) 2021; 59:e107-e108. [PMID: 32596716 DOI: 10.1093/rheumatology/keaa285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 04/23/2020] [Accepted: 04/29/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Feifeng Ren
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenhan Huang
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lei Luo
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Zhou
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dongmei Huang
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lin Tang
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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8
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Sitaula S, Das D, Sitaula S, Chhetry M. Amniotic fluid embolism: A rare cause of maternal collapse-A case report. Clin Case Rep 2020; 8:3359-3361. [PMID: 33363934 PMCID: PMC7752387 DOI: 10.1002/ccr3.3433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/04/2020] [Indexed: 11/10/2022] Open
Abstract
High index of suspicion of amniotic fluid embolism should be considered in any intrapartum or postpartum collapse where the obvious cause of collapse is not identified.
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Affiliation(s)
| | - Dipti Das
- B.P. Koirala institute of Health Sciences DharanNepal
| | - Subhas Sitaula
- Critical Care UnitSinging River Health SystemPascagoulaMSUSA
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9
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Ufuk F, Kaya F, Sagtas E, Kupeli A. Non-thrombotic pulmonary embolism in emergency CT. Emerg Radiol 2020; 27:343-350. [PMID: 32002737 DOI: 10.1007/s10140-020-01755-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 01/24/2020] [Indexed: 02/06/2023]
Abstract
Non-thrombotic pulmonary embolism (NTPE) results from the embolization of non-thrombotic materials. It can often be a challenging diagnosis due to non-specific (similar to thrombotic pulmonary embolism) or uncommon clinical and imaging findings. Patients with NTPE often present to the emergency department with acute respiratory distress, and contrast-enhanced computed tomography (CT) of the chest and CT pulmonary angiography are the imaging modalities of choice for respiratory distress. Since the treatment of NTPE is entirely different from thromboembolism, its distinction is essential. Moreover, early diagnosis of NTPE is necessary. Radiologists must be familiar with the diagnostic findings of NTPE, and this article aims to review the imaging features of various causes of NTPE.
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Affiliation(s)
- Furkan Ufuk
- Department of Radiology, University of Pamukkale, Denizli, Turkey.
| | - Furkan Kaya
- Department of Radiology, University of Kocatepe, Afyonkarahisar, Turkey
| | - Ergin Sagtas
- Department of Radiology, University of Pamukkale, Denizli, Turkey
| | - Ali Kupeli
- Department of Radiology, Erzincan Binali Yildirim University, Erzincan, Turkey
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10
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Amniotic Fluid Embolism Treated with Veno-Arterial Extracorporeal Membrane Oxygenation. Case Rep Crit Care 2019; 2019:4589636. [PMID: 31934458 PMCID: PMC6942779 DOI: 10.1155/2019/4589636] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/30/2019] [Accepted: 11/05/2019] [Indexed: 11/17/2022] Open
Abstract
Amniotic fluid embolism (AFE) is an extremely rare yet fatal obstetric emergency. AFE presents as sudden cardiovascular collapse after a breach of maternal-fetal membranes and is often complicated by severe coagulopathy. We present a case where an AFE was treated with veno-arterial extracorporeal membrane oxygenation (ECMO) to help overcome the acute cardiopulmonary insult. The use of echocardiography proved to be an invaluable tool to help guide treatment and optimal duration of ECMO in the face of severe coagulopathy.
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11
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Kinishi Y, Ootaki C, Iritakenishi T, Fujino Y. A case of amniotic fluid embolism successfully treated by multidisciplinary treatment. JA Clin Rep 2019; 5:79. [PMID: 32026080 PMCID: PMC6967009 DOI: 10.1186/s40981-019-0296-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/30/2019] [Indexed: 11/16/2022] Open
Abstract
Background Amniotic fluid embolism (AFE) is a life-threatening obstetric emergency. Because the maternal mortality associated with AFE is very high, early recognition and prompt treatment are important for improving the prognosis. We report a case of amniotic fluid embolism successfully treated by multidisciplinary treatment. Case presentation A 39-year-old woman with fetal congenital heart anomaly and polyhydramnios was scheduled for induction of delivery at 37 weeks of gestation with labor epidural analgesia. Uncontrollable bleeding occurred 30 min after vaginal delivery. Based on the clinical diagnosis of AFE, massive blood transfusion, insertion of an aortic occlusion balloon catheter, and hysterectomy was performed. Total blood loss was 12,000 mL. The diagnosis of AFE was confirmed by pathological examination. She was discharged with no complications. Conclusion We report a case of AFE who were rescued by prompt diagnosis and treatment.
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Affiliation(s)
- Yuki Kinishi
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Chiyo Ootaki
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Takeshi Iritakenishi
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Abstract
Many health care providers lack familiarity with maternal physiologic changes and the distinctive underlying etiology of cardiac arrest in pregnancy. Knowledge of what changes are expected in pregnancy and an understanding of how to adapt clinical practice is essential for the care of the pregnant woman in the emergency department. Amniotic fluid embolism should be recognized as a rare cause of cardiac arrest in pregnancy, characterized by the triad of cardiovascular collapse, hypoxic respiratory failure, and coagulopathy. Cardiopulmonary resuscitation should follow standard AHA ACLS guidelines. Resuscitative hysterotomy may be attempted to restore perfusion to both mother and fetus.
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Affiliation(s)
- Philippa N Soskin
- Department of Emergency Medicine, MedStar Georgetown University Hospital, MedStar Washington Hospital Center, Georgetown University School of Medicine, 3800 Reservoir Road Northwest, Ground Floor CCC Building, Washington, DC 20007, USA
| | - Jennifer Yu
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, 110 Irving Street Northwest, Suite 4B-42, Washington, DC 20010, USA.
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13
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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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Oglesby F, Marsh C. Amniotic fluid embolism: a diagnosis of exclusion in cases of maternal collapse. Br J Hosp Med (Lond) 2018; 79:C157-C160. [PMID: 30290750 DOI: 10.12968/hmed.2018.79.10.c157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Fiona Oglesby
- Clinical Fellow in Anaesthesia, Department of Anaesthesia, Royal United Hospitals, Bath BA1 3NG
| | - Chris Marsh
- Consultant in Anaesthesia and Obstetric Lead, Department of Anaesthesia, Royal United Hospitals, Bath
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15
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McCabe BE, Veselis CA, Goykhman I, Hochhold J, Eisenberg D, Son H. Beyond Pulmonary Embolism; Nonthrombotic Pulmonary Embolism as Diagnostic Challenges. Curr Probl Diagn Radiol 2018; 48:387-392. [PMID: 30232041 DOI: 10.1067/j.cpradiol.2018.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/16/2018] [Accepted: 07/17/2018] [Indexed: 12/23/2022]
Abstract
Nonthrombotic pulmonary embolism (NTPE) is less well understood and is encountered less frequently than pulmonary embolism from venous thrombosis. NTPE results from embolization of nonthrombotic material to the pulmonary vasculature originating from many different cell types as well as nonbiologic or foreign materials. For many radiologists NTPE is a challenging diagnosis, presenting nonspecific or unusual imaging findings in the setting of few or unusual clinical signs. The aim of this paper is to review the pathophysiology of diverse causes of NTPE, which should aid radiologists to better understand and, more importantly, diagnose these infrequent events.
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Affiliation(s)
| | - Clinton A Veselis
- Temple University Hospital, Department of Radiology, Philadelphia, PA.
| | - Igor Goykhman
- Einstein Medical Center, Department of Radiology, Philadelphia, PA.
| | - John Hochhold
- Einstein Medical Center, Department of Radiology, Philadelphia, PA.
| | - Daniel Eisenberg
- Einstein Medical Center, Department of Radiology, Philadelphia, PA.
| | - Hongju Son
- Einstein Medical Center, Department of Radiology, Philadelphia, PA.
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16
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Metodiev Y, Ramasamy P, Tuffnell D. Amniotic fluid embolism. BJA Educ 2018; 18:234-238. [PMID: 33456838 DOI: 10.1016/j.bjae.2018.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2018] [Indexed: 01/03/2023] Open
Affiliation(s)
- Y Metodiev
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - P Ramasamy
- University Hospitals of Leicester NHS Trust, Leicester, UK
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18
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Caeiro AFC, Ramilo IDTM, Santos AP, Ferreira E, Batalha IS. Amniotic Fluid Embolism. Is a New Pregnancy Possible? Case Report. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2017; 39:369-372. [PMID: 28464190 PMCID: PMC10416167 DOI: 10.1055/s-0037-1601428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/09/2017] [Indexed: 10/19/2022] Open
Abstract
Amniotic fluid embolism (AFE) is a rare but potentially catastrophic clinical condition, characterized by a combination of signs and symptoms that reflect respiratory distress, cardiovascular collapse and disseminated intravascular coagulation (DIC). Its pathogenesis is still unclear. More recently, the traditional view of obstruction of pulmonary capillary vessels by amniotic fluid emboli as the main explanation for the etiology has been ruled out, and immunologic factors and the activation of the inflammatory cascade took on an important role. Amniotic fluid embolism has an unpredictable character, its diagnosis is exclusively clinical, and the treatment consists mainly of cardiovascular support and administration of blood products to correct the DIC. No diagnostic test is recommended until now, though multiple blood markers are currently being studied. The authors present a case report of a woman who had survived AFE in her previous pregnancy and had a subsequent pregnancy without recurrence, providing one more clinical testimony of the low risks for the pregnancy after AFE.
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Affiliation(s)
| | | | - Ana Paula Santos
- Department of Gynecology and Obstetrics, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Elizabeth Ferreira
- Department of Gynecology and Obstetrics, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Isabel Santos Batalha
- Department of Gynecology and Obstetrics, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
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Indraccolo U, Battistoni C, Mastrantonio I, Di Iorio R, Greco P, Indraccolo SR. Risk factors for fatality in amniotic fluid embolism: a systematic review and analysis of a data pool. J Matern Fetal Neonatal Med 2017; 31:661-665. [PMID: 28282766 DOI: 10.1080/14767058.2017.1293034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Investigating risk factors for amniotic fluid embolism (AFE)-induced fatality. METHODS A systematic review of cases of AFE available on PubMed, Scielo, Scopus and AJOL databases that occurred from 1990 to 2015 was carried out. After careful reading of titles, abstracts and full texts, case reports of AFE were reviewed. Risk factors for AFE were considered as independent variables in logistic regression models. The first model was built on the whole data pool. The second model was built on typical cases of AFE, according to the classical triad of symptoms (heart, lungs, coagulopathy). The dependent variable was fatality in both models. RESULTS 177 cases of AFE were assessed in the first model, while 121 typical cases of AFE were assessed in the second model. Among typical cases of AFE, only oxytocin infusion during labour increases the likelihood of death (odds ratio 2.890, 95% confidence interval 1.166-7.164, p = 0.022). No risk factors for fatality were found in the whole data pool. CONCLUSIONS Further research on national registries should focus on the behaviour of oxytocin infusion during labour in AFE cases.
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Affiliation(s)
- Ugo Indraccolo
- a Complex Operative Unit of Obstetrics and Gynecology , "Alto Tevere" Hospital of Città di Castello, ASL 1 Umbria , Città di Castello , Italy
| | - Caterina Battistoni
- b Department of Gynecological, Obstetrical, and Urological Sciences , "Sapienza" University of Rome , Rome , Italy
| | - Irene Mastrantonio
- b Department of Gynecological, Obstetrical, and Urological Sciences , "Sapienza" University of Rome , Rome , Italy
| | - Romolo Di Iorio
- c Department of Surgical and Clinical Sciences and Translational Medicine , "Sapienza" University of Rome , Rome , Italy
| | - Pantaleo Greco
- d Department of Morphology, Surgery and Experimental Medicine , University of Ferrara , Ferrara , Italy
| | - Salvatore Renato Indraccolo
- b Department of Gynecological, Obstetrical, and Urological Sciences , "Sapienza" University of Rome , Rome , Italy
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Tamura N, Farhana M, Oda T, Itoh H, Kanayama N. Amniotic fluid embolism: Pathophysiology from the perspective of pathology. J Obstet Gynaecol Res 2017; 43:627-632. [DOI: 10.1111/jog.13284] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/14/2016] [Accepted: 12/19/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Naoaki Tamura
- Department of Obstetrics & Gynaecology; Hamamatsu University School of Medicine; Hamamatsu Japan
| | - Mustari Farhana
- Department of Obstetrics & Gynaecology; Hamamatsu University School of Medicine; Hamamatsu Japan
| | - Tomoaki Oda
- Department of Obstetrics & Gynaecology; Hamamatsu University School of Medicine; Hamamatsu Japan
| | - Hiroaki Itoh
- Department of Obstetrics & Gynaecology; Hamamatsu University School of Medicine; Hamamatsu Japan
| | - Naohiro Kanayama
- Department of Obstetrics & Gynaecology; Hamamatsu University School of Medicine; Hamamatsu Japan
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Lynch W, McAllister RK, Lay JF, Culp WC. Lipid Emulsion Rescue of Amniotic Fluid Embolism-Induced Cardiac Arrest. ACTA ACUST UNITED AC 2017; 8:64-66. [DOI: 10.1213/xaa.0000000000000427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Amniotic fluid embolism (AFE) is one of the catastrophic complications of pregnancy in which amniotic fluid, fetal cells, hair, or other debris enters into the maternal pulmonary circulation, causing cardiovascular collapse. Etiology largely remains unknown, but may occur in healthy women during labour, during cesarean section, after abnormal vaginal delivery, or during the second trimester of pregnancy. It may also occur up to 48 hours post-delivery. It can also occur during abortion, after abdominal trauma, and during amnio-infusion. The pathophysiology of AFE is not completely understood. Possible historical cause is that any breach of the barrier between maternal blood and amniotic fluid forces the entry of amniotic fluid into the systemic circulation and results in a physical obstruction of the pulmonary circulation. The presenting signs and symptoms of AFE involve many organ systems. Clinical signs and symptoms are acute dyspnea, cough, hypotension, cyanosis, fetal bradycardia, encephalopathy, acute pulmonary hypertension, coagulopathy etc. Besides basic investigations lung scan, serum tryptase levels, serum levels of C3 and C4 complements, zinc coproporphyrin, serum sialyl Tn etc are helpful in establishing the diagnosis. Treatment is mainly supportive, but exchange transfusion, extracorporeal membrane oxygenation, and uterine artery embolization have been tried from time to time. The maternal prognosis after amniotic fluid embolism is very poor though infant survival rate is around 70%.
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Affiliation(s)
- Kiranpreet Kaur
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
| | - Mamta Bhardwaj
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
| | - Prashant Kumar
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
| | - Suresh Singhal
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
| | - Tarandeep Singh
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
| | - Sarla Hooda
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
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Amniotic Fluid Embolism: Anaphylactic Reactions With Idiosyncratic Adverse Response. Obstet Gynecol Surv 2016; 70:511-7. [PMID: 26314236 DOI: 10.1097/ogx.0000000000000197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PROBLEM Amniotic fluid embolism (AFE) is a rare but severe emergency in obstetrics. The aim of the present study was to investigate the pathophysiology of AFE. METHODS A search was conducted between 1966 and 2014 through the English-language literature (online MEDLINE PubMed database) using the keyword amniotic fluid embolism combined with anaphylaxis, anaphylactoid, complement activation, mast cells, fetal antigens, and idiosyncratic. RESULTS Amniotic fluid embolism is a rare clinical entity but a severe obstetric emergency that can be lethal even in previously healthy women in labor or in the early postpartum period. There appears to be at least 2 mechanisms. First, adverse reactions in AFE are usually unexpected and fetal antigen dose dependent. Given the disastrous entry of amniotic fluid into the maternal circulation, they experience a sudden cardiopulmonary collapse (mechanical obstruction subtype). Second, anaphylactic and anaphylactoid reactions of the remaining AFE are also relatively unexpected and fetal antigen dose independent and can occur at the first exposure to amniotic fluid components. They are associated with complement activation and subsequent postpartum hemorrhage. Cardiac mast cells constitute a central pathogenesis of anaphylactic (immunoglobulin E-dependent) and anaphylactoid (immunoglobulin E-independent) reactions. CONCLUSIONS Recent immunologic studies provide a new approach to the study of the pathophysiology of AFE.
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McDonnell N, Knight M, Peek MJ, Ellwood D, Homer CSE, McLintock C, Vaughan G, Pollock W, Li Z, Javid N, Sullivan E. Amniotic fluid embolism: an Australian-New Zealand population-based study. BMC Pregnancy Childbirth 2015; 15:352. [PMID: 26703453 PMCID: PMC4690249 DOI: 10.1186/s12884-015-0792-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 12/11/2015] [Indexed: 11/18/2022] Open
Abstract
Background Amniotic fluid embolism (AFE) is a major cause of direct maternal mortality in Australia and New Zealand. There has been no national population study of AFE in either country. The aim of this study was to estimate the incidence of amniotic fluid embolism in Australia and New Zealand and to describe risk factors, management, and perinatal outcomes. Methods A population-based descriptive study using the Australasian Maternity Outcomes Surveillance System (AMOSS) carried out in 263 eligible sites (>50 births per year) covering an estimated 96 % of women giving birth in Australia and all 24 New Zealand maternity units (100 % of women giving birth in hospitals) between January 1 2010-December 31 2011. A case of AFE was defined either as a clinical diagnosis (acute hypotension or cardiac arrest, acute hypoxia and coagulopathy in the absence of any other potential explanation for the symptoms and signs observed) or as a post mortem diagnosis (presence of fetal squames/debris in the pulmonary circulation). Results Thirty-three cases of AFE were reported from an estimated cohort of 613,731women giving birth, with an estimated incidence of 5.4 cases per 100 000 women giving birth (95 % CI 3.5 to 7.2 per 100 000). Two (6 %) events occurred at home whilst 46 % (n = 15) occurred in the birth suite and 46 % (n = 15) in the operating theatre (location not reported in one case). Fourteen women (42 %) underwent either an induction or augmentation of labour and 22 (67 %) underwent a caesarean section. Eight women (24 %) conceived using assisted reproduction technology. Thirteen (42 %) women required cardiopulmonary resuscitation, 18 % (n = 6) had a hysterectomy and 85 % (n = 28) received a transfusion of blood or blood products. Twenty (61 %) were admitted to an Intensive Care Unit (ICU), eight (24 %) were admitted to a High Dependency Unit (HDU) and seven (21 %) were transferred to another hospital for further management. Five woman died (case fatality rate 15 %) giving an estimated maternal mortality rate due to AFE of 0.8 per 100 000 women giving birth (95 % CI 0.1 % to 1.5 %). There were two deaths among 36 infants. Conclusions A coordinated emergency response requiring resource intense multi-disciplinary input is required in the management of women with AFE. Although the case fatality rate is lower than in previously published studies, high rates of hysterectomy, resuscitation, and admission to higher care settings reflect the significant morbidity associated with AFE. Active, ongoing surveillance to document the risk factors and short and long-term outcomes of women and their babies following AFE may be helpful to guide best practice, management, counselling and service planning. A potential link between AFE and assisted reproductive technology warrants further investigation.
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Affiliation(s)
- Nolan McDonnell
- School of Women's and Infants' Health and School of Medicine and Pharmacology, University of Western Australia, Perth, Australia. .,Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital, 374 Bagot Road, Subiaco, WA, 6008, Australia. .,Department of Anaesthesia, St John of God Hospital (Subiaco), Perth, Australia.
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK.
| | - Michael J Peek
- Sydney Medical School Nepean, The University of Sydney, Sydney, Australia.
| | - David Ellwood
- School of Medicine, Gold Coast Campus, Griffith University, Gold Coast, Australia. .,Gold Coast University Hospital, Gold Coast, Australia.
| | | | - Claire McLintock
- National Women's Health, Auckland City Hospital, Auckland, New Zealand.
| | - Geraldine Vaughan
- University of Technology Sydney, Faculty of Health, Sydney, Australia.
| | - Wendy Pollock
- Judith Lumley Research Centre, La Trobe University, Melbourne, Australia. .,Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia.
| | - Zhuoyang Li
- University of Technology Sydney, Faculty of Health, Sydney, Australia.
| | - Nasrin Javid
- University of Technology Sydney, Faculty of Health, Sydney, Australia.
| | - Elizabeth Sullivan
- University of Technology Sydney, Faculty of Health, Sydney, Australia. .,School of Women's and Children's Health, The University of New South Wales, Sydney, Australia.
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Shen F, Wang L, Yang W, Chen Y. From appearance to essence: 10 years review of atypical amniotic fluid embolism. Arch Gynecol Obstet 2015; 293:329-34. [PMID: 26092134 DOI: 10.1007/s00404-015-3785-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Fangrong Shen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Soochow University, 118 Shizi Street, Suzhou, 215006, Jiangsu, China.,Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Lu Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Soochow University, 118 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Weiwen Yang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Soochow University, 118 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Youguo Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Soochow University, 118 Shizi Street, Suzhou, 215006, Jiangsu, China.
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Todo Y, Tamura N, Itoh H, Ikeda T, Kanayama N. Therapeutic application of C1 esterase inhibitor concentrate for clinical amniotic fluid embolism: a case report. Clin Case Rep 2015; 3:673-5. [PMID: 26273468 PMCID: PMC4527822 DOI: 10.1002/ccr3.316] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 04/06/2015] [Accepted: 05/21/2015] [Indexed: 11/11/2022] Open
Abstract
We present the successful application of C1 esterase inhibitor (C1INH) concentrate to a patient with clinical amniotic fluid embolism (AFE).
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Affiliation(s)
- Yusuke Todo
- Department of Obstetrics & Gynaecology, Hamamatsu University School of Medicine Hamamatsu, Shizuoka, Japan
| | - Naoaki Tamura
- Department of Obstetrics & Gynaecology, Hamamatsu University School of Medicine Hamamatsu, Shizuoka, Japan
| | - Hiroaki Itoh
- Department of Obstetrics & Gynaecology, Hamamatsu University School of Medicine Hamamatsu, Shizuoka, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics & Gynaecology, Mie University School Mie, Japan
| | - Naohiro Kanayama
- Department of Obstetrics & Gynaecology, Hamamatsu University School of Medicine Hamamatsu, Shizuoka, Japan
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Farhana M, Tamura N, Mukai M, Ikuma K, Koumura Y, Furuta N, Yaguchi C, Uchida T, Suzuki K, Sugihara K, Itoh H, Kanayama N. Histological characteristics of the myometrium in the postpartum hemorrhage of unknown etiology: a possible involvement of local immune reactions. J Reprod Immunol 2015; 110:74-80. [PMID: 26048052 DOI: 10.1016/j.jri.2015.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 04/23/2015] [Indexed: 11/27/2022]
Abstract
The aim of this study was to evaluate the histological characteristics of the myometrium obtained in postpartum hemorrhage (PPH) of unknown etiology secondary to uterine atony. These characteristics were selected from among registered cases of clinically suspected amniotic fluid embolism (AFE) and classified as PPH of unknown etiology because of no obvious cause of PPH at Hamamatsu University School of Medicine, a registration center for clinical AFE in Japan. Immunohistochemical studies were performed on myometrium using anti-mast cell tryptase, anti-neutrophil elastase, anti-CD68, anti-CD88, anti-CD3, and anti-ZnCP-1 antibodies. Massive infiltrations of inflammatory cells with mast cell degranulation within the myometrium secondary to complement activation were observed in PPH of unknown etiology (n=34), but not in control pregnant women (n=15) or after delivery in women without PPH (n=18). The concomitant immunohistochemical detection of meconium in myometrium suggests that amniotic fluids or fetal materials are one of the candidates for inducing maternal local immune activation in the PPH of unknown etiology. Postpartum acute myometritis in the absence of an infective etiology may be a histological characteristic of PPH of unknown etiology.
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Affiliation(s)
- Mustari Farhana
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
| | - Naoaki Tamura
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan.
| | - Mari Mukai
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
| | - Kotomi Ikuma
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
| | - Yukiko Koumura
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
| | - Naomi Furuta
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
| | - Chizuko Yaguchi
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
| | - Toshiyuki Uchida
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
| | - Kazunao Suzuki
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
| | - Kazuhiro Sugihara
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
| | - Hiroaki Itoh
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
| | - Naohiro Kanayama
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, 1-20-1, Handayama Higashi-Ku, Hamamatsu 4313192, Shizuoka, Japan
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Umazume T, Morikawa M, Yamada T, Akaishi R, Koyama T, Minakami H. Protein S deficiency present in a pregnant woman with dyspnea, abdominal pains, restlessness, agitation and hypofibrinogenemia. Clin Case Rep 2015; 3:213-6. [PMID: 25914811 PMCID: PMC4405304 DOI: 10.1002/ccr3.200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 11/04/2014] [Accepted: 12/07/2014] [Indexed: 12/19/2022] Open
Abstract
Hypofibrinogenemia is rare in pulmonary thromboembolism. A pregnant woman with dyspnea, abdominal pain, restlessness, agitation and protein S deficiency exhibited normal blood oxygenation and high D-dimer (370 μg/mL) and undetectable fibrinogen levels in the blood. The pathogenesis responsible for present findings may have some features similar to amniotic fluid embolism.
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Affiliation(s)
- Takeshi Umazume
- Department of Obstetrics, Hokkaido University Graduate School of Medicine Sapporo, 060-8638, Japan
| | - Mamoru Morikawa
- Department of Obstetrics, Hokkaido University Graduate School of Medicine Sapporo, 060-8638, Japan
| | - Takahiro Yamada
- Department of Obstetrics, Hokkaido University Graduate School of Medicine Sapporo, 060-8638, Japan
| | - Rina Akaishi
- Department of Obstetrics, Hokkaido University Graduate School of Medicine Sapporo, 060-8638, Japan
| | - Takahiro Koyama
- Department of Obstetrics, Hokkaido University Graduate School of Medicine Sapporo, 060-8638, Japan
| | - Hisanori Minakami
- Department of Obstetrics, Hokkaido University Graduate School of Medicine Sapporo, 060-8638, Japan
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Busardò FP, Frati P, Zaami S, Fineschi V. Amniotic fluid embolism pathophysiology suggests the new diagnostic armamentarium: β-tryptase and complement fractions C3-C4 are the indispensable working tools. Int J Mol Sci 2015; 16:6557-70. [PMID: 25807263 PMCID: PMC4394548 DOI: 10.3390/ijms16036557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 03/03/2015] [Accepted: 03/10/2015] [Indexed: 11/16/2022] Open
Abstract
Amniotic fluid embolism (AFE) is an uncommon obstetric condition involving pregnant women during labor or in the initial stages after delivery. Its incidence is estimated to be around 5.5 cases per 100,000 deliveries. Therefore, this paper investigated the pathophysiological mechanism, which underlies AFE, in order to evaluate the role of immune response in the development of this still enigmatic clinical entity. The following databases (from 1956 to September 2014) Medline, Cochrane Central, Scopus, Web of Science and Science Direct were used, searching the following key words: AFE, pathophysiology, immune/inflammatory response, complement and anaphylaxis. The main key word “AFE” was searched singularly and associated individually to each of the other keywords. Of the 146 sources found, only 19 were considered appropriate for the purpose of this paper. The clinical course is characterized by a rapid onset of symptoms, which include: acute hypotension and/or cardiac arrest, acute hypoxia (with dyspnoea, cyanosis and/or respiratory arrest), coagulopathies (disseminated intravascular coagulation and/or severe hemorrhage), coma and seizures. The pathology still determines a significant morbidity and mortality and potential permanent neurological sequelae for surviving patients. At this moment, numerous aspects involving the pathophysiology and clinical development are still not understood and several hypotheses have been formulated, in particular the possible role of anaphylaxis and complement. Moreover, the detection of serum tryptase and complement components and the evaluation of fetal antigens can explain several aspects of immune response.
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Affiliation(s)
- Francesco Paolo Busardò
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy.
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy.
- Neuromed, Istituto Mediterraneo Neurologico (IRCCS), Via Atinense 18, Pozzilli, 86077 Isernia, Italy.
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy.
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy.
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Benzidi Y, Jourdain M. Complications cardiovasculaires de la grossesse et du peripartum. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1042-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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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Morikawa M, Kuramoto A, Nakayama M, Oguchi H, Hasegawa M, Funakoshi T, Furukawa S, Hirayama E, Kanagawa T, Kaji T, Kasai M, Konishi Y, Yamamoto SI, Itakura A, Maeda M, Kobayashi T, Minakami H. Intraoperative red cell salvage during obstetric surgery in 50 Japanese women. Int J Gynaecol Obstet 2014; 128:256-9. [DOI: 10.1016/j.ijgo.2014.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 08/25/2014] [Accepted: 10/20/2014] [Indexed: 11/28/2022]
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Mo X, Feng A, Liu X, Tobe RG. Amniotic Fluid Embolism (AFE) in China: Are maternal mortality and morbidity preventable? Intractable Rare Dis Res 2014; 3:97-9. [PMID: 25364652 PMCID: PMC4214245 DOI: 10.5582/irdr.2014.01016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/25/2014] [Indexed: 11/05/2022] Open
Abstract
A case of hospital-patient conflict has occurred in China that has lifted billows in the public and highlighted the lethality of amniotic fluid embolism (AFE). AFE is a rare but severe obstetric complication with high maternal mortality and morbidity. Globally, the incidence of AFE is estimated to be approximately 2 to 6 per 100,000 deliveries. The maternal mortality rate (MMR) attributable to AFE ranges between 0.5 to 1.7 deaths per 100,000 deliveries in the developed world and 1.9 to 5.9 deaths per 100,000 deliveries in the developing world. In developed countries, AFE often accounts for a leading cause of maternal mortality; whereas the proportion of maternal death caused by AFE tends to be not as dominant compared to common perinatal complications in developing countries. With the mechanism remaining to be elucidated, AFE can neither be predicted nor prevented even in developed countries. Treatment requires a set of highly intensive advanced emergency obstetric care, challenging obstetric care in developing countries. Although this complication is currently far from preventable, China has potential to improve the prognosis of AFE by strengthening the emergency obstetric care system.
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Affiliation(s)
- Xiuting Mo
- School of Public Health, Shandong University, Ji'nan, China
| | - Aihua Feng
- School of Public Health, Shandong University, Ji'nan, China
- Obstetric Division, The Fourth People's Hospital of Jinan, Ji'nan, China
| | - Xiaoyan Liu
- School of Public Health, Shandong University, Ji'nan, China
- Qilu Hospital of Shandong University, Ji'nan, China
| | - Ruoyan Gai Tobe
- School of Public Health, Shandong University, Ji'nan, China
- Address correspondence to: Dr. Ruoyan Gai Tobe, School of Public Health, Shandong University, No.44 Wen-hua-xi Road, Jinan 250012, China. E-mail:
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Yoneyama K, Sekiguchi A, Matsushima T, Kawase R, Nakai A, Asakura H, Takeshita T. Clinical characteristics of amniotic fluid embolism: An experience of 29 years. J Obstet Gynaecol Res 2014; 40:1862-70. [DOI: 10.1111/jog.12452] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 03/12/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Koichi Yoneyama
- Department of Obstetrics and Gynecology; Nippon Medical School Hospital; Tokyo Japan
| | - Atsuko Sekiguchi
- Department of Obstetrics and Gynecology; Nippon Medical School Tama Nagayama Hospital, Tama; Tokyo Japan
| | - Takashi Matsushima
- Department of Obstetrics and Gynecology; Nippon Medical School Musashi Kosugi Hospital; Kawasaki Kanagawa Japan
| | - Rieko Kawase
- Department of Obstetrics and Gynecology; Nippon Medical School Hospital; Tokyo Japan
| | - Akihito Nakai
- Department of Obstetrics and Gynecology; Nippon Medical School Tama Nagayama Hospital, Tama; Tokyo Japan
| | - Hirobumi Asakura
- Department of Obstetrics and Gynecology; Nippon Medical School Musashi Kosugi Hospital; Kawasaki Kanagawa Japan
| | - Toshiyuki Takeshita
- Department of Obstetrics and Gynecology; Nippon Medical School Hospital; Tokyo Japan
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Abstract
OBJECTIVES Amniotic fluid embolism exhibits activation of the complement system and the kallikrein-kinin and coagulofibrinolytic systems. C1 esterase inhibitor is a major inhibitor of C1 esterase and can inhibit plasma kallikrein and also factors XIIa and XIa. Its activity has been shown to be significantly lower in pregnancy and labor than in the nonpregnant state. The purpose of this study was to determine C1 esterase inhibitor activity levels in amniotic fluid embolism. DESIGN Retrospective study. SETTING A single university-based center. PATIENTS One hundred six cases with amniotic fluid embolism in a total of 194 singleton pregnant women between January 2010 and December 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred six cases of amniotic fluid embolism had applied to the Japan amniotic fluid embolism registration center in Hamamatsu University School of Medicine between January 2010 and December 2011. In amniotic fluid embolism cases, 85 cases were nonfatal and 21 cases were fatal. Eighty-eight women who delivered without amniotic fluid embolism were regarded as a control. C1 esterase inhibitor activity levels were significantly lower in amniotic fluid embolism patients (30.0% ± 1.8%) than in control women (62.0% ± 2.0%) (p < 0.0001). C1 esterase inhibitor activity levels in fatal amniotic fluid embolism cases (22.5% ± 3.4%) were significantly lower than those in nonfatal amniotic fluid embolism cases (32.0% ± 2.1%) (p < 0.05). CONCLUSIONS These results demonstrated that low C1 esterase inhibitor activity levels were closely associated with the pathogenesis of amniotic fluid embolism suggesting that C1 esterase inhibitor activity levels have potential as a prognosis factor of amniotic fluid embolism.
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Tamura N, Nagai H, Maeda H, Kuroda RH, Nakajima M, Igarashi A, Kanayama N, Yoshida KI. Amniotic Fluid Embolism Induces Uterine Anaphylaxis and Atony following Cervical Laceration. Gynecol Obstet Invest 2014; 78:65-8. [DOI: 10.1159/000360537] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 02/10/2014] [Indexed: 11/19/2022]
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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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Ito F, Akasaka J, Koike N, Uekuri C, Shigemitsu A, Kobayashi H. Incidence, diagnosis and pathophysiology of amniotic fluid embolism. J OBSTET GYNAECOL 2014; 34:580-4. [PMID: 24865116 DOI: 10.3109/01443615.2014.919996] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Amniotic fluid embolism (AFE) is a rare clinical entity, sometimes fatal. A review was conducted to describe the frequency, diagnosis and pathophysiology of AFE. The reported incidences ranged from 1.9 cases per 100,000 maternities (UK) to 6.1 per 100,000 maternities (Australia), which can vary considerably, depending on the period, region of study and the definition. Although the development of amniotic fluid-specific markers would have an impact on early diagnosis, definition of AFE based on these markers is not widely accepted. To date, immunological mechanisms, amniotic fluid-dependent anaphylactic reaction and complement activation, have been proposed as potential pathogenetic and pathophysiological mechanisms. Immune cell activation induced through complement activation may be associated with the mechanism that immediately initiates maternal death, only in susceptible individuals. This review will focus on advances in the field of AFE biology and discuss the prevalence, diagnosis and pathophysiology of AFE.
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Affiliation(s)
- F Ito
- Department of Obstetrics and Gynecology, Nara Medical University , Nara , Japan
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Wang J, Lai Q, Pan H, Sun D, Yu C, Zhang W, Chen J, Ma L, Li L, Zhou R. Evaluation of specific marker CK13 and CK10/13 combined with APM staining for the diagnosis of amniotic fluid embolism and aspiration. Forensic Sci Int 2014; 238:108-12. [DOI: 10.1016/j.forsciint.2014.02.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/27/2014] [Accepted: 02/28/2014] [Indexed: 11/25/2022]
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Abstract
BACKGROUND The first case report to describe amniotic fluid embolism that appeared in 1926 in Basil-Medico is translated from Portuguese to English. CASE A patient with a dead fetus for several weeks, presented in labor and died suddenly with fetal squames evident in the maternal pulmonary vasculature at autopsy. CONCLUSION As can be seen from the translation, this case report is remarkably similar in many of its features to some of the eight patients described 15 years later in the first English language discussion of the disease by Steiner and Luschbaugh in JAMA. An enigma presented by this first case remains today: fetal material in the maternal pulmonary vasculature appears specific for amniotic fluid embolism at autopsy but not in living patients.
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Affiliation(s)
- A Rafael
- Centro Hospitalar e Universitario de Coimbra, Portugal
| | - MD Benson
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Deerfield, IL, USA
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Rath WH, Hofer S, Sinicina I. Amniotic fluid embolism: an interdisciplinary challenge: epidemiology, diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:126-32. [PMID: 24622759 PMCID: PMC3959223 DOI: 10.3238/arztebl.2014.0126] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 11/27/2013] [Accepted: 11/27/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Amniotic fluid embolism (AFE) is a life-threatening obstetric complication that arises in 2 to 8 of every 100 000 deliveries. With a mortality of 11% to 44%, it is among the leading direct causes of maternal death. This entity is an interdisciplinary challenge because of its presentation with sudden cardiac arrest without any immediately obvious cause, the lack of specific diagnostic tests, the difficulty of establishing the diagnosis and excluding competing diagnoses, and the complex treatment required, including cardio - pulmonary resuscitation. METHOD We selectively reviewed pertinent literature published from 2000 to May 2013 that was retrieved by a PubMed search. RESULTS The identified risk factors for AFE are maternal age 35 and above (odds ratio [OR] 1.86), Cesarean section (OR 12.4), placenta previa (OR 10.5), and multiple pregnancy (OR 8.5). AFE is diagnosed on clinical grounds after the exclusion of other causes of acute cardiovascular decompensation during delivery, such as pulmonary thromboembolism or myocardial infarction. Its main clinical features are severe hypotension, arrhythmia, cardiac arrest, pulmonary and neurological manifestations, and profuse bleeding because of disseminated intravascular coagulation and/or hyperfibrinolysis. Its treatment requires immediate, optimal interdisciplinary cooperation. Low-level evidence favors treating women suffering from AFE by securing the airway, adequate oxygenation, circulatory support, and correction of hemostatic disturbances. The sudden, unexplained death of a pregnant woman necessitates a forensic autopsy. The histological or immunohistochemical demonstration of formed amniotic fluid components in the pulmonary bloodflow establishes the diagnosis of AFE. CONCLUSION AFE has become more common in recent years, for unclear reasons. Rapid diagnosis and immediate interdisciplinary treatment are essential for a good outcome. Establishing evidence-based recommendations for intervention is an important goal for the near future.
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Affiliation(s)
- Werner H Rath
- Faculty of Medicine, Gynecology and Obstetrics, University Hospital RWTH Aachen
| | - Stefan Hofer
- Department of Anesthesiology, University of Heidelberg
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Visnjevac O, Lee K, Bulatovic R, Pourafkari L, Porhomayon J, Nader ND. Outcomes-based systematic review for management of massive intra-cardiac or pulmonary thrombotic emboli during surgery. HEART, LUNG AND VESSELS 2014; 6:24-32. [PMID: 24800195 PMCID: PMC4009594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The management of massive intra-operative embolism remains controversial. Our hypothesis was that either surgical or medical thrombectomy offers survival benefit in these patients. METHODS Published case reports were reviewed for intra-operative intra-cardiac or pulmonary embolism and outcomes for the following four intervention groups were evaluated for mortality benefit: surgical embolectomy; thrombolysis; anticoagulation; supportive care alone. We also assessed whether the use of diagnostic modalities prior to each embolism event resulted in a mortality benefit and, separately, whether post-intervention improvement in physiologic parameters resulted in improvement in outcomes. Univariate analyses and logistic regression were performed to assess the impact of the four primary interventions on mortality, the primary outcome. RESULTS Seventy-eight cases were reviewed and therapeutic interventions resulted in improved survival (70%) compared to supportive care (45%), odds ratio=0.38[0.15-0.98], p=0.04. Univariate analysis of primary interventions with death as a primary outcome resulted in a lack of significantly different outcomes (p=0.08). Mortality rates were 71% in the thrombolytic; 28% in surgical embolectomy; 18% in anticoagulation and 43% in the supportive care groups. The routine pre-event use of trans-esophageal echocardiography was not related with improved outcomes (p=0.36) but the use of pulmonary artery or central venous catheters was (p=0.035). Post-intervention improvements in the physiologic parameters of each diagnostic modality were associated with an improvement in mortality (p<0.05). CONCLUSIONS Our data present some important trends among the intervention groups, raising significant concerns about the safety for the use of thrombolytics in the management of intra-operative embolism.
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Affiliation(s)
- O Visnjevac
- Department of Anesthesiology, University at Buffalo, Buffalo, NY
| | - K Lee
- Department of Anesthesiology, University of Toronto School of Medicine, Toronto, Ontario, Canada
| | - R Bulatovic
- Department of Family Medicine, University of Toronto School of Medicine, Toronto, Ontario, Canada
| | - L Pourafkari
- Department of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - J Porhomayon
- Department of Anesthesiology and Critical Care Medicine, University at Buffalo, Buffalo, NY
| | - N D Nader
- Departments of Anesthesiology and Surgery, University at Buffalo, Buffalo, NY
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KIM JY, KIM KW, CHO CS, KIM JH, LEE SI, KIM KT, PARK JS, KIM JW, CHOE WJ. Decrease in bispectral index prior to cardiovascular collapse during Caesarean sections. Acta Anaesthesiol Scand 2014; 58:123-6. [PMID: 24112235 DOI: 10.1111/aas.12203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2013] [Indexed: 11/29/2022]
Abstract
We report a case of significant reduction in bispectral index (BIS) associated with suspected amniotic fluid embolism (AFE) that occurred prior to change in haemodynamic variables. The patient was a 29-year-old nulliparous, who was admitted for Caesarean section under general anaesthesia in the 33rd week of pregnancy. After the baby was born, the BIS value suddenly decreased to 0, with suppression ratio of 100. One minute later, saturation decreased abruptly to 85%, end-tidal carbon dioxide (EtCO2) decreased to 5 mmHg, peak inspiratory pressure increased to 35 cm H2O, and non-invasive blood pressure (BP) failed to obtain a reading. After administration of vasoactive drugs, the systolic BP was maintained at 100 mmHg or higher, the BIS value rose to 10-20, and the EtCO2 increased to 24-33 mmHg. In this case, the BIS monitoring may provide an earlier warning of impending cardiovascular collapse in the case of AFE.
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Affiliation(s)
- J. Y. KIM
- Anesthesiology and Pain Medicine; Inje University Ilsan Paik Hospital; Gyeonggi-do Korea
| | - K. W. KIM
- Anesthesiology and Pain Medicine; Inje University Ilsan Paik Hospital; Gyeonggi-do Korea
| | - C. S. CHO
- Anesthesiology and Pain Medicine; Inje University Ilsan Paik Hospital; Gyeonggi-do Korea
| | - J. H. KIM
- Anesthesiology and Pain Medicine; Inje University Ilsan Paik Hospital; Gyeonggi-do Korea
| | - S-I. LEE
- Anesthesiology and Pain Medicine; Inje University Ilsan Paik Hospital; Gyeonggi-do Korea
| | - K-T. KIM
- Anesthesiology and Pain Medicine; Inje University Ilsan Paik Hospital; Gyeonggi-do Korea
| | - J. S. PARK
- Anesthesiology and Pain Medicine; Inje University Ilsan Paik Hospital; Gyeonggi-do Korea
| | - J. W. KIM
- Anesthesiology and Pain Medicine; Inje University Ilsan Paik Hospital; Gyeonggi-do Korea
| | - W. J. CHOE
- Anesthesiology and Pain Medicine; Inje University Ilsan Paik Hospital; Gyeonggi-do Korea
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Oi H, Naruse K, Koike N, Tsunemi T, Shigetomi H, Kanayama N, Kobayashi H. Predictor of mortality in patients with amniotic fluid embolism. J Obstet Gynaecol Res 2013; 40:941-5. [DOI: 10.1111/jog.12278] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 08/06/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Hidekazu Oi
- Department of Obstetrics and Gynecology; Nara Medical University; Kashihara City Japan
| | - Katsuhiko Naruse
- Department of Obstetrics and Gynecology; Nara Medical University; Kashihara City Japan
| | - Natsuki Koike
- Department of Obstetrics and Gynecology; Nara Medical University; Kashihara City Japan
| | - Taihei Tsunemi
- Department of Obstetrics and Gynecology; Nara Medical University; Kashihara City Japan
| | - Hiroshi Shigetomi
- Department of Obstetrics and Gynecology; Nara Medical University; Kashihara City Japan
| | - Naohiro Kanayama
- Department of Obstetrics and Gynecology; Hamamatsu University School of Medicine; Hamamatsu City Japan
| | - Hiroshi Kobayashi
- Department of Obstetrics and Gynecology; Nara Medical University; Kashihara City Japan
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Abstract
Amniotic fluid embolism was first recognized in 1926, in a Brazilian journal case report, on the basis of large amounts of fetal material in the maternal pulmonary vasculature at autopsy. The first English language description appeared in 1941 and consisted of eight parturients dying suddenly in which, once again, fetal material was seen in the pulmonary vasculature. A control group of 34 pregnant women dying of other recognized causes did not have fetal material in their lungs. The incidence of recognized, serious illness is on the order of two to eight per 100,000, with a mortality rate ranging from 13% to 35%. The diagnosis rests largely on one or more of four clinical signs: circulatory collapse, respiratory distress, coagulopathy, and seizures/ coma. The only confirmatory laboratory test remains autopsy findings although serum tests for fetal antigen, insulin-like growth factor binding protein-1, and complement are currently being investigated. One of the paradoxes of diagnosis is that fetal material in the pulmonary circulation at autopsy is specific for amniotic fluid embolism, while the same finding in the living is not. The mechanism of disease remains uncertain although the best available evidence suggests that complement activation might have a role. In contrast, mast cell degranulation probably is not a mechanism, so amniotic fluid embolism is not an anaphylaxis or anaphylactoid reaction as has been occasionally suggested. Perhaps the greatest unknown is not why 1 in 50,000 pregnant women develop what appears to be an immune response to their fetus, but rather why the other 49,999 do not?
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Affiliation(s)
- Michael D Benson
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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