Transcript Amniotic Fluid Embolism - Max Brinsmead MB BS PhD

Max Brinsmead MB BS PhD
May 2015
Amniotic Fluid Embolism
 A rare event – 3.3 per 100,000 deliveries in an
Australian study based on ICD10
 Was once associated with an 85% maternal
mortality - 50% within the first hour
 35% maternal mortality with modern intensive
care and 32% perinatal mortality if it occurs before
delivery
AFE – Risk Factors
 Multiparity
 Abruption
 Intrauterine Fetal Death
 Tumultuous labour
 Oxytocin or Prostaglandin hyperstimulation
 Caesarean section
 Manual removal of the placenta
AFE - Pathophysiology
 Probably an anaphylactoid-type reaction to the
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intravascular ingress of amniotic fluid
This causes widespread vasoconstriction including
pulmonary and cardiac vessels
There is ↓myocardial contractility and acute left
heart failure
If the mother survives the initial cardiorespiratory
failure then DIC and haemorrhage is inevitable
Survivors may suffer stroke due to cerebral
infarction
The presence of fetal amniotic squames in the
maternal lung at autopsy is said to be “diagnostic”
AFE – Clinical Presentations
 Acute fetal distress followed quickly by maternal
collapse with hypotension, dyspnoea and cyanosis
 Sudden loss of consciousness or seizure
 Often proceeds or occurs immediately after delivery
 Maternal collapse during Caesarean section
 Followed by profuse post partum haemorrhage
AFE – Diagnosis
 The diagnosis is a clinical one
 Exclude alternatives (if possible)
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Placental abruption
Uterine rupture
Eclampsia
Thromboembolism
Cardiogenic causes of acute CCF
Drug toxicity e.g. Local anaesthetics
Anaphylaxis
Transfusion reaction
Massive aspiration of gastric contents
 Useful Tests
 Blood gases
 ECG
 Blood Coagulation tests
 Lung CT to look for signs of thromboembolism
 Serum zinc coproporphyrin >35 nmol/L
AFE - Management
 Remember A, B, C
 Endotracheal intubation and IPPV with 100%
O2 ASAP
 Aggressive fluid replacement preferably with
CVP monitoring
 Aggressive use of oxytocic agents plus
whatever to control PPH
 Pressor agents eg Dopamine usually required
 Multidisciplinary Intensive Care (including a
haematologist)
 FFP and Platelets for DIC
 ?Heparin ?Factor VIIa