Amniotic fluid embolism: Difference between revisions

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== Natural History, Complications and Prognosis==
== Natural History, Complications and Prognosis==
Early diagnosis and resuscitative measures can save the patient's life.
== Diagnosis ==
== Diagnosis ==
===Diagnostic Criteria===
===Diagnostic Criteria===

Revision as of 23:17, 21 October 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Aida Javanbakht, M.D.

Synonyms and keywords: AFE

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Overview

Amniotic fluid embolism (AFE) is a rare and incompletely understood obstetric emergency in which amniotic fluid, fetal cells, hair or other debris enters the mother's blood stream via the placental bed of the uterus and triggers an allergic reaction. This reaction then results in cardiorespiratory (heart and lung) collapse and coagulopathy.

The condition is so rare (less than 1 in 20,000 deliveries) that most doctors will never encounter it in their professional careers, and as a result the exact process is poorly understood. However, it is believed that once the fluid and fetal cells enter the maternal pulmonary circulation a two-phase process occurs:

First phase: The patient experiences acute shortness of breath and hypertension. This rapidly progresses to cardiac arrest as the chambers of the heart fail to dilate and there is a reduction of oxygen to the heart and lungs. Not long after this stage the patient will lapse into a coma. 50% die within the first hour of symptoms.

Second phase: Although many women do not survive beyond the first stage, about 40 per cent of the initial survivors will pass onto the second phase. This is known as the hemorrhagic phase and may be accompanied by severe shivering, coughing, vomiting and the sensation of a bad taste in the mouth. This is also accompanied by excessive bleeding as the blood loses its ability to clot. Collapse of the cardiovascular system leads to fetal distress and death unless the child is delivered swiftly.

Historical Perspective

AFE is first described in 1926. [1][2]

Classification

There is no classification for AFE.

Pathophysiology

The exact pathophisiology of AFE is unknown. [3] Abnormal maternal response to fetal tissue exposure during vaginal delivery, cesarean, second trimester of pregnancy or even post delivery could be the initial step resulting AFE[4]. It has been suggested the main reason of AFE is immune response not embolic process. [5] Amniotic fluid caused intravascular coagulation by having procoagulant products such as platelet-activating factor, cytokines, bradykinin, and thromboxane. [6] Also, Complement system activation might play a role in causing AFE.

Causes

It is mostly agreed that this condition results from amniotic fluid entering the uterine veins and in order for this to occur there are three prerequisites:

Although exposure to fetal tissue is common and thus finding fetal tissue within the maternal circulation is not significant, in a small percentage of women this exposure leads to a complex chain of events resulting in collapse and death.

  • Drugs causing amniotic fluid embolism
  • Dinoprostone.

Differentiating Amniotic fluid embolism from other Diseases

Epidemiology and Demographics

The exact incidence of AFE is unknown but it has been reported between 1 in 8000 and 1 in 80,000 deliveries.[7]

The mortality rate is between 13-26%. If it happens during pregnancy the mortality death in neonate is around 10%.[8]

Age

  • Although older maternal age is considering a risk factor, but AFE can happen in all pregnant ladies in all ages.

Gender

AFE happens in female.

Race

  • There is no racial predilection for AFE.

Risk Factors

Maternal risk factors: [9]

Fetal risk factors:

  • Male baby

Natural History, Complications and Prognosis

Early diagnosis and resuscitative measures can save the patient's life.

Diagnosis

Diagnostic Criteria

AFE is a diagnosis of exclusion. Classic triad of sudden hypoxia, hypotension, and subsequent coagulopathy in mother especially after labor could be AFE. [10]

Symptoms

Physical Examination

Laboratory Findings

Imaging Findings

  • There are no specific findings associated with AFE.

Other Diagnostic Studies

Transesophageal echocardiography: right ventricular dilation due to pulmonary vasoconstriction [14]

Treatment

The important key in treating AFE is diagnosing it as soon as posible.

Medical Therapy [15]

  • Keep patient's vital sign stable by fluid resuscitation, giving oxygen and transfusion of packed red blood cells if needed.
  • Platelet transfusion if platelets are <20,000/μL without any bleeding, or platelets are 20,000-50,000/μL with bleeding, transfuse platelets at 1-3 U/10 kg/day.

Surgery

  • Surgery is the mainstay of therapy for [disease name].
  • [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
  • [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

  • There are no primary preventive measures available for amniotic fluid embolism.

References

  1. West M (January 2016). "Amniotic fluid embolism: a historical perspective in diagnosis and management". BJOG. 123 (1): 110. doi:10.1111/1471-0528.13528. PMID 26715344.
  2. Gei AF, Vadhera RB, Hankins GD (March 2003). "Embolism during pregnancy: thrombus, air, and amniotic fluid". Anesthesiol Clin North America. 21 (1): 165–82. PMID 12698839.
  3. Tamura N, Farhana M, Oda T, Itoh H, Kanayama N (April 2017). "Amniotic fluid embolism: Pathophysiology from the perspective of pathology". J. Obstet. Gynaecol. Res. 43 (4): 627–632. doi:10.1111/jog.13284. PMID 28188959.
  4. Shamshirsaz AA, Clark SL (December 2016). "Amniotic Fluid Embolism". Obstet. Gynecol. Clin. North Am. 43 (4): 779–790. doi:10.1016/j.ogc.2016.07.001. PMID 27816160.
  5. Syed SA, Dearden CH (July 1996). "Amniotic fluid embolism: emergency management". J Accid Emerg Med. 13 (4): 285–6. PMC 1342736. PMID 8832353.
  6. Tuffnell DJ (April 2003). "Amniotic fluid embolism". Curr. Opin. Obstet. Gynecol. 15 (2): 119–22. doi:10.1097/01.gco.0000063546.93768.ba. PMID 12634603.
  7. Gist RS, Stafford IP, Leibowitz AB, Beilin Y (May 2009). "Amniotic fluid embolism". Anesth. Analg. 108 (5): 1599–602. doi:10.1213/ane.0b013e31819e43a4. PMID 19372342.
  8. Moore J, Baldisseri MR (October 2005). "Amniotic fluid embolism". Crit. Care Med. 33 (10 Suppl): S279–85. PMID 16215348.
  9. Benson MD (2012). "Current concepts of immunology and diagnosis in amniotic fluid embolism". Clin. Dev. Immunol. 2012: 946576. doi:10.1155/2012/946576. PMC 3182579. PMID 21969840.
  10. Sundin CS, Mazac LB (2017). "Amniotic Fluid Embolism". MCN Am J Matern Child Nurs. 42 (1): 29–35. doi:10.1097/NMC.0000000000000292. PMID 27755062.
  11. Hankins GD, Snyder RR, Clark SL, Schwartz L, Patterson WR, Butzin CA (April 1993). "Acute hemodynamic and respiratory effects of amniotic fluid embolism in the pregnant goat model". Am. J. Obstet. Gynecol. 168 (4): 1113–29, discussion 1129–30. PMID 8475957.
  12. Rudra A, Chatterjee S, Sengupta S, Nandi B, Mitra J (2009). "Amniotic fluid embolism". Indian J Crit Care Med. 13 (3): 129–35. doi:10.4103/0972-5229.58537. PMC 2823093. PMID 20040809.
  13. Leighton BL, Wall MH, Lockhart EM, Phillips LE, Zatta AJ (December 2011). "Use of recombinant factor VIIa in patients with amniotic fluid embolism: a systematic review of case reports". Anesthesiology. 115 (6): 1201–8. doi:10.1097/ALN.0b013e31821bdcfd. PMID 21720243.
  14. Stanten RD, Iverson LI, Daugharty TM, Lovett SM, Terry C, Blumenstock E (September 2003). "Amniotic fluid embolism causing catastrophic pulmonary vasoconstriction: diagnosis by transesophageal echocardiogram and treatment by cardiopulmonary bypass". Obstet Gynecol. 102 (3): 496–8. PMID 12962931.
  15. Thongrong C, Kasemsiri P, Hofmann JP, Bergese SD, Papadimos TJ, Gracias VH, Adolph MD, Stawicki SP (January 2013). "Amniotic fluid embolism". Int J Crit Illn Inj Sci. 3 (1): 51–7. doi:10.4103/2229-5151.109422. PMC 3665120. PMID 23724386.

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