Amniotic Fluid Embolism 

 

 

Considerations 

 

  • Life threatening condition with multi-system derangements:

    • CNS: seizures, coma

    • Cardiovascular: hypotension, cardiovascular collapse, biventricular failure  

    • Respiratory: pulmonary edema, ARDS 

    • Hematological: coagulopathy 

  • Pregnancy considerations (difficult intubation, aspiration, ↓ time to desaturation, aortocaval compression, 2 patients)

  • Need for immediate cardiopulmonary resuscitation & correction of coagulopathy 

  • Need for multidisciplinary management including the ICU 

 

 

Clinical Features (tend to happen suddenly) 

 

  • Premonitory symptoms (restlessness, agitation, numbness, tingling) 

  • Hypotension, biphasic cardiovascular collapse:

    • First phase (initial 15-30 min):  RV failure & acute pulmonary hypertension

    • Second phase: LV failure 

  • Hypoxemia, respiratory failure 

  • Coagulopathy 

  • Seizures/coma 

 

 

Management 

 

  • Call for help, code blue

  • If cardiac arrest → follow ACLS guidelines with obstetrical modifications:

    • Supradiaphragmatic IV 

    • Left uterine displacement

    • Chest compressions higher on sternum than usual

    • Early intubation 

    • Prepare for peri-mortem cesarean section; if no ROSC within 4 minutes of resuscitation, aim for delivery within 5 minutes of resuscitation

  • Ventilate/oxygenate: intubate, 100% O2 

  • Fluid resuscitate in increments, avoid fluid overload that may lead to pulmonary edema or RV over-distension  

  • Support circulation with vasopressors initially, may need inotropes in 2nd phase:

    • Start with norepinephrine 

    • Add inodilators if needed: dobutamine, milrinone 

  • Establish invasive monitoring: arterial line, central venous access & CVP monitoring 

  • Call for transesophageal echocardiography

  • Treat coagulopathy:

    • Initiate massive hemorrhage protocol 

    • Correct INR/PTT & platelets 

    • Ensure normothermia & normocalcemia 

  • Fetus management:

    • Institute fetal monitoring 

    • Deliver fetus if fetal distress or maternal cardiopulmonary arrest 

  • Post resuscitation care in ICU 

 

 

Differential Diagnosis 

 

  • Obstetrical:

    • Placental abruption 

    • Eclampsia

    • Uterine rupture or laceration 

    • Uterine atony 

    • Peripartum cardiomyopathy 

  • Non-obstetrical:

    • Myocardial infarction

    • Pulmonary embolism

    • Sepsis 

    • Anaphylaxis 

    • Venous air embolism 

    • Transfusion reaction 

  • Anesthetic: 

    • High neuraxial 

    • Local anesthetic toxicity 

    • Medication error