Maternal Morbidity - Amniotic Fluid Embolism Resources

OBJECTIVE: Amniotic fluid embolism (AFE) is a condition occurring during delivery that can lead to severe maternal morbidity and mortality. Given the rarity of its occurrence, current estimates and predictors of the incidence and outcomes are often difficult to obtain.
STUDY DESIGN: We conducted a population-based cohort study on 3 million birth records in the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 1999 to 2003 to estimate the incidence and case fatality of AFEs. Logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence intervals (CIs) of demographic and obstetrical determinants of AFEs and fatal AFEs.
RESULTS: The overall incidence of AFE was 7.7 per 100,000 births (95% CI 6.7 to 8.7), with a case fatality rate of 21.6% (95% CI 15.5 to 27.6%). AFE was associated with maternal age greater than 35 (OR 2.2, 95% CI 1.5 to 2.1), placenta previa (OR 30.4, 95% CI 15.4 to 60.1), and cesarean delivery (OR 5.7, 95% CI 3.7 to 8.7). Although AFEs were not significantly associated with induction of labor (OR 1.5, 95% CI 0.9 to 2.3), they were associated with preeclampsia, abruptio placentae, and the use of forceps. Among women with an AFE, common demographic or obstetrical determinants were not predictive of maternal mortality.
CONCLUSION: AFE is a rare but serious condition that is associated with advanced maternal age, placental pathologies, and cesarean deliveries. Further research on the treatment of this condition is necessary.

PURPOSE OF REVIEW: This review will summarize the latest publications on the causes, prevention and treatment of maternal collapse during pregnancy and the postpartum period. It will also explore some future trends particularly in the area of education and team working.
RECENT FINDINGS: Active management of the third stage of labour has been shown to decrease the incidence of postpartum haemorrhage. Inadequate or prolonged resuscitation following major postpartum haemorrhage can lead to myocardial damage. Guidelines that are followed and the use of drills and simulators may increase effective team working and lead to earlier recognition and treatment of maternal collapse. Some cases of amniotic fluid embolism resemble anaphylaxis and should be treated as such. Important evidence-based guidelines on the management of antithrombolytic prophylaxis and the management of pulmonary embolism have recently been published, which should help clinicians clarify their medical care plans. New resuscitation guidelines in the UK will probably mean that all healthcare workers (including obstetricians and midwives) will need appropriate training every year.
SUMMARY: Understanding the causes of maternal collapse, its early recognition and prompt resuscitation should decrease both maternal and fetal morbidity and mortality. There is increasing evidence that effective preventative measures and improved multidisciplinary team working may have an important impact on maternal and fetal well-being.

BACKGROUND: Amniotic-fluid embolism is a rare, but serious and often fatal maternal complication of delivery, of which the cause is unknown. We undertook an epidemiological study to investigate the association between amniotic-fluid embolism and medical induction of labour.
METHODS: We used a population-based cohort of 3 million hospital deliveries in Canada between 1991 and 2002 to assess the associations between overall and fatal rates of amniotic-fluid embolism and medical and surgical induction, maternal age, fetal presentation, mode of delivery, and pregnancy and labour complications.
FINDINGS: Total rate of amniotic-fluid embolism was 14.8 per 100,000 multiple-birth deliveries and 6.0 per 100,000 singleton deliveries (odds ratio 2.5 [95% CI 0.9-6.2]). Of the 180 cases of amniotic-fluid embolism in women with singleton deliveries during the study period, 24 (13%) were fatal. We saw no significant temporal increase in occurrence of amniotic-fluid embolism for total or fatal cases. Medical induction of labour nearly doubled the risk of overall cases of amniotic-fluid embolism (adjusted odds ratio 1.8 [1.3-2.7]), and the association was stronger for fatal cases (crude odds ratio 3.5 [1.5-8.4]). Maternal age of 35 years or older, caesarean or instrumental vaginal delivery, polyhydramnios, cervical laceration or uterine rupture, placenta previa or abruption, eclampsia, and fetal distress were also associated with an increased risk.
INTERPRETATION: Medical induction of labour seems to increase the risk of amniotic-fluid embolism. Although the absolute excess risk is low, women and physicians should be aware of this risk when making decisions about elective labour induction.

INCIDENCE: Amniotic fluid embolism is a catastrophic syndrome that occurs during pregnancy or in the immediate postpartum period. Multiple case reports have described the clinical findings and have reported variable success with supportive care. There has been discrepancy with respect to the incidence and mortality of amniotic fluid embolism. One likely explanation for this inconsistency is the lack of sensitive and specific diagnostic studies to definitively identify cases of amniotic fluid embolism, leading to both over- and underreporting. Despite the variation in reported incidence and mortality, amniotic fluid embolism remains a life-threatening condition with significant morbidity and mortality for the pregnant woman. It is the fifth most common cause of maternal mortality in the world.
DIAGNOSIS: The diagnosis of amniotic fluid embolism continues to be a clinical diagnosis and a diagnosis of exclusion based on the rapid development of a complex constellation of findings with sudden cardiovascular collapse, acute left ventricular failure with pulmonary edema, disseminated intravascular coagulation, and neurologic impairment. Given the significant morbidity and mortality associated with this condition, a high index of suspicion is warranted. Suspected risk factors have included tumultuous labor, trauma, multiparity, increased gestational age, and increased maternal age. However, many patients who develop amniotic fluid embolism have no obvious risk factors.
MANAGEMENT: Patients with amniotic fluid embolus are best managed using a multidisciplinary approach. There are no pharmacologic or other therapies that prevent or treat the amniotic fluid embolism syndrome, and supportive care typically involves aggressive treatment of multiple types of shock simultaneously. In this article we discuss the clinical presentation of amniotic fluid embolism syndrome as well as current opinions regarding pathophysiology, diagnosis, and management.

We utilised linked birth, hospital and death data for the entire population to determine the incidence of amniotic fluid embolism (AFE) and its mortality and morbidity. AFE diagnoses were identified from International Classification of Diseases, 10th Revision (ICD10)-coded hospital and/or death records with additional case definition criteria imposed. The AFE incidence was 3.3 per 100 000 (95% CI, 1.9–4.7), maternal fatality rate 35% (95% CI, 15–59) and perinatal mortality rate 32% (95% CI, 12–56). Newly identified risk factors included induction with vaginal prostaglandin and manual removal of the placenta, and survivors were at increased risk of cerebral infarction. Although two-thirds of women and infants survived, AFE also caused severe morbidity. BJOG 2010;
DOI: 10.1111/j.1471-0528.2010.02656.x.

Amniotic fluid embolism (AFE) is a rare obstetric catastrophe that occurs suddenly and without warning. AFE is a condition that is poorly understood and often difficult to diagnose, but has a high maternal and neonatal morbidity and mortality. Since it was first described in 1926, the underlying pathophysiology has eluded researchers and clinicians. While a new understanding of the syndrome has emerged with the advent of a national registry in the 1980s, recommendations for diagnostic methods and treatment in the acute phase of the event remain unclear.The purpose of this article is to provide the reader with a historical look at the phenomenon of AFE, a description of its suspected pathophysiology, and recommendations for nursing interventions. A review of data from the national registry and other classic studies are included.

Perimortem caesarean section is very rare, mostly resulting in high mortality of mother and/or fetus. We report a case of successful resuscitation of both mother and newborn following maternal cardiac arrest prior to delivery. Postoperative outcome was complicated by severe bleeding and coagulopathy following fibrinolysis and subcapsular hepatic haematoma. We consider a fast reaction time based on a special in-hospital emergency team for immediate caesarean section and an aggressive management of coagulopathy as major factors that led to both patients recovery without neurological sequelae.

Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. A high index of clinical suspicion is necessary to make an early diagnosis to reduce morbidity and mortality. We report a non-fatal case of amniotic fluid embolism occurring during a caesarean section, with special emphasis on the mode of development and diagnosis. The initial presentation of this syndrome was a coagulopathy, followed by the usual complications of massive bleeding. Although non-specific, the diagnosis of amniotic fluid embolism was supported by the observation of amniotic fluid in the central venous blood as well as in the broncho-alveolar fluid.