Amniotic Fluid Embolism

1
Amniotic Fluid Embolism

• Leah C. Tonkin, M.D.
• 9/9/2004

2
Case Presentation

• 31yo G1 _at_ 36 1/7 by 36 1/7 USG
• Admitted to LD with severe pre-eclampsia
• Started on magnesium/PCN
• Pit-foley induction
• Epidural

3
Case Presentation

• Foley bulb fell out
• AROM
• Hyperstim and prolonged decel 90s 100s
• O2 by FM, L lat, Pit dcd, terb IM x 2,
  repositioning
• Pre-op

4
Case Presentation

• Acute distress
• Cough ? agitated ? obtunded ? mild seizure
• Unresponsive, ?HR, ?BP , anesthesia called
• No spontaneous respirations ? intubated
• Pulse lost ? Code initiated
• EKG Vfib ? 200 joules ? sinus tach

5
Case Presentation

• Fetal HR persistently in 60s
• Neonatology and IM present
• Perimortem C-section, delivery lt 60 seconds
• Five minute apgar 6
• FHR 130s s/p intubation
• ABG 6.76/137.4/17.3/18.3/-25.9

6
Case Presentation

• DDx
• PE
• Abruption
• Septic/anaphylactic shock
• MI
• ARDS, aspiration pneumonia
• Coagulopathy

7
Neonatal Asphyxia

• Definition
• Metabolic or mixed acidemia (pHlt7.00)
• Apgar 0-3 gt 5 min
• Neurological manifestations
• (seizure, coma, ?tone)
• Multisystem organ dysfunction
• Compendium Committee Opinion 174, July 1996

8
Perimortem Cesarean

• Fetal survival not likely gt 15-20 mins s/p code1
• Should consider after 4 mins of CP arrest1
• With best CPR CO302
• 1. Compendium Educational Bulletin 251, Sept
  1998
• 2. Dildy, Gary A. Critical Care Obstetrics, 4th
  Edition, Blackwell, 2004

9
Amniotic Fluid Embolism

• AKA Anaphylactoid Syndrome of Pregnancy
• Incidence 1/8000-1/80,000
• Uncommon not completely understood
• One of leading causes of Maternal Mortality
• Triggered by intravascular access of foreign
  substance

10
Amniotic Fluid Embolism

• Biphasic hemodynamic response
• Transient pulmonary vasospasm ? Right ventricular
  failure
• Left ventricular failure

11
Amniotic Fluid Embolism Clinical Presentation

• In labor or after CD/SVD/Termination
• Acute dyspnea and ?BP followed by CP collapse
• Hypoxia
• Seizure in 50

12
Amniotic Fluid Embolism Signs and Symptoms

• Clark et al, Amniotic fluid embolism analysis of
  a national registry. Am J Obstet Gynecol
  19951721158-1169

13
Amniotic Fluid Embolism Diagnosis

• CLINICAL
• Historically detection debris of fetal origin
• Also found in PIH, cardiac disease, normal
  pregnancy

Clark et al, Amniotic fluid embolism analysis of
a national registry. Am J Obstet Gynecol
19951721158-1169
14
Amniotic Fluid Embolism Predisposing Factors?

• No demographic maternal RFs
• No relationship with oxytocin use
• Transfer unlikely during contractions
• Meconium not statistically significant
• Possibly male fetus h/o allergy/atopy?

15
Amniotic Fluid Embolus Pathophysiology

• Similar course and findings between AFE and
  septic and anaphylactic shock
• Mediators histamine, bradykinin, cytokines,
  prostaglandins, leukotrienes, thromboxane
• Rabbit studies pre-txmt with leukotriene
  inhibitor has prevented fatality
• Association of allergy or atopy (41)

Clark et al, Amniotic fluid embolism analysis of
a national registry. Am J Obstet Gynecol
19951721158-1169
16
Amniotic Fluid Embolism Treatment

• Supportive (CPR, O2)
• Volume expansion for preload, /- inotropics
• High dose steroids NOT standard
• since anaphylaxis
• Maternal well being take precedence but
• If CP arrest 4 min ? perimortem CD

17
Amniotic Fluid Embolism Case Study/treatment
alternatives

• 45yo G2P0 s/p cord clamp classical section
• TEE in 10 min
• CP bypass in 53 min
• Steroids, pressors
• Deficits amnesia exacerbation of carpel tunnel

Stanten el al, Obstet Gynecol 2003102496-498
18
Amniotic Fluid Embolism Maternal outcome

• 60-80 overall mortality
• 15 neurologically intact
• Only 8 after CP arrest1
• No treatment associated with improved outcome
• No change in survival small rural hospital vs.
  tertiary care center

1. Clark et al, Amniotic fluid embolism analysis
of a national registry. Am J Obstet Gynecol
19951721158-1169
19
Amniotic Fluid Embolism Neonatal outcome

• 80 survival
• 50 neurologically intact
• Clear relationship between event and delivery

Clark et al, Amniotic fluid embolism analysis of
a national registry. Am J Obstet Gynecol
19951721158-1169
20
Case Presentation

• Hospital day 40
• ARDS, MRSA pneumonia
• Responds to pain
• Anoxic brain injury
• Just transferred to Kindred Pulmonary Care
• Off vent x 2 days during entire stay
• DNR

21
Case Presentation

• Neonate with seizure activity ? phenobarbital ?
  cessation of seizures
• Baby at home with grandparents