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AMNIOTIC FLUID EMBOLISM (AFE) 1941, Steiner and Luschbaugh

Amniotic fluid embolism (AFE) is a rare obstetric emergency in which amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation, causing cardio respiratory collapse

ETIOLOGY

Multiparity Trauma medical induction of labor Cesarean section or operative vaginal delivery Abruption, placenta previa Cervical laceration or uterine rupture , IUD Very strong frequent or uterine tetanic contractions Sudden foetal expulsion (short labour)

Conti.
Placenta accreta

Polyhydramnios
Uterine rupture Maternal history of allergy Chorioamnionitis Macrosomia Oxytocin (controversial) Advanced maternal age

PATHOPHYSIOLOGY Cotton (1996)

PHASE 1:
Amniotic fluid enter the maternal circulation
pulmonary hypertension elevated right ventricular pressure hypoxia myocardial left heart failure

biochemical mediators pulmonary artery vasospasm

and pulmonary capillary damage,

acute respiratory distress syndrome

PHASE 2:

biochemical mediators DIC Hemorrhagic phase characterized by massive hemorrhage and uterine atony.

CLINICAL FEATURES
MATERNAL severe hemorrhage Hypotension Cardiac arrest Cough Dyspnea, Cyanosis Pulmonary edema Uterine atony Altered mental status/confusion/agitation Seizure

FETAL bradycardia: FHR may drop to less than 110 beats per minute (bpm).

DIAGNOSIS
4 criteria recommend by the United States and United Kingdom AFE registries
Acute hypotension or cardiac arrest Acute hypoxia Coagulopathy or severe hemorrhage in the absence of

other explanations All of these occurring during labor, cesarean delivery, D&E, or within 30 minutes postpartum with no other explanation of findings

NON SPECIFIC complete blood count coagulation parameters arterial blood gases chest x-ray electrocardiogram echocardiogram SPECIFIC cervical histology serum tryptase

MANAGEMENT:
Restoration of cardiovascular and pulmonary equilibrium Maintain systolic blood pressure >90 mm Hg. Urine output > 25 ml/hr Arterial pO2 > 60 mm Hg. Re-establishing uterine tone Correct coagulation abnormalities

IMMEDIATE MEASURES :
Set up IV Infusion, O2 administration. Airway control Lab report Treat hypotension. After correction of hypotension, restrict fluid therapy to maintenance levels . Steroids may be indicated Dopamine infusion if patient remains hypotensive Vasopressor therapy such as ephedrine

MANAGEMENT OF AFE IN THE ICU

monitor ECG, pO2, CO2, and urine output. Central venous pressure monitoring Monitor Pulmonary artery and capillary wedge pressures and echocardiography. An arterial line for repeated blood sampling and blood gases to evaluate the efficacy of resuscitation.

MANAGEMENT OF AFE COAGULOPATHY

DIC results in the depletion of fibrinogen, platelets, and coagulation factors, especially factors V, VIII, and XIII.

transfuse platelets for platelet counts less than 20,000/mm3

RESTORATION OF UTERINE TONE

Uterine atony is best treated with massage, uterine

packing, and oxytocin or prostaglandin analogues. Improvement in cardiac output and uterine perfusion helps restore uterine tone. Extreme care should be exercised when using prostaglandin analogues in hypoxic patients, as bronchospasm may worsen the situation.

SYMPATHOMIMETIC VASOPRESSOR AGENT DOPAMINE

Dopamine increases myocardial contractility and systolic BP with little increase in diastolic BP. Also dilates the renal vasculature, increasing renal blood flow and GFR.
DOSE: 2-5 mcg/kg/min IV

NURSING MANAGEMENT
Assessment: Nursing diagnosis
Impaired Gas Exchange related to embolization Altered Tissue Perfusion, peripheral and cardiac related to emboli

Dutta D C. textbook of obstetrics.6th ed. New delhi . New central book agency. 2004 Jacob A. Textbook of Midwifery. 1st ed. New Delhi. Jay pee publications. 2003 Pillitary a. Maternal and child health nursing. 4th ed. Philadelphia. Lippincott. Williams and Wilkins. 2000 Fraser DM, Cooper MA. Textbook for midwifes. 14th ed. Edinburg Churchill LIVINGStone. 2003 Green C j, Judith m. Maternal newborn nursing careplans. 1st ed. Mosby publications.2004 Dawn CS. Obstetrics and Neonatology for undergraduates and postgraduates. 16th ed