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AMNIOTIC FLUID EMBOLISM (AFE)1941, Steiner and Luschbaugh

DEFINITION

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

biochemical mediators pulmonary artery vasospasm

pulmonary hypertension elevated right  ventricular

pressure hypoxia myocardial and pulmonary

capillary damage, left heart failure 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 arrestAcute hypoxiaCoagulopathy or severe hemorrhage in the absence of

other explanationsAll of these occurring during labor, cesarean delivery,

D&E, or within 30 minutes postpartum with no other explanation of findings

NON SPECIFICcomplete blood countcoagulation parameters arterial blood gaseschest x-rayelectrocardiogramechocardiogram SPECIFICcervical histology serum tryptase

LABORATORY INVESTIGATIONS  

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

BIBLIOGRAPHY 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