Amniotic Fluid Embolism Clinical Presentation

  • Author: Lisa E Moore, MD, FACOG; Chief Editor: Carl V Smith, MD   more...
 
Updated: Jan 13, 2012
 

History

Amniotic fluid embolism (AFE) usually occurs during labor but has occurred during abortion, after abdominal trauma, and during amnioinfusion.

A woman in the late stages of labor becomes acutely dyspneic with hypotension; she may experience seizures quickly followed by cardiac arrest. Massive DIC-associated hemorrhage follows and then death. Most patients die within an hour of onset.

Currently no definitive diagnostic test exists. The United States and United Kingdom AFE registries recommend the following 4 criteria, all of which must be present to make the diagnosis of AFE.[7, 1, 9]

  1. Acute hypotension or cardiac arrest
  2. Acute hypoxia
  3. Coagulopathy or severe hemorrhage in the absence of other explanations
  4. All of these occurring during labor, cesarean delivery, dilation and evacuation, or within 30 minutes postpartum with no other explanation of findings
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Physical

In case reports, patients are described as developing acute shortness of breath, sometimes with a cough, followed by severe hypotension. The following signs and symptoms are indicative of possible AFE:

  • Hypotension: Blood pressure may drop significantly with loss of diastolic measurement.
  • Dyspnea: Labored breathing and tachypnea may occur.
  • Seizure: Tonic clonic seizures are seen in 50% of patients.
  • Cough: This is usually a manifestation of dyspnea.
  • Cyanosis: As hypoxia/hypoxemia progresses, circumoral and peripheral cyanosis and changes in mucous membranes may manifest.
  • Fetal bradycardia: In response to the hypoxic insult, fetal heart rate may drop to less than 110 beats per minute (bpm). If this drop lasts for 10 minutes or more, it is a bradycardia. A rate of 60 bpm or less over 3-5 minutes may indicate a terminal bradycardia.
  • Pulmonary edema: This is usually identified on chest radiograph.
  • Cardiac arrest
  • Uterine atony: Uterine atony usually results in excessive bleeding after delivery. Failure of the uterus to become firm with bimanual massage is diagnostic.
  • Coagulopathy or severe hemorrhage in absence of other explanation (DIC occurs in 83% of patients.)[9]
  • Altered mental status/confusion/agitation
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Causes

AFE is considered an unpredictable and unpreventable event with an unknown cause. In the national registry, 41% of patients had a history of allergies.

Reported risk factors for development of AFE include multiparity, advanced maternal age, male fetus, and trauma. In a retrospective review of a 12-year period encompassing 180 cases of AFE, of which 24 were fatal, medical induction of labor increased the risk of AFE.[10] In the same study, AFE was positively associated with multiparity, cesarean section or operative vaginal delivery, abruption, placenta previa, and cervical laceration or uterine rupture.[11, 12, 13]

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Contributor Information and Disclosures
Author

Lisa E Moore, MD, FACOG  Assistant Professor, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of New Mexico Health Sciences Center

Lisa E Moore, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

John J Kavanagh Jr  MD, Chief, Professor, Department of Internal Medicine, Section of Gynecological and Medical Therapeutics, MD Anderson Cancer Center, University of Texas Medical School at Houston

John J Kavanagh Jr is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association for the History of Medicine, American College of Physicians, American Federation for Medical Research, American Medical Association, Society of Gynecologist Oncologists, Southern Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

A David Barnes, MD, PhD, MPH, FACOG  Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Carl V Smith, MD  The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center

Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

References

  1. Clark SL, Hankins GD, Dudley DA, et al. Amniotic fluid embolism: analysis of the national registry. Am J Obstet Gynecol. Apr 1995;172(4 Pt 1):1158-67; discussion 1167-9. [Medline].

  2. Clark SL, Pavlova Z, Greenspoon J, et al. Squamous cells in the maternal pulmonary circulation. Am J Obstet Gynecol. Jan 1986;154(1):104-6. [Medline].

  3. Benson MD, Kobayashi H, Silver RK, et al. Immunologic studies in presumed amniotic fluid embolism. Obstet Gynecol. Apr 2001;97(4):510-4. [Medline].

  4. Farrar SC, Gherman RB. Serum tryptase analysis in a woman with amniotic fluid embolism. A case report. J Reprod Med. Oct 2001;46(10):926-8. [Medline].

  5. Marcus BJ, Collins KA, Harley RA. Ancillary studies in amniotic fluid embolism: a case report and review of the literature. Am J Forensic Med Pathol. Mar 2005;26(1):92-5. [Medline].

  6. Gilbert WM, Danielsen B. Amniotic fluid embolism: decreased mortality in a population-based study. Obstet Gynecol. Jun 1999;93(6):973-7. [Medline].

  7. Tuffnell DJ. United kingdom amniotic fluid embolism register. BJOG. Dec 2005;112(12):1625-9. [Medline].

  8. Stein PD, Matta F, Yaekoub AY. Incidence of amniotic fluid embolism: relation to cesarean section and to age. J Womens Health (Larchmt). Mar 2009;18(3):327-9. [Medline].

  9. O'Shea A, Eappen S. Amniotic fluid embolism. Int Anesthesiol Clin. 2007;45(1):17-28. [Medline].

  10. Kramer MS, Rouleau J, Baskett TF, Joseph KS,. Amniotic-fluid embolism and medical induction of labour: a retrospective, population-based cohort study. Lancet. Oct 21 2006;368(9545):1444-8. [Medline].

  11. Knight M, Tuffnell D, Brocklehurst P, Spark P, Kurinczuk JJ. Incidence and risk factors for amniotic-fluid embolism. Obstet Gynecol. May 2010;115(5):910-7. [Medline].

  12. Benson MD. Current concepts of immunology and diagnosis in amniotic fluid embolism. Clin Dev Immunol. 2012;2012:946576. [Medline]. [Full Text].

  13. Clark SL. Amniotic fluid embolism. Clin Obstet Gynecol. Jun 2010;53(2):322-8. [Medline].

  14. Aguilera LG, Fernandez C, Plaza A, et al. Fatal amniotic fluid embolism diagnosed histologically. Acta Anaesthesiol Scand. Mar 2002;46(3):334-7. [Medline].

  15. Hankins GD, Snyder R, Dinh T, et al. Documentation of amniotic fluid embolism via lung histopathology. Fact or fiction?. J Reprod Med. Dec 2002;47(12):1021-4. [Medline].

  16. Kobayashi H, Ohi H, Terao T. A simple, noninvasive, sensitive method for diagnosis of amniotic fluid embolism by monoclonal antibody TKH-2 that recognizes NeuAc alpha 2-6GalNAc. Am J Obstet Gynecol. Mar 1993;168(3 Pt 1):848-53. [Medline].

  17. Lim Y, Loo CC, Chia V, Fun W. Recombinant factor VIIa after amniotic fluid embolism and disseminated intravascular coagulopathy. Int J Gynaecol Obstet. Nov 2004;87(2):178-9. [Medline].

  18. Kaneko Y, Ogihara T, Tajima H, Mochimaru F. Continuous hemodiafiltration for disseminated intravascular coagulation and shock due to amniotic fluid embolism: report of a dramatic response. Intern Med. Sep 2001;40(9):945-7. [Medline].

  19. Hsieh YY, Chang CC, Li PC, Tsai HD, Tsai CH. Successful application of extracorporeal membrane oxygenation and intra-aortic balloon counterpulsation as lifesaving therapy for a patient with amniotic fluid embolism. Am J Obstet Gynecol. Aug 2000;183(2):496-7. [Medline].

  20. Goldszmidt E, Davies S. Two cases of hemorrhage secondary to amniotic fluid embolus managed with uterine artery embolization. Can J Anaesth. Nov 2003;50(9):917-21. [Medline].

 
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