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SMFM Clinical Guidelines No. 9: smfm.org Amniotic fluid embolism: diagnosis and management Society for Maternal-Fetal Medicine (SMFM) with the assistance of Luis D. Pacheco, MD; George Saade, MD; Gary D. V. Hankins, MD; Steven L. Clark, MD The practice of medicine continues to evolve, and individual circumstances will vary. This publication reflects information available at the time of its submission for publication and is neither designed nor intended to establish an exclusive standard of perinatal care. This publication is not expected to reflect the opinions of all members of the Society for Maternal-Fetal Medicine. OBJECTIVE: We sought to provide evidence-based guidelines regarding the diagnosis and manage- ment of amniotic fluid embolism. STUDY DESIGN: A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and the Cochrane Library. The search was restricted to English-language articles published from 1966 through March 2015. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion. Evidence reports and published guidelines were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used for defining the strength of recommendations and rating quality of the evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence. RESULTS AND RECOMMENDATIONS: We recommend the following: (1) we recommend consider- ation of amniotic fluid embolism in the differential diagnosis of sudden cardiorespiratory collapse in the laboring or recently delivered woman (GRADE 1C); (2) we do not recommend the use of any specific diagnostic laboratory test to either confirm or refute the diagnosis of amniotic fluid embolism; at the present time, amniotic fluid embolism remains a clinical diagnosis (GRADE 1C); (3) we recommend the provision of immediate high-quality cardiopulmonary resuscitation with standard basic cardiac life support and advanced cardiac life support protocols in patients who develop cardiac arrest associated with amniotic fluid embolism (GRADE 1C); (4) we recommend that a multidisciplinary team including anesthesia, respiratory therapy, critical care, and maternal-fetal medicine should be involved in the ongoing care of women with AFE (Best Practice); (5) following cardiac arrest with amniotic fluid em- bolism, we recommend immediate delivery in the presence of a fetus 23 weeks of gestation (GRADE 2C); (6) we recommend the provision of adequate oxygenation and ventilation and, when indicated by hemodynamic status, the use of vasopressors and inotropic agents in the initial management of amniotic fluid embolism. Excessive fluid administration should be avoided (GRADE 1C); and (7) because coa- gulopathy may follow cardiovascular collapse with amniotic fluid embolism, we recommend the early assessment of clotting status and early aggressive management of clinical bleeding with standard massive transfusion protocols (GRADE 1C). Key words: amniotic fluid embolism, cardiorespiratory arrest, pregnancy mniotic fluid embolism is a rare but potentially lethal Corresponding author: The Society for Maternal-Fetal Medicine Publications Committee. [email protected] A condition. Because of a lack of international Cite this article as: Society for Maternal-Fetal Medicine (SMFM) with consensus regarding diagnostic criteria, estimates of both the assistance of Pacheco LD, Saade G, et al. Amniotic fluid embolism: incidence and mortality rates associated with amniotic diagnosis and management. Am J Obstet Gynecol 2016;xxx:xx-xx. fluid embolism vary widely.1-4 These issues have recently Received Oct. 27, 2015; revised Feb. 22, 2016; accepted March 2, been reviewed in detail and are not the focus of this 2016. manuscript.2,5 MONTH 2016 B1 SMFM Clinical Guidelines smfm.org Rather we emphasize that despite its low incidence in the material from the fetal compartment, resulting in an general population of pregnant women, both maternal and abnormal activation of proinflammatory mediator systems perinatal morbidity and mortality are significant with amni- similar to the systemic inflammatory response syndrome. otic fluid embolism, even in cases ideally managed. The typical presentation of amniotic fluid embolism in- Because of the rarity of this condition, most physicians and cludes a triad of sudden hypoxia and hypotension, followed institutions have limited experience with the management of in many cases by coagulopathy, all occurring in relation to amniotic fluid embolism. labor and delivery. The diagnosis of amniotic fluid embolism The purpose of this document is to provide clinicians with is clinical, based on the presence of these elements and the information that may improve the ability to make a timely exclusion of other likely causes. Amniotic fluid embolism diagnosis and establish appropriate supportive treatment to should be considered in the differential diagnosis in any patients suffering from amniotic fluid embolism to improve pregnant or immediately postpartum woman who suffers maternal and perinatal outcomes. sudden cardiovascular collapse or cardiac arrest, seizures, severe respiratory difficulty, or hypoxia, particularly if such What is amniotic fluid embolism and what are its events are followed by a coagulopathy that cannot be clinical features? otherwise explained. A detailed review of the pathophysiology of amniotic fluid The analysis of the national registry reveals that 70% of embolism is beyond the scope of this document but may be cases of amniotic fluid embolism occur during labor, 11% found elsewhere and is summarized in Figures 1 and 2.1,2,5 It after a vaginal delivery, and 19% during a cesarean appears to involve a complex sequence of events triggered delivery.1 These figures suggest that the mode of delivery in certain women by entrance into the maternal circulation of may alter the timing of amniotic fluid embolism but not its FIGURE 1 Proposed pathophysiology of amniotic fluid embolism Disruption of the maternal/fetal interface with potential passage of amniotic luid to maternal circulation Increased levels of Acute respiratory pulmonary failure with severe Amniotic luid activates Factor VII and vasoconstrictors hypoxemia platelets with consequent (e.g.endothelin) and disseminated intravascular coagulation mechanical (DIC). Inlammatory response further obstruction from activates clotting cascade cellular and acellular components of amniotic luid Hemorrhage contributes to hemodynamic instability. Diffuse intravascular clotting from DIC contributes to ischemic distal organ Acute right dysfunction and multi organ ventricular failure failure Hemodynamic collapse from right ventricular infarction and/or inter- ventricular septum displacement to the left and decreased left sidedd cardiac output LateL onset left ventricular failuref with cardiogenic pulmonary edema and systemic hypotension DIC, disseminated intravascular coagulation. SMFM. Amniotic fluid embolism: diagnosis and management. Am J Obstet Gynecol 2016. B2 MONTH 2016 smfm.org SMFM Clinical Guidelines FIGURE 2 Immediate supportive treatment in suspected cases of amniotic fluid embolism AFE suspected Immediate notiication to neonatology, maternal- fetal medicine and/or Start immediate high obstetric care provider, quality CPR-ACLS anesthesiology, intensive and call for help. care Consider immediate delivery in viable Early phase commonly Second phase Coagulopathy may have pregnancies either by characterized by right characterized by left immediate or delayed operative vaginal ventricular failure. May ventricular failure and onset following delivery or emergent conirm with bedside cardiogenic pulmonary cardiovascular collapse. cesarean section. transthoracic edema. Activate massive echocardiography Maintain hemodynamics transfusion protocols with use of where available. norepinephrine and Aggressive treatment of inotropes, such as uterine atony. Search dobutamine or for anatomic etiologies Avoid excessive luid milrinone. Limit resuscitation. of bleeding such as excessive luid pelvic lacerations. Consider administration. norepinephrine to maintain blood pressure. Right ventricular failure addressed with inotropes, such as dobutamine or milrinone. Decrease pulmonary afterload with inhaled nitric oxide or inhaled/intravenous prostacyclin if indicated. CPR, cardiopulmonary resuscitation; ACLS, advanced cardiac life support; AFE, amniotic fluid embolism. SMFM. Amniotic fluid embolism: diagnosis and management. Am J Obstet Gynecol 2016. occurrence. In rare instances, amniotic fluid embolism may Dissemninated intravascular coagulation is commonly occur during the first or second trimesters of pregnancy, at manifested by hemorrhagic complications including the time of pregnancy termination, or amniocentesis.6 bleeding from venipunctures or surgical sites, hematuria, The clinical presentation of amniotic fluid embolism is, gastrointestinal hemorrhage, and vaginal bleeding. As with in its classic form, dramatic. A period of anxiety, change any condition involving diminished uterine perfusion, in mental status, agitation, and a sensation of doom may coexistence with uterine atony is not uncommon. However, precede the event.7 Patientsmayprogressrapidlyto bleeding from incompletely
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