Amniotic fluid embolism

AFE And Anesthesia

1. AMNIOTIC FLUID EMBOLISM DR PRITI PATIL, FORTIS HOSPITAL,MULUND.

2. AMNIOTIC FLUID EMBOLISM Amniotic fluid embolism (AFE) is a life-threatening obstetric emergency . It happens due to sudden gush of amniotic fluid ,fetal cells , hair and amniotic debry entering the maternal circulation. Signs and Symptoms: Sudden collapse due to profound hypotension. Hypoxemia DIC ( Disemminated intravascular coagulation)

3. Differential Diagnosis Obstetric Causes Acute hemorrhage Amniotic fluid embolism Placental abruption Uterine rupture Uterine atony Eclampsia Peripartum cardiomyopathy Anesthetic Causes High spinal anesthesia Aspiration Local anesthetic toxicity Non obstetric Causes Pulmonary embolism Air embolism Anaphylaxis Sepsis/septic shock Intracerebral bleed Drug toxicity Acute myocardial infarction

4. Factors that may be associated with AFE Advanced maternal age Multiparity Meconium stained liquor Obstructed labor Intrauterine fetal death Polyhydramnios Tetanic uterine contractions Maternal history of allergy or atopy Uterine rupture Placenta accreta Trauma Diabetes mellitus Operative delivery including cesarean section .

5. It is uncommonly known as Anaphylactoid Syndrome of Pregnancy. Exposure of maternal circulation to the amniotic fluid , fetal cells/ debry may lead to hypoxemia, pulmonary vasospasm, cardiac failure or even death. Which may result in activation of the complement cascade stimulating endogenous immunomediators , producing a reaction similar to anaphylaxis. Amniotic fluid also contains procoagulant tissue factor . It is described as a Biphasic Response PhaseI – The biochemicals released after the entry of the amniotic material has entered causes severe pulmonary artery vasospasm → pulmonary hypertension→ increased right ventricular pressures→ right ventricular dysfunction. (Lasts for 30 mins) Phase II- Left ventricular failure and pulmonary edema.Biochemical mediators lead to DIC which leads to massive hemorrhage and DIC.

6. Symptoms Signs Dyspnea Hypotension Cough Fetal Distress Headache Pulmonary edema/ARDS Chest Pain Cyanosis Coagulopathy Seizures Bronchospasm Cardiopulmonary arrest Uterine Atony Clinical Features

7. Treatment Amniotic fluid embolism is a diagnosis of exclusion. Management is symptomatic and supportive. Targets- Maintaining oxygenation ,hemodynamic support and correction of coagulopathy Immediate Resuscitation- ABC Airway and breathing Administer 100% oxygen via a non-rebreathing reservoir face mask Prompt assessment, with control of the airway and ventilation of the lungs with tracheal intubation may be essential. Circulation 2 large bore iv lines, send blood for coagulation profile, CBC, crossmatch, arrange 6units blood. Left lateral tilt/Manual uterine displacement. Hemodynamic support would include preload optimization and vasopressors .

8. Fluid resuscitation with crystalloid/colloid to optimize filling. Infusion of an inotrope may be required to maintain a mean arterial blood pressure and achieve an adequate urine output. An arterial line for continuous blood pressure monitoring is essential, and the use of a non-invasive cardiac output monitor may be helpful. Continuously monitor the fetus and early consideration should be given to delivery of baby. Uterine tone – Pharmacologic agents such as oxytocin, ergometrine and prostaglandins carboprost and misoprost . Coagulation: Use of plasma, cryoprecipitate, and platelets to be guided by clinical condition of the patient and laboratory investigations . Recombinant factor VII may be used, but one should be careful as this can cause thrombotic complications Antifibrinolytics, like e-aminocaproic acid and tranexamic acid, might be helpful but evidence is lacking.

9. Investigations Coagulation profile: AFE is associated with DIC in >80% cases Electrocardiogram shows tachycardia, ST segment and T-wave changes, and findings consistent with right ventricle strain Arterial blood gases: changes consistent with hypoxia Chest X-ray: consistent with pulmonary edema Echocardiogram Serum tryptase

10. Management Intensive care monitoring One should be aware that there is high-risk at developing: ARDS, heart failure, DIC Supportive treatment: Ventilation, inotropic support, Hematological support Steroids may be useful Potential Interventions for Severe Life Threatening Cases of AFE Inhaled nitric oxide for pulmonary hypertension leading to right-sided heart failure ECMO for severe hypoxia and left heart failure.

11. Thank You