Incidence & Risk Factors for Amniotic-Fluid Embolism

Fawad Hameedi, MS IV

Embolism An Obstetric Emergency

An AFE is an obstetric emergency in which amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation, causing cardiopulmonary collapse. Current data from the National Amniotic Fluid Embolus Registry suggest that the process is more similar to anaphylaxis than to embolism, and the term anaphylactoid syndrome of pregnancy has been suggested because fetal tissue or amniotic fluid components are not universally found in women who present with signs and symptoms attributable to AFE. The diagnosis of AFE has traditionally been made at autopsy when

Embolism An Obstetric Emergency

The initiating event is poorly understood. However, usually during labor or other procedure, amniotic fluid and debris, or some as yet unidentified substance, enters the maternal circulation; this may trigger a massive anaphylactic reaction, activation of the complement cascade, or both.
Progression usually occurs in 2 phases. In phase I, pulmonary artery vasospasm with pulmonary hypertension and elevated right ventricular pressure cause hypoxia. Hypoxia causes myocardial capillary damage and pulmonary capillary damage, left heart failure, and acute respiratory distress syndrome. Women who survive these events may enter phase II. This is a hemorrhagic phase

Objective; Study Design; Methods

Objective : To estimate the incidence of amniotic-fluid

embolism and to describe risk factors, management and outcomes. Design & Methods : Using a prospective population based cohort study and a nested case control analysis via information from the UK Obstetric Surveillance System, performed on patients who have previously experienced AFE versus a control group. Data collected thru 2 main routes, passive and active reporting and the incidence of disease patterns were studied. Clinicians were asked to report any patients diagnosed with AFE with symptoms and signs consistent with AFE or any patients in whom AFE was

Diagnostic Criteria Reqd for Dx of AFE

In the absence of any other clear cause:

Acute maternal demise with one or more of the following: Acute fetal compromise Cardiac arrest/rhythm disturbances Coagulopathy Hypotension Maternal Hemorrhage Seizure SOB
o

Excluding: women with maternal hemorrhage as the first presenting feature in whom there was no evidence of early coagulopathy or cardio-resp. compromise.

Study Information The UK OSS nominated clinicians in each

hospital with a dedicated maternal-fetal unit, to report AFE events. Also women with AFE delivering outside unit settings were transferred to capable institutions and therefore, the events were noted within the study. Details of AFE events such as presentation, management and outcomes were reported and gathered for report review. Reports from the Centre for Maternal and Child Enquiries, which has collected information on all maternal deaths in the UK for more than 50 years also provided information on maternal deaths from AFEs occurring during the study period.

Study Outcomes Over the course of the 4 years of the duration of the

study, there was no significant change in incidence. The data was released in two groups, women >35 and women <35 years old. There was a nonsignificant association between maternal ethnicity. No other sociodemographical factor significantly affected the risk of AFE. The occurrence of AFE was significantly assoc. with induction of labor and multiple pregnancy, for which the attributable risks are 35% and 13%, respectively. 85% of women who presented with AFE at or before delivery were delivered by cesarean, 58% were managed with supportive therapy (fluids, blood), 25% had hysterectomy to control the hemorrhage, and another 25% were given factor VIIa.

Discussion
The incidence of AFE estimated by the 4 year

prospective study is 2.0 per 100,000 pregnancies, which was significantly lower than other documented hospital databases in Canada and the United States. This study differed from the others by way of not reporting observed complications such as eclampsia, placenta previa and abruption as evidence of over reporting. This UK study had lowered incidence estimates due to the requirements held by the UK OSS.

Discussion Contd
Induction of labor was associated with a risk of 35%

of AFE in the study, suggesting a cause of the AFE, and if induction were not performed, 35% of cases could have been prevented. Induction is clearly a beneficial procedure with AFE being a very rare complication, but care staff should be aware of the risks and potential complications. Of the >80% of patients who had AFE at or before delivery were delivered by cesarean, which this study showed that the cesarean delivery was a consequence of AFE and not the cause of the AFE. Other studies show differing information, so noting that cesarean delivery is not risk free, and all risks and benefits should be assessed before a decision for