Question 1 of 10

    Amniotic Fluid Embolism (Embolus Amniotic Fluid)

    Amniotic fluid embolism[1]

    Amniotic fluid embolism is a rare, but potentially fatal condition that may occur during labor or the in early postnatal period. Presumably, entrance of amniotic fluid into the maternal circulation triggers an intense inflammatory response and leads to an abrupt onset of profound hypotension, heart failure, disseminated intravascular coagulation and respiratory failure. The diagnosis is made based on clinical criteria. Ensuring hemodynamic stability and adequate oxygenation of tissues is the mainstay of therapy.

    Amniotic Fluid Embolism develops due to the following process: anatomic/foreign.

    Presentation

    Symptoms and signs of amniotic fluid embolism appear abruptly during labor or sometimes early postpartum period. Most common findings include sudden onset of dyspnea, acute respiratory distress, marked hypotension, hypoxia, cyanosis and coagulopathy. Severe hemorrhage and DIC are frequent manifestations, as is arrhythmia. Within minutes, cardiogenic shock develops, as a result of pulmonary hypertension and cor pulmonale, followed by pulmonary edema [5]. Convulsions, altered mental status and seizures often develop. It is important to emphasize that these symptoms appear so rapidly that cardiac arrest may occur after just several minutes, which is why attending physicians must act quickly in starting appropriate therapy.

    Entire body system
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  • respiratoric
    Cough
    • Those patients who do survive enter the second phase of AFE, the hemorrhagic phase, which is often accompanied by severe shortness of breath, shivering, coughing, vomiting, and excessive bleeding due to a condition called DIC (disseminated intravascular[pregnancycorner.com]
    • - ‘Classic’ triad hypoxia, haemodynamic collapse, DIC APO/ALI ( 90%) Cardiac arrest ( 90%) Fetal distress (100%) SOB Bronchospasm Cough Arrhythmia Chest pain Seizure Headache Uterine atony RISK FACTORS Age 25 yrs Multiparous Obstructed labor with oxytocics[lifeinthefastlane.com]
    • […] findings Acute shortness of breath, hypertension and rapid progression to cardiac arrest, leading to reduced cardiorespiratory perfusion and coma; those who survive this first phase pass to a haemorrhagic phase, which is characterised by shivering, coughing[medical-dictionary.thefreedictionary.com]
    • "I felt like I had a tickly cough," said the 32-year-old elementary school teacher from Flintshire in Wales.[abcnews.go.com]
    Dyspnea
    • Maternal death is a frequent complication Symptoms Chest pain, dyspnea, cyanosis, tachycardia, hemorrhage, hypotension, or shock are potential symptoms.[medical-dictionary.thefreedictionary.com]
    • Amniotic fluid embolism is characterized by sudden dyspnea, chest pain, tachycardia, hypotension, and typical bluish, gray seen in patients with a pulmonary embolism.[armymedical.tpub.com]
    • Common presenting symptoms include dyspnea, nonreassuring fetal status, hypotension, seizures, and disseminated intravascular coagulation.[journals.lww.com]
    • In the case presented here the patient developed: severe pruritus, agitation, vomiting, dyspnea, paleness, tachycardia, inaudible BP, and SpO 2 85%.[scielo.br]
    • Hypotension (severe low blood pressure) Dyspnea (shortness of breath) Seizure Cough Slow fetal heartbeat (fetal bradycardia or fetal distress) Cardiac arrest (heart attack) Shock (severe drop in blood pressure) Cyanosis (blue skin caused by being in shock[pregnancycorner.com]
    Tachypnea
    • After vaginal delivery, the patient was transferred to the ICU with BP 90 60 mmHg, HR 110, and tachypnea.[scielo.br]
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  • cardiovascular
    Cyanosis
    • Pulmonary vasospasm which causes pulmonary hypertension and subsequent right sided heart failure Bronchospasm which induces signs of respiratory distress and cyanosis 1.[quizlet.com]
    • Any combination of sudden and profound shock, dyspnoea, cyanosis, apprehension, seizures, and the failure of rapid blood coagulation may herald the clinical onset of an AFE.[journals.cambridge.org]
    • Maternal death is a frequent complication Symptoms Chest pain, dyspnea, cyanosis, tachycardia, hemorrhage, hypotension, or shock are potential symptoms.[medical-dictionary.thefreedictionary.com]
    • However in the period 1991-3 only two cases were associated with augmentation of labour and only one case was associated with induction of labour clinical features sudden collapse, rapidly followed by cyanosis and the development of coagulopathy and bleeding[gpnotebook.co.uk]
    • The classic clinical presentation is of abrupt dyspnoea, cyanosis, and shock, shortly followed by a cardiorespiratory arrest and severe pulmonary oedema.[radiopaedia.org]
    Tachycardia
    • Maternal death is a frequent complication Symptoms Chest pain, dyspnea, cyanosis, tachycardia, hemorrhage, hypotension, or shock are potential symptoms.[medical-dictionary.thefreedictionary.com]
    • Amniotic fluid embolism is characterized by sudden dyspnea, chest pain, tachycardia, hypotension, and typical bluish, gray seen in patients with a pulmonary embolism.[armymedical.tpub.com]
    • Adrenaline 1 mg IV was given to the mother after which she developed transient ventricular tachycardia but this resolved spontaneously.[ispub.com]
    • In the case presented here the patient developed: severe pruritus, agitation, vomiting, dyspnea, paleness, tachycardia, inaudible BP, and SpO 2 85%.[scielo.br]
    • The electrocardiogram may show tachycardia, with a right ventricular strain pattern in the early stage and ST and T wave abnormalities.[pubmedcentralcanada.ca]
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  • urogenital
    Cesarean Section
    • The decision was quickly made to perform bedside cesarean section.[anesthesiology.pubs.asahq.org]
    • Doctors at Petah Tikva’s Rabin Medical Center-Beilinson Campus for the first time in Israel saved the life of a woman who developed such an embolism while undergoing delivery of her baby during cesarean section.[jpost.com]
    • Incidence of amniotic fluid embolism: Relation to cesarean section and to age.[freebirth.com.au]
    • Other Conditions to Consider When a pregnant woman during labor, Cesarean section, or pregnancy termination develops sudden shortness of breath with a drop in blood pressure, AFE is one of the possible causes, but others need to be considered and quickly[pregnancycorner.com]
    • If the fetus is deemed viable outside the maternal host, consider quick transport to a facility prepared for a crash cesarean section.[emsworld.com]
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  • Workup

    The diagnosis of amniotic fluid embolism currently rests on clinical grounds. In practice, the nature of the condition mandates a rapid therapeutic approach regardless of laboratory tests. Workup comprises CBC, with emphasis on hemoglobin, hematocrit and platelet count, which are important in assessing the need for blood transfusions, as well as a full coagulation panel, including prothrombin time (PT), activated partial thromboplastin time (aPTT) and fibrinogen should be obtained, to confirm DIC. Additionally, serum electrolytes and arterial blood gas analysis should be obtained. Electrocardiography and plain chest radiography are quick and useful methods to determine the presence of arrhythmia, pulmonary edema and heart failure. At this moment, specific diagnostic markers for amniotic fluid embolism do not exist, but significant attempts toward finding tests that may aid in making the diagnosis are made [10] [11].

    Pathology

    Biopsy
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  • Laboratory

    Serum
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  • ECG

    Axis
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  • Other ECG Findings
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  • Imaging

    X-ray
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  • Ultrasound
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  • Treatment

    Managing patients suffering from amniotic fluid embolism can be extremely difficult. Rapid supportive measures should be initiated as early as possible. Severe hemorrhage and anemia are often corrected with blood transfusions, sometimes including both red blood cells and plasma, to replenish coagulation factors that are depleted because of ongoing DIC. Hypotension in these patients requires administration of crystalloid solutions and vasopressor agents such as norepinephrine, dobutamine and dopamine, while correction of electrolytes is also necessary. Oxygen therapy and assisted or mechanical ventilation may be frequently required because of marked hypoxia and heart failure that is unable to compensate for generalized ischemia. Extracorporeal oxygenation, hemodialysis and plasmapheresis are techniques that have shown to life-saving in some studies [12] [13], and their use should be advocated in these patients as frequently as possible. Additionally, uterine artery embolization has shown to be a promising procedure in managing this condition [14].

    Prognosis

    This condition often leads to fatal outcomes and studies have indicated that death may occur only after a few hours after the onset of symptoms [9]. Mortality rates significantly reduced with advances in intensive care medicine throughout the past decades, but it is still very high, which shows the risk this condition poses to the patient. Variable mortality rates have been reported, but usually range between 20-60% [3], while mortality rates in the last decade have shown to be from 9-44% [2]. Unfortunately, women who do survive amniotic fluid embolism often have neurological sequelae.

    Complications

    Acute Cor Pulmonale
    • cor pulmonale without evidence of left ventricular compromise. 65 This was attributed to a vasoconstrictor response of the pulmonary vasculature to the presence of amniotic fluid or particulate matter in amniotic fluid. 11 In 1985, Clark et al 66 challenged[pubmedcentralcanada.ca]
    Acute Respiratory Distress Syndrome
    • CT Chest CT may show diffuse ground glass opacities (similar to early stage of acute respiratory distress syndrome) and prominent hilar pulmonary vasculature 9 .[radiopaedia.org]
    • Hypoxia causes myocardial capillary damage and pulmonary capillary damage, left heart failure, and acute respiratory distress syndrome.[emedicine.medscape.com]
    • Two clinical forms of AFE can be distinguished: 1) typical, (classic) with three phases (phase 1—respiratory and circulatory disorders, phase 2—coagulation distur- bances of maternal hemostasis, phase 3-acute renal fai- lure and acute respiratory distress[dx.doi.org]
    • respiratory distress syndrome (ARDS) are seen in the late phase.[joacc.com]
    • Maternal death due to AFE is typically caused by sudden cardiac arrest, hemorrhage from coagulopathy or the development of acute respiratory distress syndrome and/or multisystem organ failure after initial survival of the acute event.[pubmedcentralcanada.ca]
    Acute Respiratory Failure
    Anaphylaxis
    • Anaphylaxis The first specific suggestion of anaphylaxis as a mechanism of AFE was made by Attwood in 1956 [ 14 ].[hindawi.com]
    • Mast cell degranulation is a central aspect of anaphylaxis which releases large quantities of tryptase.[emedicine.medscape.com]
    • Although originally thought to be an embolic phenomena, because of the similarities with anaphylaxis, some authors believe that AFE is an immunologic phenomena, and go so far as to suggest that the name “amniotic fluid embolism ” is a misnomer [Clark[openanesthesia.org]
    • […] syndrome causing organ failure (BOYLE 2002) Is it always dangerous if fetal cells/amniotic fluid enter the maternal circulation Not always - it can enter with no tragic consequences but some women also develop an extreme inflammatory response similar to anaphylaxis[quizlet.com]
    • A recent study has likened the reaction more to an allergic reaction than to an embolic reaction, and has proposed the term “anaphylactoid syndrome of pregnancy” instead of amniotic fluid embolus, because of the close resemblance to anaphylaxis.3 Additional[emsworld.com]
    Cardiac Arrest
    Cardiac Arrhythmia
    • In the absence of any other clear cause, acute maternal collapse with one or more of the following features : • Acute fetal compromise • Cardiac arrhythmias or arrest • Coagulopathy • Convulsion • Hypotension • Maternal haemorrhage • Shortness of breath[freebirth.com.au]
    • This is followed by cardiac arrest and/or coagulopathy. [13] The signs and symptoms in this early phase include dyspnea, desaturation, hypotension, cardiac arrhythmias, seizures, loss of consciousness, bleeding, and cardiac arrest. [13] Fetal hypoxia[joacc.com]
    • Cardiac arrhythmias or asystole can be seen with severe cardiovascular collapse.[pubmedcentralcanada.ca]
    Complication of Labor and Delivery
    • […] of Labor and Delivery .)[merckmanuals.com]
    • Amniotic Fluid Embolism This is one of the most serious complications of labor and delivery .[webmd.com]
    Disseminated Intravascular Coagulation
    • NOTE : Disseminated intravascular coagulation is an acute abnormal stimulation of the normal coagulation process.[armymedical.tpub.com]
    • ., Buller, H.R. and Ten Cate, J.W. (1991) Management of disseminated intravascular coagulation in obstetrics.[scirp.org]
    • Cardiac arrest and disseminated intravascular coagulation (DIC) commonly occur.[medical-dictionary.thefreedictionary.com]
    • Six of the 9 women with AFE died, and all 9 required blood transfusions for disseminated intravascular coagulation (DIC).[emedicine.medscape.com]
    • On the basis of this clinical heterogeneity, it was recently suggested that AFE may involve disseminated intravascular coagulation (DIC), uterine atony, and (or) cardiopulmonary collapse [ 4 ].[jaclinicalreports.springeropen.com]
    Hypoxia
    • […] uncertain probably due to an anaphylactic reaction to fluid or fetal tissue intravascular entry of prostaglandins, leukotrienes, endothelin and fetal debris within 30min - complement activation intense pulmonary vasoconstriction - right heart failure - hypoxia[lifeinthefastlane.com]
    • Usually presents with respiratory distress, hypotension, hypoxia.[openanesthesia.org]
    • In phase I, pulmonary artery vasospasm with pulmonary hypertension and elevated right ventricular pressure cause hypoxia.[emedicine.medscape.com]
    • When the AFE occurs before or during delivery, the fetus is impacted quickly by any hypoxia.[emsworld.com]
    • AFE is always associated with hypoxia.[journals.lww.com]
    Pulmonary Embolism
    • Amniotic fluid embolism is characterized by sudden dyspnea, chest pain, tachycardia, hypotension, and typical bluish, gray seen in patients with a pulmonary embolism.[armymedical.tpub.com]
    • (See "Critical illness during pregnancy and the peripartum period" and "Deep vein thrombosis and pulmonary embolism in pregnancy: Treatment" .)[uptodate.com]
    • It is usually fatal to the mother if it is a pulmonary embolism. amniotic fluid embolism A condition resulting from a traumatic delivery and “injection” of amniotic fluid containing lanugo, squames, mucus and debris into the opened maternal circulation[medical-dictionary.thefreedictionary.com]
    • Similarly the initial symptoms are difficult to interpret and distinguish from other acute and life-threatening emergencies (i.e. pulmonary embolism, placental abruption, septic shock, stroke, myocardial ischemia, etc.), therefore the diagnosis is one[eurekaselect.com]
    • Contemporary OB/GYN, 53, 53-64. [ 15 ] Steiner, P.E. and Lushbaugh, C.C. (1941) Maternal pulmonary embolism by amniotic fluid as a cause of obstetric shock and unexpected deaths in obstetrics.[scirp.org]
    Pulmonary Hypertension
    • hypertension Decreased cardiac output due to an increase in pulmonary hypertension Hypotension due to decrease in cardiac output which reduces placental perfusion and causes FHR abnormalities Confusion Seizures Atonic uterus as amniotic fluid in the[quizlet.com]
    • May lead to an anaphylactoid reaction that produces pulmonary hypertension and right heart failure (which can eventually progress to biventricular failure and cardiac arrest).[openanesthesia.org]
    • The initial response is acute pulmonary hypertension and vasospasm leading to right ventricular failure, hypoxia, and cardiac arrest.[journals.lww.com]
    • In phase I, pulmonary artery vasospasm with pulmonary hypertension and elevated right ventricular pressure cause hypoxia.[emedicine.medscape.com]
    • The hemodynamic response in AFE is biphasic, with initial pulmonary hypertension and right ventricular failure, followed by left ventricular failure.[pubmedcentralcanada.ca]
    Respiratory Failure
    • The first stage of AFE usually includes cardiac arrest and rapid respiratory failure.[healthline.com]
    • Once it reaches the maternal circulation, it can precipitate cardiogenic shock, respiratory failure, and, most likely, an inflammatory and anaphylactoid response.[uptodate.com]
    • The ECMO, which is being used more abroad now in adults with cardiac and respiratory failure, works by removing blood from the persons body and artificially removing the carbon dioxide and oxygenating red blood cells.[jpost.com]
    • Acute respiratory failure in pregnancy: an analysis of 19 cases.[journals.lww.com]
    Shock
    • Once it reaches the maternal circulation, it can precipitate cardiogenic shock, respiratory failure, and, most likely, an inflammatory and anaphylactoid response.[uptodate.com]
    • The diagnosis of disseminated intravascular coagulation (DIC) and shock (anaphylactic, septic, hypovolemic) was made.[scielo.br]
    • Hypotension (severe low blood pressure) Dyspnea (shortness of breath) Seizure Cough Slow fetal heartbeat (fetal bradycardia or fetal distress) Cardiac arrest (heart attack) Shock (severe drop in blood pressure) Cyanosis (blue skin caused by being in shock[pregnancycorner.com]
    • Delivery was uneventful, but massive vaginal bleeding without clotting and ensuing hypovolemic shock occurred 4 h later.[jaclinicalreports.springeropen.com]
    • Any combination of sudden and profound shock, dyspnoea, cyanosis, apprehension, seizures, and the failure of rapid blood coagulation may herald the clinical onset of an AFE.[journals.cambridge.org]
    Sudden Death
    • DISCUSSION Amniotic fluid embolism also known as amniotic caseous embolism or amniotic caseous fluid embolisms, and more recently as anaphylactic syndrome of pregnancy 3, is one of the causes of sudden death in obstetrics.[scielo.br]
    • AFE has been diagnosed since 1941, when two Ame- rican gynecologists, Steiner and Lushbaugh [3], descri- bed eight cases of sudden death of childbearing women It was only after their publication that Meyer’s report of 1926 was noticed—the description[dx.doi.org]
    • The DIC subtype carried a lesser mortality when compared with the classical subtype which was associated with a higher incidence of sudden death. [26] Diagnosis Amniotic fluid embolism is essentially a clinical diagnosis and a diagnosis of exclusion as[joacc.com]
    Thrombocytopenia
    • The blood transfusion strategy for AFE patients is thus similar to the massive transfusion protocol for trauma patients, in which disruption of hemostasis occurs because of dilution coagulopathy, inflammatory mediator activation, hyperfibriolysis, thrombocytopenia[jaclinicalreports.springeropen.com]
    • Thrombocytopenia is a rare finding.[pubmedcentralcanada.ca]
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  • Etiology

    The exact cause and events that lead to amniotic fluid embolism are still unclear. It is established, however, that the pathogenesis almost always includes interruption of the maternal-fetal barrier and consequent introduction of amniotic fluid into the maternal circulation, which frequently occurs in conditions such as placental rupture, placenta previa, in medically induced labor and in various other conditions [5]. In addition to mechanical factors, immune-mediated reactions to fetal material that is contained in the amniotic fluid is also one of the main theories that attempt to explain the presumed etiology [5].

    Epidemiology

    Amniotic fluid embolism is rarely encountered in medical practice. Incidence rates have determined that this disorder develops in approximately 1 in 15,200 deliveries in North America. For unknown reasons, the incidence rate in Europe is much lower, with 1 in 59,900 deliveries developing amniotic fluid embolism [2]. After pulmonary embolism and hypertension, this condition is the most common cause of non-abortion-related maternal mortality during labor and is responsible for roughly 10% of all maternal deaths in the United States [6]. Moreover, it is the most common cause of maternal death in Australia and among the top three in the majority of developed countries [2]. Despite its ambiguous etiology, mechanical disruption of the maternal-fetal barrier is almost certain to be one of key events and various risk factors have been established in regard to this factor. Medical induction of labor, advanced maternal age, cesarean section, forceps delivery, placental rupture, placenta previa, uterine rupture, cervical lacerations and multiple-birth deliveries are shown to significantly increase the risk for amniotic fluid embolism [7].

    Sex distribution
    Age distribution

    Pathophysiology

    It is postulated that mechanical and immunological factors are the most important contributors to the development of this disorder. For amniotic fluid to reach maternal circulation, it is thought that some form for breach of the maternal-fetal barrier is necessary, leading to changes in pressure gradients that force amniotic fluid to pool into maternal vessels [2]. But invasion of amniotic fluid alone is determined to be insufficient for the pathogenesis of this disorder, which bring into question the immune-mediated mechanisms that are presumed to be involved [6]. From one hand, various contents of the amniotic fluid (meconium, particulate matter, but also various inflammatory molecules including prostaglandins and leukotrienes) are shown to be important mediators of vasoconstriction and it is assumed that some form of anaphylaxis occurs when these substances interact with the immune system of the mother; and from the other, activation of the complement system in response to these contents are shown to be of key elements in the development of severe inflammation, DIC and shock [5] [8]. Once the amniotic fluid reaches the pulmonary artery, marked vasoconstriction and pulmonary hypertension develops within a few hours, leading to cor pulmonale, right heart failure and severe hypoxia, and eventually left-heart failure and shock.

    Prevention

    Despite the fact that this life-threatening condition was described almost 100 years ago, the exact factors that lead to this condition remain unknown, hence prevention strategies currently do not exist.

    Summary

    Amniotic fluid embolism is a life-threatening obstetric complication that results in rapid patient deterioration, usually occurring either during labor or in the early postpartum period [1]. Although this medical phenomenon was initially described almost 100 years ago [2], the exact reasons for the appearance of this disorder remain unclear. It is thought that the entry of amniotic fluid into maternal circulation stems from disruption of the maternal-fetal barrier during labor and subsequent changes in pressure gradients that force amniotic fluid out of the fetal compartment. This theory is supported by the fact that a significantly increased risk for amniotic fluid embolism is established in women who present with placenta previa, polyhydramnios, abruption of the placenta and in those in whom operative deliveries were necessary [3]. This condition is seen in approximately 1 in 15,200 women in North America, while incidence in rates in Europe indicate that 1 in 59,900 deliveries are complicated by an amniotic fluid embolism [1]. The pathogenesis model, apart from amniotic fluid entry into the systemic circulation of the mother, is thought to involve a systemic inflammatory response due to the contents of the fluid. As the amniotic fluid reaches the circulation, extensive vasoconstriction occurs, especially in the pulmonary artery and results in cor pulmonale and severe right heart failure, eventually leading to severe hemodynamic instability. It is shown that amniotic fluid directly reduces coagulation time, activates the complement cascade and induces severe coagulopathy by interfering with various factors involved in this process [4]. Disseminated intravascular coagulation (DIC), initially right and followed by left heart failure, respiratory failure and shock ensue rapidly. Since this condition is known to be fatal within the first few hours in approximately 20-60% of women, early and aggressive therapy may significantly improve survival rates [3]. The diagnosis is made based on clinical criteria, the most common symptoms being abrupt development of hypotension, arrhythmia, respiratory distress, convulsions and hemorrhage. Guided by laboratory studies comprising of a complete blood count (CBC), coagulation panel, serum electrolytes and arterial blood gasses, treatment aims to stabilize blood pressure and tissue oxygenation that often calls for blood transfusions, assisted ventilation, fluid administration, use of vasopressors and various other strategies that are required to restore hemodynamic stability.

    Patient Information

    Amniotic fluid embolism is a rare but often life-threatening condition that develops during birth or shortly after birth. It is established to occur approximately once in every 15,000-60,000 deliveries and despite that almost a century has passed since this condition was described in literature, the exact cause remains unknown. Several conditions have shown to increase the risk for developing this condition, including rupture of the placenta, multiple-birth pregnancies, placenta previa, advanced age of the mother, but also medical induction of labor and cesarean delivery. It is hypothesized that the barrier that separates the fetus and the mother is disrupted during labor, which leads to passage of amniotic fluid into maternal blood vessels. More importantly, various components of the amniotic fluid supposedly cause a marked inflammatory reaction in the mother, leading to abrupt and profound changes in the circulatory system. Rapid development of severe symptoms such as hypotension, arrhythmia, heart failure, respiratory arrest and shock is observed. Severe bleeding and marked disturbances in blood coagulation are frequent, together with convulsions and seizures. The diagnosis is made based on clinical grounds, as the rapid onset and profound deterioration of the condition of the patient during labor are hallmarks of amniotic fluid embolism. Treatment aims to restore blood pressure and establish adequate oxygenation of tissues through administering both blood and plasma transfusions and intravenous fluids together with drugs that increase tension of blood vessels. Because cessation of breathing may occur within minutes after onset, oxygen therapy and either assisted or mechanical ventilation are indicated to prevent lung failure. Recently, various techniques that can more efficiently reach adequate blood pressure control have been recommended in these patients, such as hemodialyis and extracorporeal oxygenation, which includes the use of machines for inserting oxygen into the circulation. Amniotic fluid embolism is often a fatal condition, with maternal mortality rates reaching up to 60%, which is why early and aggressive treatment within the first few minutes after the onset of symptoms can save the patient. Unfortunately, prevention strategies of this condition remain to be created ad women who survive this condition often have long-term neurological sequelae, which illustrates the danger this condition poses.

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    References

    1. Conde-Agudelo A, Romero R. Amniotic fluid embolism: An evidence-based review. Am J Obstet Gynecol. 2009;201(5):445.e1-445.13.
    2. Meyer JR. Embolis pulmonary caseosa. Braz J Med Biol Res 1926;1:301-303.
    3. Clark SL. Amniotic fluid embolism. Obstet Gynecol. 2014;123(2 pt 1):337-348.
    4. Courtney LD, Allington M. Effect of amniotic fluid on blood coagulation. Br J Haematol. 1972;22:353–355.
    5. Rossi SE, Goodman PC, Franquet T. Nonthrombotic pulmonary emboli. AJR Am J Roentgenol. 2000;174(6):1499-508.
    6. Benson MD. Current concepts of immunology and diagnosis in amniotic fluid embolism. Clin Dev Immunol. 2012;946576.
    7. Kramer MS, Rouleau J, Baskett TF, Joseph KS,. Amniotic-fluid embolism and medical induction of labour: a retrospective, population-based cohort study. Lancet. 2006;368(9545):1444-1448.
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    10. Farrar SC, Gherman RB. Serum tryptase analysis in a woman with amniotic fluid embolism. A case report. J Reprod Med. 2001;46(10):926-928.
    11. 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. 1993;168(3 Pt 1):848-853.
    12. 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. 2001;40(9):945-947.
    13. 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. 2000;183(2):496-497.
    14. Goldszmidt E, Davies S. Two cases of hemorrhage secondary to amniotic fluid embolus managed with uterine artery embolization. Can J Anaesth. 2003;50(9):917-921.

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    1. Amniotic fluid embolism, CC BY-SA 2.0

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