Amniotic Fluid Emboli

Question 1

Risk factors

Answer 1

• Induction/augmentation of labour with oxytocin
• Cesarean section
• maternal age >35 yr,
• male fetus,
• multiple pregnancy,
• polyhydramnios,
• eclampsia,
• uterine rupture,
• cervical trauma,
• placenta praevia,
• placental abruption,
• ethnic minority.

Question 2

Incidence of AFE

Answer 2

1:8 000 to 1: 80 000
Europe 1 : 53 800
North America 1: 15 200

Question 3

Mortality rates of AFE

Answer 3

20-40%

Question 4

Pathophysiology of AFE: mechanical theory

Answer 4

a mechanical element to a large bolus of amniotic fluid containing fetal squamous cells, vernix caseosa, lanugo, trophoblasts, fetal gut mucin, and bile-stained meconium

Question 5

Pathophysiology of AFE: immune-mediated theory

Answer 5

Mast-cell degranulation occurs on exposure to fetal antigens, including platelet activating factor, interleukins, complement factors, and tumour necrosis factor-alpha.
Serum mast-cell tryptase is not ^ after AFE.

Question 6

Pathophysiology of AFE: phase 1

Answer 6

last 30 min
follow the initial entry of amniotic fluid into the circulation.
The PAP ^ , and
RF failure ensues with subsequent microvascular damage and hypotension.
Pulmonary obstruction can be exacerbated by the formation of microthrombi in the pulmonary vasculature once DIC has developed.

Question 7

Pathophysiology of AFE: phase 2

Answer 7

occurs in patients who survive the initial insult, and is characterised by left mventricular failure, endothelial activation and leakage, and DIC

Question 8

UKOSS diagnostic criteria

Answer 8

Question 9

Maternal resuscitation for AFE should focus on which three priorities?

Answer 9

(1) maintenance of oxygenation;
(2) hemodynamic support;
(3) correction of coagulopathy

Question 10

How to manage MX right heart failure in AFE?

Answer 10

Inhaled NO
Prostacyclin
Right ventricular assist devices
Vasopressor; Milrinone, dobutamin, vasopressin

Question 11

Which Left sided failure adjuncts can be used in AFE?

Answer 11

ECMO

IABP

Question 12

Coagulation mx in AFE

Answer 12

• activate massive transfusion protocol
• components will be guided by presentation
• antifibrinolytic agents
• Recombinant factors ( rIV causes micro thrombi)
• fibrinogen concentrate

Question 13

Neonatal outcomes AFE

Answer 13

50% survivors have neuro impairment

21-32% mortality

Question 14

Differential diagnosis: pregnancy specific

Answer 14

Eclampsia
Uterine rupture
Acute haemorrhage
Peripartum Cardiomyopathy

Question 15

Differential diagnosis : anaesthetic?

Answer 15

Hight spinal

Local anaesthetic toxicity

Question 16

Differential diagnosis: other ?

Answer 16

PE
Air embolism
Anaphylaxis
Sepsis
MI
Arrhythmia 
Transfusion reaction

Question 17

Pre monitory symptoms of AFE?

Answer 17

Breathless
Chest pain
Light headedness 
Restless 
Distress
Panic
Pins and needles in the fingers 
Nausea and vomiting