Amniotic fluid embolism syndrome
- Marie R Baldisseri, MD, FCCM
Marie R Baldisseri, MD, FCCM
- Professor of Critical Care Medicine
- University of Pittsburgh Medical Center
- Section Editors
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Associate Professor of Medicine
- University of Pennsylvania School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Amniotic fluid embolism syndrome (AFES; also called anaphylactoid syndrome of pregnancy) is a catastrophic condition that occurs during pregnancy or shortly after delivery [1-3]. Although first reported in 1926, it was not widely recognized until 1941 when an autopsy series of eight women who had died from sudden shock during labor reported squamous cells and mucin of fetal origin in the maternal pulmonary vasculature [4,5]. Fetal squamous cells have also been described in the vascular beds of the maternal kidneys, liver, spleen, pancreas, and brain .
Amniotic fluid embolism syndrome is reviewed here. The management of critically ill obstetric patients is discussed separately, including those with venous thromboembolism. (See "Critical illness during pregnancy and the peripartum period" and "Deep vein thrombosis and pulmonary embolism in pregnancy: Treatment".)
Amniotic fluid embolism syndrome is rare. Most studies indicate that the incidence rate is between 1 and 12 cases per 100,000 deliveries [7-15].
Several factors have been associated with amniotic fluid embolism syndrome (AFES). They include precipitous or tumultuous labor, advanced maternal age, cesarean and instrumental delivery, placenta previa and abruption, grand multiparity (≥5 live births or stillbirths), cervical lacerations, fetal distress, eclampsia, and medical induction of labor [7,12,16]. Our understanding of the pathogenesis suggests that these factors probably are associated with amniotic fluid embolism syndrome, but not the direct cause. The syndrome is best considered unpredictable and unpreventable.
Amniotic fluid is believed to enter the maternal circulation through the endocervical veins, the placental insertion site, or a site of uterine trauma . It is more frequently associated with uterine trauma, such as seen in miscarriages, abortions, amniocentesis, and vaginal and cesarean deliveries. Once it reaches the maternal circulation, it can precipitate cardiogenic shock, respiratory failure, and, most likely, an inflammatory and anaphylactoid response.
- Gilmore DA, Wakim J, Secrest J, Rawson R. Anaphylactoid syndrome of pregnancy: a review of the literature with latest management and outcome data. AANA J 2003; 71:120.
- Gist RS, Stafford IP, Leibowitz AB, Beilin Y. Amniotic fluid embolism. Anesth Analg 2009; 108:1599.
- Clark SL. Amniotic fluid embolism. Obstet Gynecol 2014; 123:337.
- Meyer, JR. Embolia pulmonar amnio caseosa. Brasil Medico 1926; 2:301.
- Steiner PE, Lushbaugh CC. Landmark article, Oct. 1941: Maternal pulmonary embolism by amniotic fluid as a cause of obstetric shock and unexpected deaths in obstetrics. By Paul E. Steiner and C. C. Lushbaugh. JAMA 1986; 255:2187.
- Liban E, Raz S. A clinicopathologic study of fourteen cases of amniotic fluid embolism. Am J Clin Pathol 1969; 51:477.
- Abenhaim HA, Azoulay L, Kramer MS, Leduc L. Incidence and risk factors of amniotic fluid embolisms: a population-based study on 3 million births in the United States. Am J Obstet Gynecol 2008; 199:49.e1.
- Clark SL, Hankins GD, Dudley DA, et al. Amniotic fluid embolism: analysis of the national registry. Am J Obstet Gynecol 1995; 172:1158.
- Tuffnell DJ. United kingdom amniotic fluid embolism register. BJOG 2005; 112:1625.
- Morgan M. Amniotic fluid embolism. Anaesthesia 1979; 34:20.
- Kramer MS, Rouleau J, Baskett TF, et al. Amniotic-fluid embolism and medical induction of labour: a retrospective, population-based cohort study. Lancet 2006; 368:1444.
- Knight M, Tuffnell D, Brocklehurst P, et al. Incidence and risk factors for amniotic-fluid embolism. Obstet Gynecol 2010; 115:910.
- Shen F, Wang L, Yang W, Chen Y. From appearance to essence: 10 years review of atypical amniotic fluid embolism. Arch Gynecol Obstet 2016; 293:329.
- Yoneyama K, Sekiguchi A, Matsushima T, et al. Clinical characteristics of amniotic fluid embolism: an experience of 29 years. J Obstet Gynaecol Res 2014; 40:1862.
- Fitzpatrick KE, Tuffnell D, Kurinczuk JJ, Knight M. Incidence, risk factors, management and outcomes of amniotic-fluid embolism: a population-based cohort and nested case-control study. BJOG 2016; 123:100.
- Turner LA, Kramer MS, Liu S, Maternal Mortality and Morbidity Study Group of the Canadian Perinatal Surveillance System. Cause-specific mortality during and after pregnancy and the definition of maternal death. Chronic Dis Can 2002; 23:31.
- Courtney LD. Amniotic fluid embolism. Obstet Gynecol Surv 1974; 29:169.
- Clark SL. New concepts of amniotic fluid embolism: a review. Obstet Gynecol Surv 1990; 45:360.
- ATTWOOD HD, DOWNING ES. EXPERIMENTAL AMNIOTIC FLUID AND MECONIUM EMBOLISM. Surg Gynecol Obstet 1965; 120:255.
- Reis RL, Pierce WS, Behrendt DM. Hemodynamic effects of amniotic fluid embolism. Surg Gynecol Obstet 1969; 129:45.
- Clark SL, Cotton DB, Gonik B, et al. Central hemodynamic alterations in amniotic fluid embolism. Am J Obstet Gynecol 1988; 158:1124.
- Clark SL, Montz FJ, Phelan JP. Hemodynamic alterations associated with amniotic fluid embolism: a reappraisal. Am J Obstet Gynecol 1985; 151:617.
- Shechtman M, Ziser A, Markovits R, Rozenberg B. Amniotic fluid embolism: early findings of transesophageal echocardiography. Anesth Analg 1999; 89:1456.
- Stanten RD, Iverson LI, Daugharty TM, et al. Amniotic fluid embolism causing catastrophic pulmonary vasoconstriction: diagnosis by transesophageal echocardiogram and treatment by cardiopulmonary bypass. Obstet Gynecol 2003; 102:496.
- Price TM, Baker VV, Cefalo RC. Amniotic fluid embolism. Three case reports with a review of the literature. Obstet Gynecol Surv 1985; 40:462.
- Nishio H, Matsui K, Miyazaki T, et al. A fatal case of amniotic fluid embolism with elevation of serum mast cell tryptase. Forensic Sci Int 2002; 126:53.
- Farrar SC, Gherman RB. Serum tryptase analysis in a woman with amniotic fluid embolism. A case report. J Reprod Med 2001; 46:926.
- Benson MD, Kobayashi H, Silver RK, et al. Immunologic studies in presumed amniotic fluid embolism. Obstet Gynecol 2001; 97:510.
- Fineschi V, Gambassi R, Gherardi M, Turillazzi E. The diagnosis of amniotic fluid embolism: an immunohistochemical study for the quantification of pulmonary mast cell tryptase. Int J Legal Med 1998; 111:238.
- Benson MD. A hypothesis regarding complement activation and amniotic fluid embolism. Med Hypotheses 2007; 68:1019.
- Benson MD. Current concepts of immunology and diagnosis in amniotic fluid embolism. Clin Dev Immunol 2012; 2012:946576.
- Azegami M, Mori N. Amniotic fluid embolism and leukotrienes. Am J Obstet Gynecol 1986; 155:1119.
- Benson MD. Nonfatal amniotic fluid embolism. Three possible cases and a new clinical definition. Arch Fam Med 1993; 2:989.
- Lawson HW, Atrash HK, Franks AL. Fatal pulmonary embolism during legal induced abortion in the United States from 1972 to 1985. Am J Obstet Gynecol 1990; 162:986.
- Hasaart TH, Essed GG. Amniotic fluid embolism after transabdominal amniocentesis. Eur J Obstet Gynecol Reprod Biol 1983; 16:25.
- Mainprize TC, Maltby JR. Amniotic fluid embolism: a report of four probable cases. Can Anaesth Soc J 1986; 33:382.
- Ellingsen CL, Eggebø TM, Lexow K. Amniotic fluid embolism after blunt abdominal trauma. Resuscitation 2007; 75:180.
- Rainio J, Penttilä A. Amniotic fluid embolism as cause of death in a car accident--a case report. Forensic Sci Int 2003; 137:231.
- Masson RG, Ruggieri J, Siddiqui MM. Amniotic fluid embolism: definitive diagnosis in a survivor. Am Rev Respir Dis 1979; 120:187.
- Wasser WG, Tessler S, Kamath CP, Sackin AJ. Nonfatal amniotic fluid embolism: a case report of post-partum respiratory distress with histopathologic studies. Mt Sinai J Med 1979; 46:388.
- Peterson EP, Taylor HB. Amniotic fluid embolism. An analysis of 40 cases. Obstet Gynecol 1970; 35:787.
- Beller FK. Disseminated intravascular coagulation and consumption coagulopathy in obstetrics. Obstet Gynecol Annu 1974; 3:267.
- Bastien JL, Graves JR, Bailey S. Atypical presentation of amniotic fluid embolism. Anesth Analg 1998; 87:124.
- Malhotra P, Agarwal R, Awasthi A, et al. Delayed presentation of amniotic fluid embolism: lessons from a case diagnosed at autopsy. Respirology 2007; 12:148.
- Davies S. Amniotic fluid embolism and isolated disseminated intravascular coagulation. Can J Anaesth 1999; 46:456.
- Lee W, Ginsburg KA, Cotton DB, Kaufman RH. Squamous and trophoblastic cells in the maternal pulmonary circulation identified by invasive hemodynamic monitoring during the peripartum period. Am J Obstet Gynecol 1986; 155:999.
- Sinicina I, Pankratz H, Bise K, Matevossian E. Forensic aspects of post-mortem histological detection of amniotic fluid embolism. Int J Legal Med 2010; 124:55.
- Oi H, Kobayashi H, Hirashima Y, et al. Serological and immunohistochemical diagnosis of amniotic fluid embolism. Semin Thromb Hemost 1998; 24:479.
- Kobayashi H, Ooi H, Hayakawa H, et al. Histological diagnosis of amniotic fluid embolism by monoclonal antibody TKH-2 that recognizes NeuAc alpha 2-6GalNAc epitope. Hum Pathol 1997; 28:428.
- Legrand M, Rossignol M, Dreux S, et al. Diagnostic accuracy of insulin-like growth factor binding protein-1 for amniotic fluid embolism*. Crit Care Med 2012; 40:2059.
- Clark SL. Amniotic fluid embolism. Crit Care Clin 1991; 7:877.
- Vanmaele L, Noppen M, Vincken W, et al. Transient left heart failure in amniotic fluid embolism. Intensive Care Med 1990; 16:269.
- McDonnell NJ, Chan BO, Frengley RW. Rapid reversal of critical haemodynamic compromise with nitric oxide in a parturient with amniotic fluid embolism. Int J Obstet Anesth 2007; 16:269.
- Nagarsheth NP, Pinney S, Bassily-Marcus A, et al. Successful placement of a right ventricular assist device for treatment of a presumed amniotic fluid embolism. Anesth Analg 2008; 107:962.
- Hsieh YY, Chang CC, Li PC, et al. 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; 183:496.
- Leighton BL, Wall MH, Lockhart EM, et al. Use of recombinant factor VIIa in patients with amniotic fluid embolism: a systematic review of case reports. Anesthesiology 2011; 115:1201.
- Gilbert WM, Danielsen B. Amniotic fluid embolism: decreased mortality in a population-based study. Obstet Gynecol 1999; 93:973.
- Clark SL. Amniotic fluid embolism. Clin Perinatol 1986; 13:801.
- Suidan JS. Amniotic fluid embolism. Middle East J Anaesthesiol 1989; 10:279.
- Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116:1302.
- Clark SL. Amniotic fluid embolism. Clin Obstet Gynecol 2010; 53:322.
- RISK FACTORS
- Cardiogenic shock
- Respiratory failure
- CLINICAL PRESENTATION
- DIFFERENTIAL DIAGNOSIS
- Initial assessment
- Hemodynamic support
- - Intravenous fluids
- - Vasoactive agents
- Blood products
- Delivery of the fetus
- Novel interventions
- SUMMARY AND RECOMMENDATIONS