Amniotic Fluid Embolism

Question 1

What is AFE?

Answer 1

passage of amniotic fluid into the maternal circulation typically resulting in sudden profound unepexcted shock and cardiopulmonary collapse

Question 2

What are clinical features in AFE?

What can AFE lead to?

Answer 2

Hypotension, cardiopulmonary arrest
Fetal distress 
Pulmonary edema/ARDS 
Cyanosis, dyspnea
coagulopathy 
seizures 
AFE can lead to an anaphylactoid reaction that produces pulmonary hypertension and right heart failure (which can eventually progress to biventricular failure and cardiac arrest).

Question 3

What is your DDX if someone is experiencing sxs that are AFE like?

Answer 3

acute hemorrhage
high/total spinal if NA administered
PE, anaphylaxis, sepsis

Question 4

How do you manage AFE?
What are you doing first/second
What do you need to establish?
What are you expanding?
What are you supporting? What drug is a good choice in this instance-early vs late?
What monitor do you need to start? STAT labs?
Then, treat what? what’s not first line but could be used-and when?

Answer 4

Call for help, inform OB-prompt delivery of fetus improves maternal resuscitation outcomes
ensure adequate oxygenation and ventilation-intubate trachea and ventilate with 100% O2
If pulseless-chest compressions (maintain Left uterine displacement to ensure venous return) and ACLS protocol
Establish large bore IV access x2
Expand circ volume IV bolus of saline x 2-3 L
Support circulation with vasopressors-phenylephrine is a rational choice EARLY because vasodilation is the main abnormality, but later-epi may be required.
Later-epi, levo, dobutamine, or milrinone may be good choices, or vasopressin-it avoids any further increases in PVR
Start arterial line for monitoring and frequent blood draws
STAT ABG, CBC, PT, PTT, INR, Fibrinogen, FDP, tryptase, cross match 4-6 units of PRBCs
Start central venous access for infusion of vasopressors and inotropes
Treat coagulopathy: maintain O2 carrying capacity by giving RBCs (type o negative if cross match not available)
-FFP and platelets as necessary
-cryo is NOT first line, but useful if fibrinogen is low and volume oveerload or ARDS is a concern
-use factor 8 for refractory bleeding (possibility of intravascular thrombosis)

Question 5

How do you guide therapy?

Answer 5

You guide therapy by using CVP, PAP, CO, SVR
Urine output (1 mL/kg/hr)
TTE or TEE-amniotic fluid has a different appearance in the heart than blood