gynecology and obstetrics
Amniotic Fluid Embolism
Treatment of Amniotic Fluid Embolism
Critical care team and intensive care unit support Cardiopulmonary resuscitation Uterotonics Usually, red blood cell and cryoprecipitate transfusion Amniotic fluid embolism is a life-threatening emergency and requires urgent management by a clinical team with obstetric and critical care experience and access to intensive care equipment. The Society for Maternal-Fetal Medicine has provided a concise checklist for the immediate management of amniotic fluid embolism to help obstetric practitioners respond rapidly and efficiently ( Treatment reference ). Respiratory arrest is managed with endotracheal intubation and maintenance of airway and oxygen flow. Heart rate is monitored and cardiopulmonary resuscitation is often required. To improve venous return from the vena cava, the patient is positioned in a lateral tilt or the uterus may be manually displaced. Fluid overload should be avoided, and vasopressors may be necessary. If maternal cardiac arrest does not resolve with other resuscitative interventions, operative delivery (referred to as a perimortem cesarean delivery or resuscitative hysterotomy) is recommended at 4 minutes with delivery of the fetus by 5 minutes. Delivery results in autotransfusion of the blood in the myometrial veins and the evacuated uterus no longer restricts venous return. Delivery can be critical for survival of a pregnant patient and a fetus that is a viable gestational age. Oxytocinand other uterotonics are given prophylactically, because uterine atony and hemorrhage may occur. Red blood cell transfusion (as needed to replace lost blood) and cryoprecipitate (as needed to reverse the coagulopathy) are given; cryoprecipitate is preferred rather than fresh frozen plasma because it results in less volume overload. Recombinantfactor VIIashould not be used routinely but may be given to women who continue to bleed heavily despite use of other clotting factors.Tranexamic acidmay also be given for hemorrhage (1 g IV over 10 minutes). 1.Combs CA, Montgomery DM, Toner LE, Dildy GA: Society for Maternal-Fetal Medicine special statement: Checklist for initial management of amniotic fluid embolism.Am J Obstet Gynecol224(4):PB29-B32, 2021. doi: 10.1016/j.ajog.2021.01.001 