Definition of AFE
• AFE is a rare obstetric emergency in which amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation, causing cardiorespiratory collapse.
epidemiology
• The incidence of clinically detectable AFE is low
• estimated to be 1 in 20,000 to 80,000 live births.
• Maternal mortality approaches 80%.
• 5%- 10% of maternal mortality in the United States is due to AFE.
• Of patients with AFE, 50% die within the first hour of onset of symptoms.
• Of survivors of the initial cardiorespiratory phase, 50% develop a coagulopathy.
• Neonatal survival is 70%.
• Current data suggest that the process is more similar to anaphylaxis than to embolism
• term anaphylactoid syndrome of pregnancy has been suggested
Major causes and factors
• occurs in obstetric terms or during labor
• multiparous woman with a large baby
• a short tumultuous labor
• use of uterine stimulants
• occurred during abortion
• amnioinfusion
• Amniocentesis
• caesarian section
• placenta accreta
• ruptured uterus
pathology
• Amniotic fluid and fetal cells enter the maternal circulation, possibly triggering an anaphylactic reaction to fetal antigens.
• (1) Clinical symptoms result from mast cell degranulation with the release of histamine and tryptase,
• (2) Clinical symptoms result from activation of the complement pathway.
• . Progression usually occurs in 2 phases.
• phase I:
• pulmonary artery vasospasm with pulmonary hypertension and elevated right ventricular pressure cause hypoxia.
• Hypoxia causes myocardial capillary damage and pulmonary capillary damage, left heart failure, and acute respiratory distress syndrome.
•
• Women who survive these events may enter phase II.
• This is a hemorrhagic phase characterized by massive hemorrhage with uterine atony and DIC
• however, fatal consumptive coagulopathy may be the initial presentation.
Presentation
• The clinical presentation of AFE is generally dramatic
• in the late stages , acutely dyspnea and hypotension with rapid progression to cardiopulmonary arrest
• In 40% of cases, followed by some degree of consumptive coagulopathy,
• Hypotension: Blood pressure may drop significantly with loss of diastolic measurement.
• Dyspnea: Labored breathing and tachypnea may occur.
• Seizure: The patient may experience tonic-clonic seizures.
• Cough: This is usually a manifestation of dyspnea.
• Cyanosis: As hypoxia/hypoxemia progresses, circumoral and peripheral cyanosis and changes in mucous membranes may manifest.
• Pulmonary edema: identified on chest radiograph.
• Cardiac arrest
• Uterine atony:
• Fetal bradycardia: In response to the hypoxic
• Uterine atony usually results in excessive bleeding after delivery.
Differentials
• Anaphylaxis
• Aortic Dissection(动脉瘤）
• Cholesterol Embolism
• Myocardial Infarction
• Pulmonary Embolism
• Septic Shock
Lab Studies
• Arterial blood gas (ABG) levels: Expect changes consistent with ypoxia/hypoxemia
.
• Decreased pH levels
• Decreased PO2 levels
• Increased PCO2 levels
• Base excess increased
• Hemoglobin and hematocrit /Thrombocytopenia is rare/ platelets /
• Prothrombin time (PT)
• Activated partial thromboplastin time (aPTT)
• fibrinogen (Fg)
• Blood type and screen
• Chest radiograph
• A 12-lead ECG
Treatment
• Administer oxygen to maintain normal saturation.
• Initiate cardiopulmonary resuscitation (CPR) if the patient arrests.
• Treat hypotension with crystalloid and blood products.
• Consider pulmonary artery catheterization in patients who are hemodynamically unstable.
• Treat coagulopathy with fresh frozen plasma(FFP) for a prolonged aPTT, cryoprecipitate for a fibrinogen level less than 100 mg/dL, and transfuse platelets for platelet counts less than 20,000/mL.
• Continuously monitor the fetus.
• Delivery quickly (forceps)
• Surgical Care: Perform emergent cesarean delivery in arrested mothers who are unresponsive to resuscitation.
• hemorrhage was controlled with bilateral uterine artery embolization.
Uterine Rupture
• is one of the most feared complications of pregnancy
• the fetus, placenta, and a lot of blood extruding into the mother's abdomen
• from a weak spot in the uterine wall or uterus scar
epidemiology
• the risk of uterine rupture was 1 per 625 women who chose repeat cesarean without labor,
• 1 per 192 women who went into labor and tried for VBAC,
• 1 per 129 for those who had their labor induced without prostaglandins (usually with Pitocin)
• 1 per 41 when prostaglandin medications were used for induction
• When the uterus did rupture, 1 in 18 babies died, and 1 in 23 of the women required a hysterectomy.
Causes and factors
• previous surgery on the uterus
• Prior classical cesareans, where the incision is near the top of the uterus
• prior removal of fibroid tumors
• any other uterine surgery that went through the full depth of the muscular portion of the uterus,
• multiple (three or more) prior low transverse cesareans
• having had more than five full-term pregnancies
• having an overdistended uterus (as with twins or other multiples),
• abnormal positions of the baby such as transverse lie
• the use of Pitocin and other labor-inducing medications like prostaglandins
presentation
• Most uterine ruptures occur without symptoms and do not cause problems for the mother or fetus.
• This mild type is only noticed when surgery is required for other reasons.
• In the most severe form , the laceration is large or cuts across the uterine blood vessels
• the mother may hemorrhage and require a blood transfusion
• the uterus may not be repairable and must be surgically removed (hysterectomy)
• Many women will be advised not to get pregnant again, due to the risk of repeated rupture
• the baby may not survive
• the mother's life cannot be saved
Signs of uterine rupture
• severe, localized pain
• abnormalities of the fetal heart rate
• vaginal bleeding
• the vaginal examination may show that the baby is not as low in the birth canal as he had been earlier.
Preventing and Treatment
• Some uterine ruptures occur before labor and are considered unpreventable.
• Sudden severe abdominal pain in later pregnancy should be reported
• Women with risk factors ( prior classical cesareans, deep fibroid excisions, and other major uterine surgeries )should not attempt labor
• should be scheduled for cesarean usually between 36 and 39 weeks' gestation.
• If trying for vaginal birth after low transverse cesarean(VBAC), fetal monitoring is important
• When uterine rupture is diagnosed during labor, an emergency cesarean is performed.
• Usually the baby's life can be saved.
• AFE is a rare obstetric emergency in which amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation, causing cardiorespiratory collapse.
epidemiology
• The incidence of clinically detectable AFE is low
• estimated to be 1 in 20,000 to 80,000 live births.
• Maternal mortality approaches 80%.
• 5%- 10% of maternal mortality in the United States is due to AFE.
• Of patients with AFE, 50% die within the first hour of onset of symptoms.
• Of survivors of the initial cardiorespiratory phase, 50% develop a coagulopathy.
• Neonatal survival is 70%.
• Current data suggest that the process is more similar to anaphylaxis than to embolism
• term anaphylactoid syndrome of pregnancy has been suggested
Major causes and factors
• occurs in obstetric terms or during labor
• multiparous woman with a large baby
• a short tumultuous labor
• use of uterine stimulants
• occurred during abortion
• amnioinfusion
• Amniocentesis
• caesarian section
• placenta accreta
• ruptured uterus
pathology
• Amniotic fluid and fetal cells enter the maternal circulation, possibly triggering an anaphylactic reaction to fetal antigens.
• (1) Clinical symptoms result from mast cell degranulation with the release of histamine and tryptase,
• (2) Clinical symptoms result from activation of the complement pathway.
• . Progression usually occurs in 2 phases.
• phase I:
• pulmonary artery vasospasm with pulmonary hypertension and elevated right ventricular pressure cause hypoxia.
• Hypoxia causes myocardial capillary damage and pulmonary capillary damage, left heart failure, and acute respiratory distress syndrome.
•
• Women who survive these events may enter phase II.
• This is a hemorrhagic phase characterized by massive hemorrhage with uterine atony and DIC
• however, fatal consumptive coagulopathy may be the initial presentation.
Presentation
• The clinical presentation of AFE is generally dramatic
• in the late stages , acutely dyspnea and hypotension with rapid progression to cardiopulmonary arrest
• In 40% of cases, followed by some degree of consumptive coagulopathy,
• Hypotension: Blood pressure may drop significantly with loss of diastolic measurement.
• Dyspnea: Labored breathing and tachypnea may occur.
• Seizure: The patient may experience tonic-clonic seizures.
• Cough: This is usually a manifestation of dyspnea.
• Cyanosis: As hypoxia/hypoxemia progresses, circumoral and peripheral cyanosis and changes in mucous membranes may manifest.
• Pulmonary edema: identified on chest radiograph.
• Cardiac arrest
• Uterine atony:
• Fetal bradycardia: In response to the hypoxic
• Uterine atony usually results in excessive bleeding after delivery.
Differentials
• Anaphylaxis
• Aortic Dissection(动脉瘤）
• Cholesterol Embolism
• Myocardial Infarction
• Pulmonary Embolism
• Septic Shock
Lab Studies
• Arterial blood gas (ABG) levels: Expect changes consistent with ypoxia/hypoxemia
.
• Decreased pH levels
• Decreased PO2 levels
• Increased PCO2 levels
• Base excess increased
• Hemoglobin and hematocrit /Thrombocytopenia is rare/ platelets /
• Prothrombin time (PT)
• Activated partial thromboplastin time (aPTT)
• fibrinogen (Fg)
• Blood type and screen
• Chest radiograph
• A 12-lead ECG
Treatment
• Administer oxygen to maintain normal saturation.
• Initiate cardiopulmonary resuscitation (CPR) if the patient arrests.
• Treat hypotension with crystalloid and blood products.
• Consider pulmonary artery catheterization in patients who are hemodynamically unstable.
• Treat coagulopathy with fresh frozen plasma(FFP) for a prolonged aPTT, cryoprecipitate for a fibrinogen level less than 100 mg/dL, and transfuse platelets for platelet counts less than 20,000/mL.
• Continuously monitor the fetus.
• Delivery quickly (forceps)
• Surgical Care: Perform emergent cesarean delivery in arrested mothers who are unresponsive to resuscitation.
• hemorrhage was controlled with bilateral uterine artery embolization.
Uterine Rupture
• is one of the most feared complications of pregnancy
• the fetus, placenta, and a lot of blood extruding into the mother's abdomen
• from a weak spot in the uterine wall or uterus scar
epidemiology
• the risk of uterine rupture was 1 per 625 women who chose repeat cesarean without labor,
• 1 per 192 women who went into labor and tried for VBAC,
• 1 per 129 for those who had their labor induced without prostaglandins (usually with Pitocin)
• 1 per 41 when prostaglandin medications were used for induction
• When the uterus did rupture, 1 in 18 babies died, and 1 in 23 of the women required a hysterectomy.
Causes and factors
• previous surgery on the uterus
• Prior classical cesareans, where the incision is near the top of the uterus
• prior removal of fibroid tumors
• any other uterine surgery that went through the full depth of the muscular portion of the uterus,
• multiple (three or more) prior low transverse cesareans
• having had more than five full-term pregnancies
• having an overdistended uterus (as with twins or other multiples),
• abnormal positions of the baby such as transverse lie
• the use of Pitocin and other labor-inducing medications like prostaglandins
presentation
• Most uterine ruptures occur without symptoms and do not cause problems for the mother or fetus.
• This mild type is only noticed when surgery is required for other reasons.
• In the most severe form , the laceration is large or cuts across the uterine blood vessels
• the mother may hemorrhage and require a blood transfusion
• the uterus may not be repairable and must be surgically removed (hysterectomy)
• Many women will be advised not to get pregnant again, due to the risk of repeated rupture
• the baby may not survive
• the mother's life cannot be saved
Signs of uterine rupture
• severe, localized pain
• abnormalities of the fetal heart rate
• vaginal bleeding
• the vaginal examination may show that the baby is not as low in the birth canal as he had been earlier.
Preventing and Treatment
• Some uterine ruptures occur before labor and are considered unpreventable.
• Sudden severe abdominal pain in later pregnancy should be reported
• Women with risk factors ( prior classical cesareans, deep fibroid excisions, and other major uterine surgeries )should not attempt labor
• should be scheduled for cesarean usually between 36 and 39 weeks' gestation.
• If trying for vaginal birth after low transverse cesarean(VBAC), fetal monitoring is important
• When uterine rupture is diagnosed during labor, an emergency cesarean is performed.
• Usually the baby's life can be saved.
