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WELCOME
AMNIOTIC FLUID EMBOLISM (AFE)1941, Steiner and Luschbaugh
DEFINITION
Amniotic fluid embolism (AFE) is a rare obstetric emergency in which amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation, causing cardio respiratory collapse
ETIOLOGY
Multiparity Trauma medical induction of labor Cesarean section or operative vaginal delivery Abruption, placenta previa Cervical laceration or uterine rupture , IUD Very strong frequent or uterine tetanic
contractions Sudden foetal expulsion (short labour)
Conti….Placenta accreta Polyhydramnios Uterine rupture Maternal history of allergy Chorioamnionitis Macrosomia Oxytocin (controversial) Advanced maternal age
PATHOPHYSIOLOGY Cotton (1996)
PHASE 1:
• Amniotic fluid enter the maternal circulation
biochemical mediators pulmonary artery vasospasm
pulmonary hypertension elevated right ventricular
pressure hypoxia myocardial and pulmonary
capillary damage, left heart failure acute
respiratory distress syndrome
PHASE 2:
biochemical mediators DIC
Hemorrhagic phase characterized by massive
hemorrhage and uterine atony.
CLINICAL FEATURES
MATERNAL severe hemorrhage Hypotension Cardiac arrest Cough Dyspnea, Cyanosis Pulmonary edema Uterine atony Altered mental
status/confusion/agitation Seizure
FETAL bradycardia: FHR
may drop to less than 110 beats per minute (bpm).
DIAGNOSIS
4 criteria recommend by the United States and United Kingdom AFE registries
Acute hypotension or cardiac arrestAcute hypoxiaCoagulopathy or severe hemorrhage in the absence of
other explanationsAll of these occurring during labor, cesarean delivery,
D&E, or within 30 minutes postpartum with no other explanation of findings
NON SPECIFICcomplete blood countcoagulation parameters arterial blood gaseschest x-rayelectrocardiogramechocardiogram SPECIFICcervical histology serum tryptase
LABORATORY INVESTIGATIONS
MANAGEMENT:
Restoration of cardiovascular and pulmonary equilibrium
Maintain systolic blood pressure >90 mm Hg. Urine output > 25 ml/hr Arterial pO2 > 60 mm Hg. Re-establishing uterine tone Correct coagulation abnormalities
IMMEDIATE MEASURES :
Set up IV Infusion, O2 administration. Airway control Lab report Treat hypotension. After correction of hypotension, restrict fluid
therapy to maintenance levels . Steroids may be indicated Dopamine infusion if patient remains
hypotensive Vasopressor therapy such as ephedrine
MANAGEMENT OF AFE IN THE ICU
monitor ECG, pO2, CO2, and urine output.
Central venous pressure monitoring Monitor Pulmonary artery and capillary
wedge pressures and echocardiography. An arterial line for repeated blood
sampling and blood gases to evaluate the efficacy of resuscitation.
MANAGEMENT OF AFE COAGULOPATHY
DIC results in the depletion of fibrinogen, platelets, and coagulation factors, especially factors V, VIII, and XIII.
transfuse platelets for platelet counts less than 20,000/mm3
RESTORATION OF UTERINE TONE
Uterine atony is best treated with massage,
uterine packing, and oxytocin or prostaglandin analogues.
Improvement in cardiac output and uterine perfusion helps restore uterine tone.
Extreme care should be exercised when using prostaglandin analogues in hypoxic patients, as bronchospasm may worsen the situation.
SYMPATHOMIMETIC VASOPRESSOR AGENT DOPAMINE
Dopamine increases myocardial contractility and systolic BP with little increase in diastolic BP. Also dilates the renal vasculature, increasing renal blood flow and GFR.
DOSE: 2-5 mcg/kg/min IV
NURSING MANAGEMENT
• Assessment:
• Nursing diagnosis
Impaired Gas Exchange related to embolization Altered Tissue Perfusion, peripheral and cardiac related to emboli
BIBLIOGRAPHY Dutta D C. textbook of obstetrics.6th ed. New delhi . New
central book agency. 2004 Jacob A. Textbook of Midwifery. 1st ed. New Delhi. Jay pee
publications. 2003 Pillitary a. Maternal and child health nursing. 4th ed.
Philadelphia. Lippincott. Williams and Wilkins. 2000 Fraser DM, Cooper MA. Textbook for midwifes. 14th ed.
Edinburg Churchill LIVINGStone. 2003 Green C j, Judith m. Maternal newborn nursing careplans. 1st
ed. Mosby publications.2004 Dawn CS. Obstetrics and Neonatology for undergraduates and
postgraduates. 16th ed