![]() ![]() ![]() ![]() Because most of the cases had coagulopathy and bleeding, coagulation management and surgical interventions to stop the bleeding appeared to improve overall survival. To some degree, the varying treatment modalities reported by Fitzpatrick and colleagues reflect the variation in presenting symptoms among the AFE cases included in their study. Optimal volume management in response to changing hemodynamics is also crucial, although it is difficult to strike the correct balance between maintaining cardiac output and preventing fluid overload and pulmonary edema. Even before the diagnosis of AFE is established, high-quality cardiopulmonary resuscitation (CPR) should be the first response to cardiac arrest, followed by ongoing cardiorespiratory support. The AFE presentation that dominates the main clinical picture-e.g., coagulopathy (with or without massive bleeding), refractory pulmonary hypertension, or neurological symptoms-should dictate the therapeutic approach. The new study further confirms the unsurprising association between cardiac arrest and poor outcome. Using the UKOSS case definition, Fitzpatrick and colleagues observed a case fatality rate of 21%, whereas the INOSS and Clark case definitions yielded case fatality rates of 29% and 24%, respectively. In previous studies, the case fatality of AFE varied between 11% and 48%, depending on the study design (population versus hospital based) and case definition. Knowledge of these risk factors has little utility for clinical prediction of AFE, however, because the vast majority of women with these risk factors will have a normal pregnancy and delivery. This new evidence corroborates the results of previous studies and should spawn further etiologic research. Several risk factors were related to common obstetric interventions: induction of labor, operative vaginal delivery, and cesarean delivery. Prenatal risk factors included advanced maternal age, multiple pregnancy, gestational diabetes, polyhydramnios, placenta previa, and placental abruption. Interestingly, the main risk factors identified in this study were consistent across all three case definitions. The latter two definitions were modified to harmonize the data collected across international sites. ![]() For these reasons, Fitzpatrick and coauthors examined risk factors, prognosis, and clinical management of AFE using three different definitions: the most liberal definition proposed by the United Kingdom Obstetric Surveillance System (UKOSS), a consensus-driven definition developed by the International Network of Obstetric Survey Systems (INOSS), and the most restrictive definition developed by Clark and colleagues and used by the Amniotic Fluid Embolism Registry in the United States. īecause AFE is a diagnosis of exclusion, a precise case definition is difficult to establish. Given the acuity and complexity of AFE signs and symptoms, an immediate response by a multidisciplinary team including experienced specialists in obstetrics, maternal–fetal medicine, anesthesia, intensive care, and hematology is probably key for survival, as observed by Fitzpatrick and colleagues. Myocardial infarction and other conditions can also resemble AFE. Consumptive coagulopathy without cardiorespiratory symptoms is sometimes recognized as a forme fruste of AFE, but it is important to exclude other possible diagnoses, such as septic shock or coagulopathy caused by, rather than the cause of, excessive bleeding. Premonitory symptoms such as tingling, shortness of breath, and agitation may occur before the signs and symptoms of cardiovascular collapse. The clinical signs and symptoms of AFE include a rapid deterioration of maternal condition, cardiac arrest or arrhythmia, hypotension, respiratory distress, coagulopathy and massive hemorrhage, and acute fetal compromise. In a new international study published in PLOS Medicine, Kathryn Fitzpatrick and colleagues provide valuable clinical information about this rare complication, which occurs in 2–8 of 100,000 pregnancies. Owing to its uncertain etiology, varying symptoms, rapid onset, and high fatality rate, amniotic fluid embolism (AFE) is one of the most challenging obstetric emergencies. ![]()
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