If you are suffering from AFE, it is important to know your treatment options. Read on to learn about amniotic fluid embolism treatment. 

 

By OBGYN and fertility specialist Dr. Mare Mbaye

What is an amniotic fluid embolism?

An amniotic fluid embolism is a rare and often catastrophic complication of pregnancy. While it isn’t common, it is still an important diagnosis for birthers to know about. When an amniotic fluid embolism occurs, amniotic fluid (the fluid that surrounds the baby in the uterus during pregnancy), fetal cells, or hair enters into the maternal blood circulation and can travel elsewhere in the body to cause serious health issues for both parent and child.

While some patients survive an amniotic fluid embolism with no long-term concerns, there is a high risk of complications like neurological problems. This depends on if and for how long a patient has little to no oxygen to the brain.

Who is at risk for having an amniotic fluid embolism?

Amniotic fluid embolisms can typically occur during labor, soon after vaginal or cesarean delivery, or during second-trimester dilation and evacuation procedures. They can also occur up to 48 hours after a delivery. A 1995 analysis of the US national registry revealed that the majority of amniotic fluid embolisms occur during labor (70%). Of the rest, 19% occurred during cesarean delivery while 11% occurred during a vaginal delivery. 

The reported number of cases per year is around 1 in 40,000 deliveries. Missed diagnoses and inconsistent reporting of non-fatal cases has made it hard to pin down a specific incidence, but several risk factors have been identified.

These include maternal factors such as:

  • Older maternal age
  • Multiples pregnancy (twins, triplets, etc.)
  • Induction of labor
  • Intense contractions during labor
  • Cesarean section
  • Multiparity (having had more than 1 child)
  • Abdominal trauma
  • Polyhydramnios (high amount of amniotic fluid)
  • Placenta previa
  • Eclampsia
  • Tears in the uterus or cervix
  • Placental abruption (early separation of the placenta from the uterine wall)

There are also a few fetal factors:

  • Fetal distress
  • Fetal death
  • Male baby

Maternal risks associated with amniotic fluid embolism occurrence

Survival rates after an amniotic fluid embolism are poor, but they have improved significantly over the past few decades as we’ve improved our ability to detect it and intervene as early as possible. Reported rates of death have been as high as 86%, with about 50% of these patients dying very quickly, usually within the first hour after symptoms begin.

Although death rates have gotten much better, complication rates are still high and include severe health consequences such as:  

  • Brain injury: Blood clots in the lungs from the embolism can reduce the amount of oxygen traveling to the brain, which can result in permanent brain damage.
  • Disseminated intravascular clotting: A systemic process with the potential for causing thrombosis (blood clots) and hemorrhage (excessive bleeding usually requiring transfusion of blood and other products)
  • Sudden cardiac arrest: The effects of AFE can develop so rapidly that the blood clots in the lungs send the birther into cardiac arrest.
  • Multiple organ failure: As the condition progresses, it can start to cause organs like the kidneys or lungs to fail from lack of oxygen in the blood.
  • Maternal death

Recognizing this diagnosis quickly and accurately is critical to a patient’s care and to retaining as much quality of life as possible. For patients who do survive an amniotic fluid embolism, the majority will have long-term neurological deficits. Long-term effects can include:

  • Memory loss
  • Organ failure
  • Heart damage that can be temporary or permanent
  • Nervous system problems affecting the brain or nerves
  • Need for a partial or complete hysterectomy
  • Damage to the pituitary gland
  • Emotional consequences, especially if the baby does not survive 

Fetal risks associated with amniotic fluid embolism

Fetal outcomes after an amniotic fluid embolism vary somewhat based on the gestational age; babies that are further along tend to have better outcomes. However, the overall survival rate is close to 70%, which is much more promising than the maternal rate. Neurologic status of the baby is directly related to the amount of time that has gone by from when the amniotic fluid embolism causes maternal arrest and when the baby is delivered (i.e., the faster the better). Fetal complications can include:

  • Fetal distress: an amniotic fluid embolism can affect the labor process causing the baby to become distressed. This can potentially lead to other complications if not dealt with appropriately.
  • Fetal hypoxia (oxygen deprivation), which can then result in permanent brain damage and conditions like cerebral palsy
  • Infant death: If the baby is deprived of oxygen for too long and/or is not delivered quickly enough, the baby can die during delivery.

Amniotic fluid embolism treatment and prevention

There is unfortunately no clear way to predict, and therefore prevent, an amniotic fluid embolism. However, close monitoring during the labor and delivery process can help with getting patients treatment as soon as possible. While we may not fully understand the pathophysiology of how and why amniotic fluid embolisms happen, it has become clear that early and aggressive management for patients who are suspected to have an amniotic fluid embolism improves both fetal and maternal survival. 

The key factors in the management of an amniotic fluid embolism are: 

  • Early diagnosis
  • Prompt resuscitation efforts
  • Delivery of the baby—this includes delivery via cesarean section in order to expedite the process 

Treatment mainly focuses on stabilizing the birther and preventing the condition from progressing and causing the more severe complications listed earlier. Among the therapies used are:

  • A ventilator or oxygen therapy to assist with breathing
  • Pulmonary artery catheter to better monitor the birther's heart and other vitals
  • Medications that can help control blood pressure
  • Transfusion products such as red blood cells, platelets, and plasma to replace blood loss from hemorrhage

In terms of the baby, continuous monitoring for any signs of distress is crucial. Once an amniotic fluid embolism is diagnosed or a birther goes into cardiac arrest, the baby will be delivered as soon as possible as per the recommendations of the Society for Maternal Fetal Medicine. This means that if a vaginal delivery is not about to happen in seconds to minutes, an emergent cesarean section is indicated to decrease the risk of birth injury. After delivery, the baby is typically sent to the neonatal intensive care unit for evaluation and close observation.

To sum it up

Amniotic fluid embolisms are difficult to predict and therefore difficult to prevent. While this condition is very rare, birthers should be aware of the possible risks involved. Amniotic fluid embolisms have the potential to be fatal for both the birther and the baby, so immediate medical intervention is necessary to ensure they survive. If you've previously had an amniotic fluid embolism and are planning for a future pregnancy, it's important to talk to your doctor before you get pregnant again so measures can be put in place to protect your health.

 

Featured Image by Stijn Dijkstra