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Jo, Jung, Lee, Kim, Choi, Joo, Choi, Jang, Hwang, and Choi: Amniotic Fluid Embolism: Maternal Disseminated Intravascular Coagulation, Cardiovascular Collapse, and Acute Hypoxic Cases Shortly after Delivery
Case report

Perinatology 2018;29(2):89-96.

Published online: 19 June 2018

DOI: https://doi.org/10.14734/PN.2018.29.02.89

Amniotic Fluid Embolism: Maternal Disseminated Intravascular Coagulation, Cardiovascular Collapse, and Acute Hypoxic Cases Shortly after Delivery

Eun Ae Jo, MD, Su Keong Jung, MD, Jung Hoon Lee, MD, Jeong Ok Kim, MD, Heaong Eun Choi, MD, Hae Sun Joo, MD, Hoa Yeon Choi, MD, Shin A Jang, MD, Sung Ook Hwang, MD, PhD, Soo Ran Choi, MD, PhD

Department of Obstetrics and Gynecology, Inha University Hospital, Inha University College of Medicine, Incheon, Korea

Correspondence to Soo Ran Choi, MD, PhD Department of Obstetrics and Gynecology, Inha University Hospital, Inha University College of Medicine, 27 Inhang-ro, Jung-gu, Incheon 22332, Korea Tel: +82-32-890-3501 Fax: +82-32-890-2274 E-mail: csran@inha.ac.kr

Received 26 August 201723 October 2017       Accepted 3 December 2017

Copyright © 2018 The Korean Society of Perinatology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Amniotic fluid embolism (AFE) is a fatal disease in only pregnant woman during labor and delivery. The pathologic findings that have demonstrated fetal squamous cells in the pulmonary circulation are no more specific. Then, clinically characteristic signs and symptoms, such as cardiovascular collapse, acute hypoxia, disseminated intravascular coagulation, mental change and laboratory findings are the key points for diagnosis. Having a doubt on those sign and symptoms is the beginning of diagnosis and promptly multidisciplinary management is required. Korean National Registry for AFE must be established and we have to find out the diagnostic criteria, possible etiology, pathophysiology, management and treatment for AFE.

Keywords: Pregnancy, Amniotic fluid embolism, Shock, Disseminated intravascular coagulation, Hypoxia

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Table 1.
Clinical Characteristics of AFE Cases That Have Been Reported in Korea
  125 226 317 427 528 629
Presented at 1994, Perinatology 1997, KJOG 1997, KJA 2002, KJOG 2006, KJOG 2010, KJA
Method of diagnosis Autopsy∗ Histopathological test at uterine cervical vessel Clinical symptoms, blood test† Clinical symptoms Clinical symptoms Clinical symptoms, autopsy
Age (year) 34 27 30 42 36 33
Gravida Primigravida Multigravida Multigravida Primigravida Multigravida Primigravida
GA (weeks) 40 38 15+2 40+6 39+3 40
IOL Yes - - Yes, oxytocin Yes, oxytocin Yes, oxytocin
Delivery method Vaginal Vaginal Dilatation & curettage Did not delivery Vaginal Cesarean section
Time of initiation 2 hours after delivery Just after delivery 28 minutes after procedure Simultaneous with fetal distress Simultaneous with fetal distress 5 minutes after spinal anesthesia
Initial sign and symptoms Postpartum bleeding, irritability, semicoma Postpartum bleeding, shock Cyanosis, hypotension Fetal distress, maternal cyanosis, hypotension Fetal distress, seizure, loss of consciousness Maternal respiratory distress, coughing, hypotension
Clinical sign and symptoms Postpartum bleeding, irritability, semicoma, hypotension Postpartum atony bleeding Cyanosis, hypotension, loss of cons Respiratory arrest, cardiac arrest ciousness, DIC Fetal distress, coma, hypotension Respiratory distress, hypotension, profuse tracheal discharge
Prognosis Death within 6 hours after delivery Improved Hypoxic brain damage, motor disability Death within 2 hours after initial symptoms Death within 5 hours after initial symptoms Death within 3 hours after initial symptoms

Abbreviations: AFE, Amniotic Fluid Embolism; KJOG, Korean J Obstet Gynecol; KJA, Korean J Anesthesiology; GA, gestaional age; IOL, induction of labor; DIC, disseminated intravascular coagulation.

∗ Confirm fetal origin squamous cells at maternal pulmonary vessel.

† Blood tests for DIC.

Table 2.
Suggested Diagnostic Criterias for AFE
Diagnostic sign & symptoms UK18 Australia18 Netherlands30 Japan18 USA18
Clinical sign and symptoms          
Acute hypotension + + + + Systolic <90 mmHg)
Cardiac arrest + + + + +
Acute hypoxia + + + + SpO2 <90%
DIC + + + + +
Coma, seizure     +    
Heavy bleeding ≥ 1,500 mL, within 2 hours after delivery
Body temperature         <38°C
Time of initiation     Within 48 hours after delivery During pregnancy, or labor, and within 12 hours after delivery Within labor, or 30 minutes after placenta delivery
Histopathological test (fetal origin squamous cells at maternal pulmonary vessels) + +   +, and at uterine artery  
Needs to differentiate other disease + + + + +

Abbreviations: AFE, amniotic fluid embolism; DIC, disseminated intravascular coagulation.

Table 3.
Suggestion of Diagnostic Criteria of AFE
Time of initiation During labor, delivery, and cesarean section. At least within 2 hours after delivery. Do not over 24 hours after delivery.
Clinical sign and symptoms Acute hypotension∗, cardiac arrest, acute hypoxia∗, DIC∗, Loss of consciousness, seizure, heavy bleeding∗.
Differential diagnosis Pulmonary thromboembolism, transfusion complications, ischemic heart disease, anaphylactic shock, septic shock, perinatal cardiomyopathy, air embolism, high level spinal anesthesia, uterine rupture, uterine atony, reproductive tract laceration, postpartum heavy bleeding, acute fatty liver, severe preeclampsia, eclampsia, medical problems of heart, lung, and hematologic parts.
  Do not include histopathological test for fetal origin squamous cells at pulmonary and uterine vessels.

Abbreviations: AFE, Amniotic Fluid Embolism; DIC, disseminated intravascular coagulation.

∗ Diagnostic criterias for hypotension, hypoxia, DIC must be suggested in the future.

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