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Thee Epitome
p o e of
o thee Obstetric
Obs e c Emergency
e ge cy
Jeanne. S. Sheffield, M.D.
Maternal Fetal Medicine
University of Texas Southwestern
Medical Center
T
Transferred
f
d to
t the
th SICU for
f ventilator
til t andd
hemodynamic management
Published in 1995 by
y Clark et al
19%
11%
Male fetus
Oxytocin
Uterine hyperstimulation
M
Meconium-stained
i
i d AF
Hydramnios
AROM/IUPC placement
** Significant association
67% **
50%
4%
19%
5%
14%
Risk Factors for AFE in 2 large populationbased cohorts (3 million hospital deliveries)
Kramer et al 2006
Abenhaim 2008
0 2 (0.1-0.96)
0.2
(0 1 0 96)
0 4 (0.2-0.9)
0.4
(0 2 0 9)
1.9 (1.4-2.7)
2.2 (1.5-2.1)
Previous cesarean
0.8 (0.5-1.2)
0.9 (0.6-1.3)
1.8 (1.3-2.7)
-----
Cesarean delivery
12.5 (7.9-19.9)
5.7 (3.7-8.7)
F
Forceps
delivery
d li
5 9 (3.4-10.3)
5.9
(3 4 10 3)
4 3 (1.9-6.6)
4.3
(1 9 6 6)
Vacuum delivery
2.9 (1.6-5.3)
1.9 (1.0-3.7)
Multiple
p ppregnancy
g
y
2.5 ((0.9-6.2))
1.5 ((0.6-4.1))
Placenta previa/abruption
3.5 (2.3-5.5)
-----
Preeclampsia
1.4 (0.8-2.5)
7.3 (4.3-12.5)
11.5 (2.8-46.9)
29.1 (7.1-119.3)
1.7 (1.2-2.5)
1.5 (1.0-2.2)
Eclampsia
Fetal distress
Vaginal delivery
Cesarean delivery
Induced abortion
Feticide
Intrapartum
amnioinfusion
Manual extraction of
the placenta
Transabdominal
amniocentesis
Blunt abdominal
trauma
Surgical trauma
Removal of cerclage
Pathophysiology of AFE
Conventional thinking defined the process
as an event
event, ii.e.
e tetanic contraction that
forced amniotic fluid into the maternal
circulation. This fetal debri led to
obstruction of the pulmonary vasculature
with subsequent pulmonary hypertension
and eventually acute cor pulmonale.
pulmonale
Pathophysiology: Contemporary
Thinking
Foreign Substance Enters the Maternal Circulation
(Common)
Myocardial Depression
Decreased Cardiac Output
Pulmonary Hypertension
DIC
Pathophysiology: Cardiopulmonary
Few reports of initial severe pulmonary
h
hypertension
i with
i h right
i h heart
h
failure
f il
Followed by an increase in PCWP with left
ventricular dysfunction and a decreased LV
stroke-work index leading to pulmonary edema
Decrease also in systemic vascular resistance
Severe ventilation
ventilation-perfusion
perfusion mismatch due to
intense vasoconstriction of pulmonary vasculature
All leading to profound hypoxia
Pathophysiology: Cardiopulmonary
These findings suggest that pulmonary
vasoconstriction and increased pulmonary
vascular resistance are the primary
mechanisms responsible for cardiovascular
collapse
Pathophysiology: Coagulopathy
Bick 2002
Differential Diagnosis
Pulmonary
thromboembolism
Transfusion reaction
Hemorrhage
Air embolism
p y
Anaphylaxis
High spinal anesthesia
Placental abruption
p
Peripartum
cardiomyopathy
Eclampsia
Myocardial infarction
Septic
p shock
Uterine rupture
Clark et al
n= 46
Weiwen
n = 38
43 (94)
30/30
28/30
40 (87)
38 (83)
38 (83)
22/45
22 (48)
38 (100)
NS
11 (29)
38 (100)
38 (100)
12/16
38 (100)
6 (16)
DIC
Multisystem organ failure
ARDS
Neurologic dysfunction
?? Premonitory Symptoms
UK Confidential Inquiry into Maternal Deaths
Breathlessness
Chest pain
Lightheadedness
Di
Distress
or panic
i
Pins and needles in the fingers
Nausea and vomiting
Feeling cold
11/17 women with an AFE
Diagnosis:Laboratory Evaluation
AFE is based on clinical presentation and is
a diagnosis of exclusion. That being said
Disseminated Intravascular Coagulopathy
(DIC) evaluation
Cardiac enzymes may be elevated
EKG may show tachycardia with RV
strainpattern
ABG: hypoxemia
WBCs may
y be elevated
Diagnosis:Laboratory Evaluation
TKH-2
TKH 2 monoclonal antibody to fetal mucin
(Sialyl Tn fetal antigen)
Maternal zinc coproporphyrin I
component of fetal meconium
Tryptase levels
assuming an anaphylactoid pathophysiology
Diagnosis: Transesophageal
Echocardiography
Case reports using TEE
Normal left ventricular contractility
Gross enlargement of the right ventricle and
main ppulmonary
y tree
Acute right ventricular pressure overload
Underloading of the left ventricle due to pulmonary
vasoconstriction
James CF et al. Int J Ob Anesth 13:279-83,, 2004
Stanten RD et al. Obst Gyn 102:496-498, 2003
McDonnell et al Int J Obstet Anesth 16:269-73, 2007
Management of AFE
Supportive care with the goal of maintaining
oxygenation and vital organ perfusion
100% supplemental
pp
oxygen
yg
Mechanical ventilation usually required
Management of AFE
Combat the severe coagulopathy
Blood component therapy
FFP versus Cryoprecipitate
C
i i
depending
d
di on volume
l
needs
Recombinant Factor VIIa
Aprotinin and serine proteinase inhibitor FOY
Annecke et al algorithm based coagulation
management 2010
Tuffnell DJ 2005
37% maternal mortality
7% of survivors remaining neurologically
i
impaired
i d
Knight et al 2010
20% case fatality rate
Maternal Outcomes
Gilbert et al 1999
1.1 million women delivering at a California acute
care civilian hospital over a 2 year period
53 cases with a maternal mortality rate of 26.4%