Naohiro Kanayama, Junko Inori, Hatsue Ishibashi-Ueda, Makoto Takeuchi, Masahiro Nakayama, Satoshi Kimura, Yoshio Matsuda, Jun Yoshimatsu, Tomoaki Ikeda
Maternal death analysis from the Japanese autopsy registry for recent 16 years: significance of amniotic fluid embolism.
J Obstet Gynaecol Res. 2011 Jan;37(1):58-63. doi: 10.1111/j.1447-0756.2010.01319.x. Epub 2010 Nov 18.
Abstract/Text
AIM: To clarify the cause of maternal deaths, an autopsy is essential. However, there has been no systemic analysis of maternal death in Japan based on autopsy cases.
MATERIAL & METHODS: Maternal death reports were retrieved from a large amount of registered autopsy data on maternal death in the series of 'Annual of pathological autopsy cases in Japan'. These files contain 468,015 autopsy records from 1989 to 2004. We collected 193 cases of maternal death due to direct obstetric causes. We recorded all the data into Excel files. Then we analyzed the causes of death and classified them into 11 categories.
RESULTS: The causes of maternal death were as follows: amniotic fluid embolism (AFE), 24.3%; disseminated intravascular coagulation (DIC) related to pregnancy-induced hypertension, 21.2%; pulmonary thromboembolism, 13.0%; injury to the birth canal, 11.4%; medical and surgical complications, 9.8%; and atonic bleeding or DIC of unknown cause, 8.3%. A discrepancy between the clinical diagnosis and pathological diagnosis was frequently observed in cases of AFE, septic DIC and injury to the birth canal. AFE diagnosed by autopsy was often clinically diagnosed as atonic bleeding or DIC of unknown cause before death. Half of the cases of AFE diagnosed by autopsy were associated with DIC.
CONCLUSION: We found that AFE, DIC related to pregnancy-induced hypertension, pulmonary thromboembolism and injury to the birth canal were the major causes of maternal death in Japan. AFE had various clinical features such as uterine atony and DIC in addition to pulmonary cardiac collapse.
© 2010 The Authors. Journal of Obstetrics and Gynaecology Research © 2010 Japan Society of Obstetrics and Gynecology.
S L Clark, G D Hankins, D A Dudley, G A Dildy, T F Porter
Amniotic fluid embolism: analysis of the national registry.
Am J Obstet Gynecol. 1995 Apr;172(4 Pt 1):1158-67; discussion 1167-9.
Abstract/Text
OBJECTIVE: We analyzed the clinical course and investigated possible pathophysiologic mechanisms of amniotic fluid embolism.
STUDY DESIGN: We carried out a retrospective review of medical records. Forty-six charts were analyzed for 121 separate clinical variables.
RESULTS: Amniotic fluid embolism occurred during labor in 70% of the women, after vaginal delivery in 11%, and during cesarean section after delivery of the infant in 19%. No correlation was seen with prolonged labor or oxytocin use. A significant relation was seen between amniotic fluid embolism and male fetal sex. Forty-one percent of patients gave a history of allergy or atopy. Maternal mortality was 61%, with neurologically intact survival seen in 15% of women. Of fetuses in utero at the time of the event, only 39% survived. Clinical and hemodynamic manifestations were similar to those manifest in anaphylaxis and septic shock.
CONCLUSIONS: Intact maternal or fetal survival with amniotic fluid embolism is rare. The striking similarities between clinical and hemodynamic findings in amniotic fluid embolism and both anaphylaxis and septic shock suggest a common pathophysiologic mechanism for all these conditions. Thus the term amniotic fluid embolism appears to be a misnomer.
Michael S Kramer, Jocelyn Rouleau, Thomas F Baskett, K S Joseph, Maternal Health Study Group of the Canadian Perinatal Surveillance System
Amniotic-fluid embolism and medical induction of labour: a retrospective, population-based cohort study.
Lancet. 2006 Oct 21;368(9545):1444-8. doi: 10.1016/S0140-6736(06)69607-4.
Abstract/Text
BACKGROUND: Amniotic-fluid embolism is a rare, but serious and often fatal maternal complication of delivery, of which the cause is unknown. We undertook an epidemiological study to investigate the association between amniotic-fluid embolism and medical induction of labour.
METHODS: We used a population-based cohort of 3 million hospital deliveries in Canada between 1991 and 2002 to assess the associations between overall and fatal rates of amniotic-fluid embolism and medical and surgical induction, maternal age, fetal presentation, mode of delivery, and pregnancy and labour complications.
FINDINGS: Total rate of amniotic-fluid embolism was 14.8 per 100,000 multiple-birth deliveries and 6.0 per 100,000 singleton deliveries (odds ratio 2.5 [95% CI 0.9-6.2]). Of the 180 cases of amniotic-fluid embolism in women with singleton deliveries during the study period, 24 (13%) were fatal. We saw no significant temporal increase in occurrence of amniotic-fluid embolism for total or fatal cases. Medical induction of labour nearly doubled the risk of overall cases of amniotic-fluid embolism (adjusted odds ratio 1.8 [1.3-2.7]), and the association was stronger for fatal cases (crude odds ratio 3.5 [1.5-8.4]). Maternal age of 35 years or older, caesarean or instrumental vaginal delivery, polyhydramnios, cervical laceration or uterine rupture, placenta previa or abruption, eclampsia, and fetal distress were also associated with an increased risk.
INTERPRETATION: Medical induction of labour seems to increase the risk of amniotic-fluid embolism. Although the absolute excess risk is low, women and physicians should be aware of this risk when making decisions about elective labour induction.
Tomoaki Oda, Naoaki Tamura, Rui Ide, Toshiya Itoh, Yoshimasa Horikoshi, Masako Matsumoto, Megumi Narumi, Yukiko Kohmura-Kobayashi, Naomi Furuta-Isomura, Chizuko Yaguchi, Toshiyuki Uchida, Kazunao Suzuki, Hiroaki Itoh, Naohiro Kanayama
Consumptive Coagulopathy Involving Amniotic Fluid Embolism: The Importance of Earlier Assessments for Interventions in Critical Care.
Crit Care Med. 2020 Dec;48(12):e1251-e1259. doi: 10.1097/CCM.0000000000004665.
Abstract/Text
OBJECTIVES: Amniotic fluid embolism is a rare disease that induces fatal coagulopathy; however, due to its rarity, it has not yet been examined in detail. The strict diagnostic criteria by Clark for amniotic fluid embolism include severe coagulopathy complicated by cardiopulmonary insufficiency, whereas the Japanese criteria also include postpartum hemorrhage or Disseminated Intravascular Coagulation in clinical practice. Amniotic fluid embolism cases with preceding consumptive coagulopathy may exist and are potential clinical targets for earlier assessments and interventions among amniotic fluid embolism cases fulfilling the Japanese, but not Clark criteria. The present study was performed to compare coagulopathy in the earlier stage between the amniotic fluid embolism patients diagnosed by Clark criteria (Clark group, n = 6), those by the Japanese criteria (Non-Clark group, n = 10), and peripartum controls and identify optimal clinical markers for earlier assessments of amniotic fluid embolism-related consumptive coagulopathy.
DESIGN: Retrospective case-control study.
SETTING: A single university-based center. Our amniotic fluid embolism registry program has accumulated clinical information and blood samples since 2003.
PATIENTS: Amniotic fluid embolism patients in the Clark and Non-Clark groups between 2009 and 2017 and peripartum controls.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Clinical information was collected on hemoglobin levels, platelet counts, and coagulation- and fibrinolysis-related variables. Fibrinolytic parameters were also measured and compared among the three groups before blood transfusion. Fibrinogen levels in all patients in the Clark group and most in the Non-Clark group decreased earlier than hemoglobin levels, which was consistent with the high hemoglobin/fibrinogen ratio and, thus, is a promising clinical marker for the earlier assessment of amniotic fluid embolism-related consumptive coagulopathy.
CONCLUSIONS: Earlier evaluations of consumptive coagulopathy and hyperfibrinolysis using the hemoglobin/fibrinogen ratio following preemptive treatment may reduce the occurrence or prevent the aggravation of severe coagulopathy in amniotic fluid embolism patients.
Naoaki Tamura, Mustari Farhana, Tomoaki Oda, Hiroaki Itoh, Naohiro Kanayama
Amniotic fluid embolism: Pathophysiology from the perspective of pathology.
J Obstet Gynaecol Res. 2017 Apr;43(4):627-632. doi: 10.1111/jog.13284. Epub 2017 Feb 11.
Abstract/Text
Amniotic fluid embolism (AFE) is recognized as a type of syndrome characterized by the abrupt onset of hypoxia, hypotension, seizures, or disseminated intravascular coagulopathy (DIC), occurring during labor, delivery, or immediately postpartum, caused by the inflow of amniotic components into the maternal circulation. AFE is a rare condition but one of the most serious obstetrical complications, resulting in a high mortality rate among pregnant women. Despite earlier recognition and intensive critical management, we often encounter patients who unfortunately do not recover from the exacerbation of AFE-related conditions. A major concern is that there are no effective evidence-based therapies for AFE, because its pathophysiology is still not well understood. This article reviewed AFE, focusing on the pathology and currently proposed pathophysiology.
© 2017 Japan Society of Obstetrics and Gynecology.
妊産婦死亡症例検討評価委員会・日本産婦人科医会: 母体安全への提言2020;69-80, 2021.
Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org, Luis D Pacheco, George Saade, Gary D V Hankins, Steven L Clark
Amniotic fluid embolism: diagnosis and management.
Am J Obstet Gynecol. 2016 Aug;215(2):B16-24. doi: 10.1016/j.ajog.2016.03.012. Epub 2016 Mar 14.
Abstract/Text
OBJECTIVE: We sought to provide evidence-based guidelines regarding the diagnosis and management of amniotic fluid embolism.
STUDY DESIGN: A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and the Cochrane Library. The search was restricted to English-language articles published from 1966 through March 2015. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion. Evidence reports and published guidelines were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used for defining the strength of recommendations and rating quality of the evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence.
RESULTS AND RECOMMENDATIONS: We recommend the following: (1) we recommend consideration of amniotic fluid embolism in the differential diagnosis of sudden cardiorespiratory collapse in the laboring or recently delivered woman (GRADE 1C); (2) we do not recommend the use of any specific diagnostic laboratory test to either confirm or refute the diagnosis of amniotic fluid embolism; at the present time, amniotic fluid embolism remains a clinical diagnosis (GRADE 1C); (3) we recommend the provision of immediate high-quality cardiopulmonary resuscitation with standard basic cardiac life support and advanced cardiac life support protocols in patients who develop cardiac arrest associated with amniotic fluid embolism (GRADE 1C); (4) we recommend that a multidisciplinary team including anesthesia, respiratory therapy, critical care, and maternal-fetal medicine should be involved in the ongoing care of women with AFE (Best Practice); (5) following cardiac arrest with amniotic fluid embolism, we recommend immediate delivery in the presence of a fetus ≥23 weeks of gestation (GRADE 2C); (6) we recommend the provision of adequate oxygenation and ventilation and, when indicated by hemodynamic status, the use of vasopressors and inotropic agents in the initial management of amniotic fluid embolism. Excessive fluid administration should be avoided (GRADE 1C); and (7) because coagulopathy may follow cardiovascular collapse with amniotic fluid embolism, we recommend the early assessment of clotting status and early aggressive management of clinical bleeding with standard massive transfusion protocols (GRADE 1C).
Copyright © 2016 Elsevier Inc. All rights reserved.