Clinical Management of Amniotic Fluid Embolism

 

Sarika Sukesh Nair

MGM Institute’s University Department of Nursing, Kamothe, Navi Mumbai

*Corresponding Author Email: sarika.sk28@gmail.com

 

ABSTRACT:

Amniotic Fluid Embolism is an obstetric emergency in which amniotic fluid, fetal cells, hair or other debris enters the mother’s blood stream via the placental bed of the uterus and brings about anaphylactic reactions. The intensity of the complications completely relies on the immediate actions carried out for maintaining oxygenation, blood pressure, cardiac output and managing coagulopathy. Adequate and appropriate nursing actions and family support are another important aspects, that enhances the effectiveness of the management of the syndrome.

 

KEYWORDS: Amniotic fluid, Anaphylaxis, Septic shock, Pulmonary embolism

 

 


INTRODUCTION:

Amniotic Fluid Embolism (AFE) is a rare obstetric emergency in which amniotic fluid, fetal cells, hair or other debris enters the mother’s blood stream via the placental bed of the uterus and triggers an allergic like reaction. It is the most serious, unpredictable and unpreventable cause of maternal mortality1. Recently a new name has been proposed for the disorder: ‘Anaphylactoid syndrome of pregnancy. The proposed new name resulted from research that indicates that AFE resembles anaphylaxis and septic shock than it does pulmonary embolism2.

 

Incidence:

The overall incidence of AFE has been reported to range from 1 in 80,000 deliveries3. As per a case report, available from Indian Medical Gazette, 2014,the overall maternal mortality rate in India during 2007-2009 was 212 per 1,00,000 live births4.

 

Etiology:

1.    AFE results from amniotic fluid entering maternal circulation via the uterine veins which has either a direct effect on the lungs, or triggers an immune response in the mother5.

2.    For amniotic fluid to enter into maternal circulation, there are three pre requisites:-

a.    Ruptured membranes

b.    Ruptured uterine or cervical veins

c.    Pressure gradient from uterus to vein

3.    Pre disposing factors include:-

a.    Multiparity

b.    Advanced maternal age

c.    Macrosomia

d.    Intrauterine fetal death

e.    Meconium stained amniotic fluid6

 

Pathophysiology and Clinical Signs:7

 

Diagnostic Evaluations:3

There is no single clinical or laboratory test to diagnose AFE. The diagnosis of AFE has traditionally been at post mortem by identifying fetal squamous and debris in the pulmonary vasculature. The investigations include: -

1.    ABG: -

It may demonstrate metabolic acidosis and hypoxemia.

 

2.    ECG: - It may reveal right ventricular strain pattern and tachycardia.

 

3.    Chest X ray: -

It may uncover changes consistent with pulmonary edema in the absence of any clinical evidence of left ventricular failure.

 

4.    Coagulation screening: -

It may show features of disseminated intravascular coagulation and prolonged bleeding time.

 

5.    Use of zinc coproporphyrin and the monoclonal antibody TKAH-2: -

It has been reported as a means of rapid diagnosis of AFE.

 

SIGNS AND SYMPTOMS:

1.     Hypotension

2.    Hypoxia

3.    DIC

4.    Altered mental status

5.    Seizure activity

6.    Fever

7.    Chills

8.    Headache

9.    Nausea

10. Vomiting

11. Evidence of fetal distress

 

Clinical Management:

The general goals of management are to maintain oxygenation, blood pressure and cardiac output and to manage any coagulopathy3.


 

Flow chart depicting clinical management priorities for Amniotic Fluid Embolism.

ACLS: - Advanced Cardiac Life Support; AFE: - Amniotic Fluid Embolism; BP: - Blood Pressure; CPR: - Cardio Pulmonary Resuscitation; FFP: - Fresh Frozen Plasma; DIC: - Disseminated Intravascular Coagulation; ICU: - Intensive Care Unit; TEE: - Trans Esophageal Echocardiography ECMO: - Extra Corporeal Membrane Oxygenation; IABP: - Intra Aortic Balloon counter pulsation


Nursing Management:8

Ø Assess for the signs of DIC such as bleeding and thrombosis including chest pain, shortness of breath, hematuria, abdominal pain, headache, numbness and coolness of an extremity.

Ø Institute bleeding precautions.

Ø Monitor for signs and symptoms of allergic reactions, anaphylaxis and volume overload during blood products administration.

Ø Promote tissue perfusion by keeping the patient warm.

Ø Monitor ECG and laboratory tests for dysfunction of vital organs.

Ø Monitor for signs of vascular occlusion.

Ø Ensure adequate ventilation and oxygenation through the use of supplemental oxygen or mechanical ventilation.

Ø In case of Endotracheal intubation, consider the patients nutritional needs early in process, that nutritional status does not decline further. It is difficult to warm patients who have compromised nutritional status.

Ø In case of persistent uterine bleeding, increase the energy level by encouraging good dietary intake.

Ø Help limit patients exertion and also to relieve fear by reviewing pattern of menstrual flow with patient and helping her plan for excessive bleeding.

Ø Monitor intake and output chart.

Ø Monitor fetal heart rate in case if the client has not yet given birth.

Ø Assess for the signs of HELLP syndrome.

Ø Monitor for liver function and bleeding and signs of shock.

Ø Alert medical staff immediately and assist with emergency procedures such as delivery and with the CPR as needed.

 

Prognosis:

Ø Survival after AFE has improved significantly with early recognition of this syndrome and prompt and early resuscitative measures.

Ø The decrease in the mortality rate results solely from early diagnosis and prompt treatment rather than prevention of the syndrome, since the cause is unknown.

Ø Those women who survive long enough to be transferred to the ICU have a better chance of survival.

Ø Although mortality rates have declined, morbidity remains high with severe sequelae, particularly neurologic impairment.

 

Family Support:

Because the maternal and fetal mortality rates are so high, it is important to support the patient's family members. When the mother and infant are gravely ill, keeping their family members well informed and allowing as much access to the loved ones as possible are important.

 

CONCLUSION:

Amniotic fluid embolism syndrome is an infrequent, unpredictable, and catastrophic complication of pregnancy. It is virtually impossible to predict which patients are at risk for AFE. Diagnosis must be based on a spectrum of clinical signs and symptoms and by exclusion of other causes. Most cases of AFE are associated with dismal maternal and fetal outcomes, regardless of the quality of care rendered. Improved understanding of the pathophysiology of AFE may lead to the development of preventive measures and more effective and specific treatment. Although there are many new developments with respect to the understanding of the disease, amniotic fluid embolism continues to be a catastrophic illness requiring a high index of suspicion, a multidisciplinary approach and rapid resuscitation efforts in order to have a desirable clinical outcomes.

 

REFERENCES:

1.    D. C. Dutta, Textbook of Obstetrics, 6th Edition, New Central Book Agency Pvt Ltd, 628

2.    Susan A Orshan, Maternity, Newborn and Women’s Health Nursing, Lippincott Williams and Wilkins, 650

3.    Sabaratnam Arulkumaran, et al, Obstetrics and Gynecology for Post graduates, Volume 1, Universities Press, 524 – 526

4.    Ph. Madhubala Devi, Th. Meera, Babina Sarangthem and N. Ratan Singh. Amniotic Fluid Embolism: A Case Report. Available from: URL: https://www.google.co.in/incidence of AFE in India/ Indian Medical Gazette, 2014

5.    Harsh Mohan, Textbook of Pathology, 6th Edition, Jaypee Publications, 123 – 124

6.    N. Jayne Klossner, et al, Introductory Maternity and Pediatric Nursing, Lippincott Williams and Wilkins, 446

7.    https://www.google.co.in/pathophysiology of AFE

8.    Lippincott, Manual of Nursing practice, 8th Edition, Jaypee Publications, 215-219, 825-826, 1291-1292

 

 

 

Received on 22.06.2016                Modified on 08.07.2016

Accepted on 17.08.2016                © A&V Publications all right reserved

Asian J. Nur. Edu. and Research.2017; 7(1): 120-122.

DOI: 10.5958/2349-2996.2017.00024.6