Amniotic fluid embolism after blunt abdominal trauma

Amniotic fluid embolism (AFE) is a rare, but potentially fatal complication of pregnancy, with an incidence between 1 in 8000 and 1 in 80,000 pregnancies. The pathogenesis is not fully understood, but the generally accepted belief is that amniotic fluid enters the mother's circulation, most commonly via tears in the lower uterine segment. In the fluid there are substances with pro-inflammatory, vasospastic and pro-coagulative properties. AFE after blunt trauma is very rare, only described a few times in the literature. We report a case of fatal AFE after probable minor blunt trauma to the abdomen and give a review of the literature.     

Responding to Amniotic Fluid Embolism

Amniotic fluid embolism (AFE), an uncommon disorder with a high fatality rate, is an obstetric emergency that requires swift recognition and intervention to save both the mother's life and that of her child.The high mortality rate and varying theories as to its cause make it difficult to diagnose AFE, which can occur at any point during labor and delivery, including during cesarean birth. These factors make it important for perioperative nurses to understand and recognize AFE when it occurs in the OR. Rapid delivery of the fetus is imperative for the survival of both mother and child. Monitoring and aggressively providing respiratory and circulatory support interventions are required if the mother is to survive AFE. AORN J 89 (June 2009) 1079–1088. © AORN, Inc, 2009.     

Amniotic fluid embolism

Amniotic fluid embolism (AFE) (also known as anaphylactoid syndrome of pregnancy)is a catastrophic condition that occurs during pregnancy or shortly after delivery. It is found throughout the world in developed and undeveloped countries and occurs at an incidence of between 1 in 80000 live births. In the United States, AFE occurs in 1 in 20000 to 80000 deliveries.     

Amniotic fluid embolism associated with castor oil ingestion

We report a case of an amniotic fluid embolism (AFE) causing a cardiorespiratory arrest associated temporally with ingestion of castor oil in a full-term normal pregnancy. Risk factors usually associated with AFE were not found in this patient.     

Determining zinc coproporphyrin in maternal plasma--a new method for diagnosing amniotic fluid embolism.

We measured the concentration of zinc coproporphyrin I (ZnCP-I), a characteristic component of meconium, in maternal plasma by fluorometry after HPLC. We obtained plasma samples from 89 women: 35 at weeks 10-40 of normal pregnancy, 41 shortly after normal delivery, 4 from patients with amniotic fluid embolism (AFE), and 9 from non-AFE patients with intra- or postpartum shock caused by genital bleeding. The plasma ZnCP-I concentration was 97 (SD 83, range 38-240) nmol/L in the AFE patients, 11 (SD 9.2) nmol/L in the non-AFE patients, 12 (SD 7.9) nmol/L during normal pregnancy, and 26 (SD 10) nmol/L shortly after normal delivery. We suggest that measuring ZnCP-I in maternal plasma by fluorometry on HPLC is a rapid, noninvasive, and sensitive method for diagnosing AFE and propose 35 nmol/L as the cutoff value for the ZnCP-I concentration in maternal plasma for the diagnosis of AFE.     

Amniotic fluid embolism: A case with non-cardiogenic pulmonary edema

We report an uncommon case of amniotic fluid embolism (AFE) in a 24-year-old woman with a 26th-week, second pregnancy. Clinical manifestations were dominated by acute respiratory distress and pulmonary edema. Recovery was complete. Early invasive hemodynamic studies showed normal function of the left ventricle with a low pulmonary artery occluded pressure. These findings are controversial to the concept of cardiogenic pulmonary edema in AFE.     

转化生长因子-β1在家兔羊水栓塞后肺损伤中的作用

目的探讨羊水栓塞（AFE）肺损伤发病机制,探讨转化生长因子-β1（TGF-β1）在AFE肺损伤中的作用。方法将20只健康妊娠晚期家兔随机分为对照组（生理盐水组,10只）及羊水组（10只）,建立AFE动物模型,1h后取家兔肺组织制作病理切片观察肺组织病理变化,采用链霉素亲和-生物素-过氧化酶复合物法对肺组织细支气管上皮细胞TGF-β1蛋白表达进行免疫组织化学染色,采用MIAS-2000医学图像分析系统进行蛋白半定量分析,以最大灰度值反映TGF-β1蛋白表达量。结果羊水组肺组织病理切片见肺组织水肿,肺组织TGF-β1蛋白水平：对照组（5．02±0．76）μg／L,羊水组（19．85±1．92）μg／L,羊水组TGF—β1蛋白水平明显升高（P〈0．05）。结论AFE肺损伤与TGF—β1水平升高密切相关。     

Amniotic fluid embolism: a case report and review

A 41-year old primigravida underwent caesarean section because of foetal distress following prostin induction of labour. Intraoperative coagulopathy, haemorrhage and hypotension necessitated a hysterectomy. Subsequently, she developed respiratory and renal failure, requiring mechanical ventilation and haemodialysis. She made a full recovery. The likely diagnosis was amniotic fluid embolism (AFE), a rare complication of pregnancy with a variable presentation, ranging from cardiac arrest and death through to mild degrees of organ system dysfunction with or without coagulopathy. The differential diagnosis includes pre-eclamptic toxaemia/pregnancy-induced hypertension, anaphylaxis and pulmonary embolism. There is no diagnostic test for AFE; the finding of foetal elements in the maternal circulation is non-specific. Historically, AFE was thought to induce cardiovascular collapse by mechanical obstruction of the pulmonary circulation. It is now thought that a combination of left ventricular dysfunction and acute lung injury occur, with activation of several of the clotting factors. An immunological basis for these effects is postulated. There is no specific therapy and treatment is supportive. The mortality of the condition remains high.     

Amniotic fluid embolism.

Pulmonary embolism is the leading cause of maternal death in the United States. Amniotic fluid embolism (AFE) represents the least preventable and most lethal of complications with a reported mortality of 86% and an associated fetal demise of 50%. Although it is widely accepted as a clinical entity, AFE is incompletely understood. A combination of clinical presentation, laboratory findings, and exclusion of other pathologies leads to the diagnosis of AFE. The mainstays of treatment are oxygenation, maintenance of cardiac output, and correction of coagulopathy. The prognosis for the patient experiencing AFE remains bleak because it is largely unpredictable and, except for supportive measures, cannot be corrected.     

Transient left heart failure in amniotic fluid embolism

We report a patient with amniotic fluid embolism (AFE) in whom the occurrence of late onset, severe pulmonary oedema was due to isolated left ventricular (LV) failure. Following institution of diuretics and inotropic support, the situation promptly improved and follow-up haemodynamic assessment showed complete recovery of LV function. This report indicates that reversible LV failure may occur late after AFE and emphasises the usefulness of pulmonary artery catheterisation for proper assessment and guidance of therapy of pulmonary oedema in AFE.     

Acute renal failure in pregnancy

Acute renal failure (ARF) during pregnancy is a rare event. However, the care of the woman diagnosed with ARF is a challenge for the perinatal care team. The physiologic hydronephrosis and hydroureter of pregnancy alters clinical parameters for assessing the woman diagnosed with ARF. Urinary stasis and enhanced filtration predisposes to alterations in 24-hour urine evaluations, increased urinary creatinine excretion, and lower BUN and serum creatinine values. If the renal system becomes compromised, the woman is at risk for acidemia, fluid and electrolyte imbalances, and pregnancy compromise. The perinatal nurse must have an understanding of normal pregnancy physiology and an appreciation for how pregnancy physiology may alter renal assessments. Furthermore, the nurse must know the impact that ARF can have on maternal status and fetal well-being. Astute, continuous assessments of maternal and fetal status are required to detect subtle changes. While maternal status is the primary concern, it must not be forgotten that a change in fetal status may be the first indication of underlying maternal compromise.     

Amniotic fluid embolism: prophylaxis with heparin and aspirin

The thromboplastic activity of amniotic fluid (AF) from women in labor may be a significant factor in amniotic fluid embolism (AFE) and obstetric disseminated intravascular coagulation (DIC). Infusion of AF from women in labor into laboratory animals was found to depress the platelet count, as seen in DIC. In this study we also investigated the ability of heparin and aspirin to block the thromboplastic activity and thrombocytopenia subsequent to AF infusion. In animals, heparin prophylaxis before infusion of AF prevented thrombocytopenia, whereas aspirin prophylaxis did not. Heparin prophylaxis may be useful in the management of coagulation defects associated with AFE and labor.     

IL-8在大鼠羊水栓塞发病机制中的实验研究

目的探讨羊水栓塞(AFE)的发病机制。方法孕晚期Wistar大鼠30只,胎龄20天,根据注入液体不同,随机分为:对照组(生理盐水组)10只、羊水组10只、胎粪组10只。建立羊水栓塞动物模型,观察60分钟抽动脉血1毫升随后处死动物,行酶联免疫法检测血中白介素-8(IL-8)含量。取肺组织行HE染色观察肺血管腔内中性粒细胞的表达。结果实验组(羊水组与胎粪组)与对照组比较血中IL-8含量升高(P0.01),实验组肺血管腔内中性粒细胞的数量较对照组增多(P0.01),胎粪组与羊水组比较亦有差异(P0.05)。结论羊水中的细胞因子IL-8与中性粒细胞参与了羊水栓塞的发生及发展,在羊水栓塞发病过程中发挥重要的作用。     

A case presentation of Sweet's syndrome and discussion of life-threatening dermatoses

Sweet first described acute febrile neutrophilic dermatosis in 1964. Since then, more than 425 cases of this typically benign, steroid-responsive disease have been recorded. Although often associated with myelodysplastic syndromes or hematologic malignancies, Sweet's syndrome has also been related to pregnancy, autoimmune disorders, and many drug therapies. Although it is not typically an acutely life-threatening illness, there is a potential for significant pulmonary involvement and respiratory compromise. Additionally, emergency physicians should be aware of this unusual disease and its frequent association with systemic illnesses. We report the first case of Sweet's syndrome in the emergency medicine literature and present a review and discussion of several common life-threatening dermatoses.     

Maternal mortality--a review of current trends

Pregnancy-related maternal deaths, although rare,are higher than the public health goal of no more than 3 per 100000 live births [5,6]. Achievement of this goal mandates complete and consistent reporting of all maternal deaths to identify causes of death accurately and correct underreporting [2]. Racial disparity between white and African American women must be reduced. Further research is needed to identify the factors contributing to the higher mortality rates in the African American population. Risk factors currently identified with adverse perinatal outcomes do not explain the differences in mortality rates adequately. Perinatal nurses and primary care providers should take an active role in identifying current trends in causes of matemal mortality. The population of women encountered daily in perinatal units is changing, with an increasing number of pregnancies complicated by preexisting and pregnancy-related medical conditions. Caring for these women within the framework that pregnancy is a normal, physiologic state can lead to complacency and increase the probability of missing early signs of maternal decompensation from an undiagnosed cardiac lesion, because shortness of breath and decreased exercise tolerance are considered normal changes as the pregnancy advances.Common complaints of pregnancy often mimic early signs of cardiopulmonary compromise, delaying an accurate diagnosis.The perinatal nurse must be aware of the early signs of an impending cardiopulmonary arrest. If recognized. subtle changes in levels of mentation, increasing pulse and respiratory rates, and changes in blood pressure lead to earlier interventions to correct maternal hemodynamic status and possibly prevent cardiopulmonary collapse. To further complicate the issue, the mindset in perinatal units often is, "It can't happen here" or "We don't have codes in obstetrics."Perinatal units should practice emergency drills, including management of eclampsia, hemorrhage, and cardiopulmonary arrest. Rehearsal of the emergency situation helps decrease anxiety for the staff and increase response times.The goal of the irreducible minimum for prevent-able maternal deaths is one to strive for in today's perinatal practice. Active surveillance to identify causes of maternal mortality allows for initiation of early interventions to minimize maternal compromise, thereby decreasing preventable deaths.     

Free Fluid in Morison's Pouch on Bedside Ultrasound Predicts Need for Operative Intervention in Suspected Ectopic Pregnancy

Background Ectopic pregnancies are frequently present in women who present to the emergency department with pregnancy and abdominal pain or bleeding, a subset of whom may require operative intervention.
Objectives To prospectively determine if emergency physician (EP)-performed transabdominal pelvic ultrasonography (US) with determination of free abdominal fluid in the hepatorenal space predicted the need for operative intervention.
Methods Patients who were suspected to have an ectopic pregnancy were prospectively enrolled over a ten-month period. An EP-performed bedside transabdominal pelvic US that included a view of the hepatorenal space (Morison's pouch) for free fluid. The EP US was classified as intrauterine pregnancy (IUP) or no definitive IUP, with Morison's pouch classified as positive or negative. The majority of patients had a subsequent transvaginal pelvic US performed by the Department of Radiology. Patients were followed up for radiology results, need for operative intervention, and ultimate outcome of the pregnancy.
Results There were 242 patients enrolled, with an average time to complete the EP US of 4 minutes and 27 seconds. There were 28 ectopic pregnancies diagnosed (11.6%), of which 18 patients underwent operative intervention. Free fluid in Morison's pouch was identified in ten patients, nine of whom underwent operative intervention, yielding a positive likelihood ratio of 112 (95% confidence interval = 15 to 831) for patients with suspected ectopic pregnancy who required operative intervention.
Conclusions Free intraperitoneal fluid found in Morison's pouch in patients with suspected ectopic pregnancy may be rapidly identified at the bedside by EP-performed US and predicts the need for operative intervention.     

Therapeutic application of C1 esterase inhibitor concentrate for clinical amniotic fluid embolism: a case report

We present the successful application of C1 esterase inhibitor (C1INH) concentrate to a patient with clinical amniotic fluid embolism (AFE).     

Amniotic fluid embolism: an obstetric emergency

AFE is an unpredictable, unpreventable, and, for the most part, an untreatable obstetric emergency. Management of this condition includes prompt recognition of the signs and symptoms, aggressive resuscitation efforts, and supportive therapy. Any delays in diagnosis and treatment can result in increased maternal and/or fetal impairment or death. Whereas once the invariable outcome of AFE was death of the mother, today the prognosis is somewhat brighter thanks to increased awareness of the syndrome and advances in intensive care medicine. In any case, intensive care nurses are called on to provide physical, life-saving care to the patient and her fetus. Both during and after the event, supportive care must be administered to the patient's family members, who are dealing with crisis and loss.