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Year : 2011  |  Volume : 5  |  Issue : 2  |  Page : 230-232  

Amniotic fluid embolism: A catastrophic problem in need of a prepared team with a plan

Department of Surgery, Division of Cardiac Surgery, The Ohio State University Medical Center, Columbus, Ohio, USA

Date of Web Publication9-Apr-2012

Correspondence Address:
Michael S Firstenberg
Division of Cardiac Surgery, N817 Doan Hall, 410 W 10th Avenue, Columbus, Ohio 43210
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Karen Nelson D O, Firstenberg MS. Amniotic fluid embolism: A catastrophic problem in need of a prepared team with a plan. Anesth Essays Res 2011;5:230-2

How to cite this URL:
Karen Nelson D O, Firstenberg MS. Amniotic fluid embolism: A catastrophic problem in need of a prepared team with a plan. Anesth Essays Res [serial online] 2011 [cited 2021 Sep 16];5:230-2. Available from:

There are few things more tragic than the death of a new mother - particularly one who was previously healthy and the cause of death is sudden and unpredictable. Amniotic fluid embolism (AFE) is one case catastrophic problem - as illustrated in the case and review by Kulshrestha and Mathur. [1] AFE is rare, occurring in less than 10 per 100 000 deliveries, but it has a mortality rate of 60-80% and accounts for 10% of maternal deaths. [2] Furthermore, it affects mothers worldwide and spares no culture, no demographic group, no society, and no corner of the world - it affects the rich, as well as the poor. Fortunately, this problem is rare and few clinicians - even in busy delivery suites - will encounter this horrible problem. However, this very fact illustrates the challenges in diagnosis and management, particularly when even the slightest delay can mean the difference between life and death. With such a high mortality and the patient's demise occurring suddenly, often within a few hours after delivery, Reviews such as this one presented by Kulshrestha, become critical in raising the level of awareness by helping clinicians recognize the signs and symptoms of AFE and provide adequate resuscitation. To improve survival, the clinical team must have a high suspicion and quickly work through a differential diagnoses in which many problems can be confused with AFE. But, more importantly, the team needs to be prepared. Even if the problem is recognized immediately, as with most disasters - medical and otherwise - if everyone is prepared and if there are checklists and protocols in place, then the chances for success increase dramatically. [3] Such concepts are not new to medicine. Even disease-specific check-lists exist with malignant hyperthermia being the prototypical example. Many operating rooms, even in the disadvantaged areas have checklists, emergency Dantroline kits, and easy to follow instructions that facilitate care in unusual areas and unexpected situations. [4],[5] AFE can and should follow a similar model.

Unfortunately, again with most catastrophes throughout the world, preparation and anticipation of a problem rarely occurs until there is a disaster that raises the level of awareness and concern. However, there is no reason why obstetric and critical care teams across the world should not anticipate, prepare, and maybe even practice for the worse. The key is to do this before a death occurs. Hopefully this review, as so many other discussions on this topic, can precipitate a wake-up call. [6] While specific guidelines and protocols do not exists and treatment options can vary with the resources available in each center, clearly the topic is worthy of discussion. The question of "how do we respond to peri-partum cardiovascular collapse" needs to be asked. There might not be a simple answer to this problem since each center might answer the question differently based upon resources and expertise. Such a fact does not excuse the fact that such a question needs to be asked and discussed before it happens - and it will happen.

In such situations, while recognition is critical and a definitive diagnosis might come later, the responses need to be the same. Attention to the basics are obviously the first steps - establish an airway, ensure breathing, maintain and support the circulation should be practiced to the point in which they are routine and second nature. Then comes the more difficult part. If the baby has not been delivery then that must be the priority of one team, but just as importantly, there needs to be a second team solely dedicated to the acute needs of the mother. Such a protocol must incorporate a cry for help, and that help must be available in some form or another. One team cannot serve the complex needs of two lives in such situations. Such teams need to be defined in advance and roles assigned such that when the time comes, there is order rather than chaos. As importantly, the two teams must work side-by-side despite somewhat different priorities. Again, practice and review is critical. This is why elementary schools have fire drills, why airplanes instruct passengers on what to do in the event of loss of cabin pressure, and why even the best trained rescue teams spend most of the time practicing. A key is also that rules are followed with little question. The process is tried and true. [7]

No one would refute that algorithms such as those used in basic life support (BLS), advanced cardiac life support (ACLS), or even advanced trauma life support (ATLS) courses improve patient outcomes, especially when used regularly by healthcare teams. What about an inexperienced team or one which does not encounter such situations or one that does not have access to the training, resources, and expertise necessary to develop skills? Algorithms can still improve standardization and overall performance in stressful, time-critical situations. Algorithms used in a crisis scenario have shown that participants thought that they would provide safer care using the algorithms in real life situations. Teams managing simulated crises exhibited an overall failure rate of 1 in 4 when working from memory alone, compared with a 96% success rate when using a checklist. [8] In fact, initiating an algorithm in a crisis situation allows time to recruit members to assist, notifiy more experienced team members, or contact facilities with more resources to stabilize the patient. It is important to remember that one algorithm is not ideal of every environment. What might work in a major medical center in a developed country with immediate access to technology such as extra-corporeal membrane oxygenation (ECMO), trauma surgery, computed tomography (CT scans), transesophageal echocardiography, and even advanced critical care might not work in a small village in Africa. Hence, it is imperitive that such "Code Teams" realize the extent of their resources when developing and implementing such protocols and algorithms. In fact, it is not unreasonable to believe that those with limited resources, if better prepared, might have better outcomes that those with unlimited technology but no plan for use or availability in the time of an emergency. But, the key first step is to get people together to talk before a catstrophie occurs and so a plan can be outlined.

Maternal amniotic fluid embolism is and will, most likely, unfortunately for years to come, remain a major cause of peri-partrum mortality in an otherwise healthy mother. There are no clues to prevention and treatment success, even in ideal situations, is rare. However, the keys to success are awareness, immediate recognition of a problem (even if the exact cause is undefined), and rapid implementation of a disaster plan for dealing with such problems. Such a plan needs to be developed, rehersed, recognizing the patterns of failure and correcting these, and having these plans readily accessable before it is needed. Unfortunately, despite what might be an obvious way to potentially save a life, few centers undertake such steps. Nevertheless, excellent reviews and discussions, such as the one by Kulshrestha, need to raise the awareness of all of those who might someday be faced with such a horrible problem.

Hopefully those reading this will agree and act. If one additional life gets saved because of these efforts, then we all can claim a small victory in a battle that might never be won.

   References Top

1.Kulshrestha A, Mathur M. Amniotic fluid embolism: A diagnostic dilemma. Anesth Essays Res 2011;5:227-30.  Back to cited text no. 1
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2.Clark SL, Hankins GD, Dudley DA, Dildy GA, Porter TF. Amniotic Fluid Embolism: analysis of the national registry. Am J Obstet Gynecol 1995;172:1158-67.  Back to cited text no. 2
3.Ziewacz JE, Arriaga AF, Bader AM, Berry WR, Edmondson L, Wong JM, et al. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg 2011;213:212-7.  Back to cited text no. 3
4.Firstenberg M, Abel E, Blais D, Andritsos M. Delayed malignant hyperthermia after routine coronary artery bypass. Ann Thorac Surg 2010;89:947-8.  Back to cited text no. 4
5.Miranda AD, Donovan LA, Schuster LL, Gerber DR. Malignant hyperthermia. Am J Crit Care 1997;6:368-74.  Back to cited text no. 5
6.Firstenberg MS, Abel E, Blais D, Turner K, Halim-Armanios M, Dimitrova G, et al. Temporary extracorporeal circulatory support and pulmonary embolectomy for catastrophic amniotic fluid embolism. Heart Surg Forum 2011;14:E157-9.  Back to cited text no. 6
7.Holzman RS, Cooper JB, Gaba DM, Philip JH, Small SD, Feinstein D. Anesthesia crisis resource management: real-life simulation training in operating room crises. J Clin Anesth 1995;7:675-87.  Back to cited text no. 7
8.Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, et al. Communication failures in the operating room: An observational classification of recurrent types and effects. Qual Saf Health Care 2004;13:330-4.  Back to cited text no. 8


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