Amniotic Fluid Embolism (AFE) & Disseminated Intravascular Coagulation (DIC)

What is amniotic fluid embolism (AFE)?

• Is rare, unpredictable, and poorly understood

• Occurs when amniotic fluid, fetal cells, hair and other “debris” enter the maternal circulation causing cardiorespiratory collapse

• Is also referred to as anaphylactoid syndrome of pregnancy or sudden maternal collapse syndrome

2006 - 2020…

In New Zealand, AFE has contributed to 15 direct maternal deaths since 2006. (PMMRC 2024)

True or False?

True

2024…

PMMRC (2024) found from the amniotic fluid embolism deaths between 2006–2020, that attention to early recognition and prompt resuscitation may improve outcomes for AFE in New Zealand

True or False?

True

What are the risk factors for AFE?

• Multiparity

• Induction of Labour with oxytocin and/or ARM

• Physiologically intense contractions

• >30 years age (advanced maternal age)

• Caesarean Section

• Premature placental separation

• Cervical tear

• Intrauterine death

• Placental abruption

• Abdominal trauma

• AFE CANNOT BE PREDICTED OR PREVENTED

What are the general signs of AFE?

• Tingling

• Numbness

• Lightheaded

• Chest pains

• Vomiting

• Coughing

What are the respiratory signs of AFE?

• Dyspnoea

• Bronchospasm

• Pulmonary oedema

• Acute respiratory distress

What are the cardiovascular signs of AFE?

• Cyanosis

• Hypotension

• Transient hypertension

• Chest pain

• Cardiopulmonary arrest

What are the neurological signs of AFE?

• Seizures

• Headache

• Loss of consciousness

What are the haematological signs of AFE?

• Coagulopathy

• Disseminated intravascular coagulation

What are fetal signs of AFE?

• Fetal bradycardia

When should AFE be considered?

• A woman presents with acute behavioural changes such as sudden anxiety, agitation (eg, removing IV lines, oxygen masks, aggression) and dyspnoea in labour or immediately postpartum (within 30 minutes).

• Any of the following that occur during labour, caesarean birth, dilation and evacuation or within 30 minutes postpartum without other explanation should alert the practitioner to the possibility of AFE: acute hypotension, cardiac arrest, acute hypoxaemia or respiratory distress, severe haemorrhage.

What is disseminated intravascular coagulation (DIC)?

DIC is the massive activation of the coagulation system resulting in excessive bleeding. plasma (from bone marrow) and fibrin (from fibrinogen) to form a clot - not enough fibrin and plasma to stem bleeding. Therefore, scattered blood clots within blood vessels.

• Disseminated - widely spread/scattered

• Intravascular - inside the blood vessels

• Coagulation - clotting

• Always secondary to a primary condition

What are the risk factors for DIC?

• HELLP Syndrome

• Placental abruption

• Severe pre - eclampsia/eclampsia

• Amniotic Fluid Embolism (AFE)

• Intrauterine death with or without retained fetus or placenta

• Severe infection or sepsis

• Acute fatty liver disease

• Haemorrhagic shock

• Blood transfusion reactions

How does DIC present clinically?

• Bleeding – from oozing to frank haemorrhage.

• Purpura (looks like bruising) or Petechiae (small red or black dots on the skin)

• Respiratory distress

• Shock

• Central Nervous System Dysfunction

How is DIC diagnosed?

• Incidence approximately quoted 12.5 per 10 000 pregnancies/births

• There is no single test. Diagnosis is through the complete clinical picture

• Management is supportive but the underlying condition needs to be treated

What is the management of DIC?

• Tests may include: Prothrombin time (PT) / Activated Partial Prothrombin Time (APPT)

• Treatment includes blood products e.g. FFP or packed cells

• Close monitoring – HDU or ICU