What is the treatment for amniotic fluid embolism?

Treatment of Amniotic Fluid Embolism

The treatment of amniotic fluid embolism (AFE) requires immediate high-quality cardiopulmonary resuscitation with standard basic and advanced cardiac life support protocols, followed by aggressive hemodynamic support and management of coagulopathy through massive transfusion protocols. 1

Initial Resuscitation

• Initiate immediate high-quality cardiopulmonary resuscitation:

  • Perform rapid chest compressions (100/minute)
  • Achieve compression depth of at least 2 inches
  • Ensure adequate chest recoil between compressions
  • Minimize interruptions of chest compressions
  • Switch providers every 2 minutes to avoid fatigue 2

• For undelivered patients:

  • Tilt patient to left lateral position or have assistant displace uterus laterally to prevent aortocaval compression 2
  • Consider immediate delivery in pregnancies ≥23 weeks if cardiac arrest occurs 1

• Provide respiratory support:

  • Administer oxygen to maintain saturation >95%
  • Consider early intubation for respiratory distress
  • After successful resuscitation, wean inspired oxygen fraction to maintain pulse oximetry 94-98% to avoid hyperoxia-induced reperfusion injury 2

Hemodynamic Management

AFE typically presents in two phases requiring different management approaches:

Phase 1: Right Ventricular Failure

• Perform transthoracic or transesophageal echocardiography as soon as possible to identify right ventricular failure 3

• Manage right ventricular failure with:

  • Inotropes to improve right ventricular output:
    • Dobutamine (2.5-5.0 μg/kg/min)
    • Milrinone (0.25-0.75 μg/kg/min) 2
  • Pulmonary vasodilators to decrease pulmonary vascular resistance:
    • Sildenafil (20 mg TID)
    • Inhaled nitric oxide (5-40 ppm)
    • Inhaled prostacyclin (10-50 ng/kg/min)
    • Intravenous prostacyclin (1-2 ng/kg/min) 2
  • Vasopressors for hypotension:
    • Norepinephrine (0.05-3.3 μg/kg/min)
    • Vasopressin 2

• Avoid excessive fluid administration as it may worsen right ventricular failure 2, 1

Phase 2: Left Ventricular Failure

• Optimize cardiac preload
• Consider noninvasive ventilation or intubation if not already performed
• Target mean arterial pressure of 65 mmHg using fluids, vasopressors, and inotropes as needed 2

Coagulopathy Management

• Activate massive transfusion protocol immediately 1
• Administer blood products in 1:1:1 ratio of packed red cells, fresh frozen plasma, and platelets 3
• Maintain platelet count above 50,000/mm³ 1
• Administer cryoprecipitate to maintain fibrinogen >150-200 mg/dL 3
• When available, use bedside thromboelastography to guide transfusion therapy 2, 1
• Consider antifibrinolytics (tranexamic acid or epsilon aminocaproic acid) if hyperfibrinolysis is identified 2, 1
• Recombinant Factor VIIa should only be considered as a last resort when hemorrhage cannot be controlled with standard measures 2, 1, 4

Management of Uterine Atony

• Aggressively treat uterine atony with uterotonics:
  • Oxytocin
  • Ergot derivatives
  • Prostaglandins 2, 1
• For refractory cases, consider:
  • Uterine tamponade with packing or intrauterine balloons
  • Bilateral uterine artery ligation
  • B-Lynch suture
  • Hysterectomy in extreme cases 2, 1
• Thoroughly inspect cervix and vagina for lacerations in vaginal deliveries 2
• For diffuse bleeding during cesarean delivery not amenable to surgical control, consider packing the pelvis and transfer to ICU for delayed closure 2

Post-Resuscitation Care

• Maintain mean arterial pressure of 65 mmHg 2
• Aggressively treat fever to prevent worsening of ischemia-reperfusion brain injury 2
• Maintain serum glucose between 140-180 mg/dL with insulin infusions if needed 2
• Consider targeted temperature management (32-36°C) in patients without significant bleeding or coagulopathy 2
  • Target 36°C rather than lower temperatures to minimize hemorrhage risk 2

Advanced Therapies

• Consider venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cases with:
  • Prolonged cardiopulmonary resuscitation
  • Severe ventricular dysfunction refractory to medical management 3, 5, 6
• Note that anticoagulation during ECMO may worsen bleeding in coagulopathic patients 2

Key Pitfalls to Avoid

• Do not delay blood product administration while awaiting laboratory results 1
• Avoid making the diagnosis of AFE based solely on hemorrhage from persistent atony with secondary coagulopathy 2, 1
• Do not administer excessive fluids in the setting of right ventricular failure 2, 1
• Avoid prolonged administration of 100% oxygen after successful resuscitation 2
• Do not routinely use recombinant Factor VIIa as it may increase mortality 4