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Anaphylactoid Syndrome/Amniotic Fluid Embolism

Anaphylactoid Syndrome/Amniotic Fluid Embolism is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Amniotic fluid embolism (AFE) is a syndrome associated with cardiorespiratory collapse during pregnancy or shortly after delivery.
  • Classically includes a triad of hypoxia, hypotension, and coagulopathy surrounding labor and delivery

Epidemiology

Incidence
  • Varies widely because of lack of diagnostic criteria
  • 1.2 to 7.7 per 100,000 deliveries in the United Kingdom, Canada, and United States

Prevalence
Difficult to assess, as this is a rare event

Etiology and Pathophysiology

  • Incompletely understood
  • Amniotic fluid enters maternal circulation through disruption of uterine vessels.
  • Causes an abnormal activation of proinflammatory mediators in susceptible patients, leading to cardiopulmonary arrest similar to anaphylaxis or systemic inflammatory response syndrome
  • However, fetal cells can also be found in pulmonary artery samples following normal delivery.
  • Hemodynamic response not caused by pulmonary vasculature obstruction. Instead, an initial period of pulmonary and systemic hypertension is followed by:
    • Pulmonary vasoconstriction, resulting in severe pulmonary HTN, VQ mismatch, and hypoxia
    • Acute cor pulmonale: right ventricular failure with ventricular dilation and deviation of the interventricular septum
    • Impaired left ventricular filling and myocardial ischemia causing left ventricular failure as the dominant hemodynamic alteration
  • Coagulopathy present in 83% of patients (1)[B], but incompletely understood
    • Amniotic fluid can induce platelet aggregation, lead to release of platelet factor III, activate factor X, and the complement cascade.
    • Tissue factor in amniotic fluid can induce thrombocytopenia in animal models, but it is unclear if any of these factors are present in large enough quantities to induce such a significant coagulopathy.
    • Disseminated intravascular coagulation (DIC) results with potential for massive hemorrhage.

Genetics
A genetic component has not been identified.

Risk Factors

Large population based studies have identified several risk factors:

  • Medical induction of labor
  • Maternal age ≥35 years old
  • Multiple gestation
  • Cesarean section prior to development of symptoms
  • Cervical laceration or uterine rupture
    • Causality of association with operative vaginal delivery or cesarean section is not always clear.
  • Placental abruption

General Prevention

No identified measure known to reduce the risk of AFE

Commonly Associated Conditions

  • Cesarean section: Strong association with AFE as emergent cesarean may be required for delivery given fetal distress; may be causative in some cases
  • DIC: consumptive coagulopathy that is often a component of the initial presentation of AFE

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Citation

Stephens, Mark B., et al., editors. "Anaphylactoid Syndrome/Amniotic Fluid Embolism." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688196/all/Anaphylactoid_Syndrome_Amniotic_Fluid_Embolism.
Anaphylactoid Syndrome/Amniotic Fluid Embolism. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688196/all/Anaphylactoid_Syndrome_Amniotic_Fluid_Embolism. Accessed April 24, 2019.
Anaphylactoid Syndrome/Amniotic Fluid Embolism. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688196/all/Anaphylactoid_Syndrome_Amniotic_Fluid_Embolism
Anaphylactoid Syndrome/Amniotic Fluid Embolism [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 24]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688196/all/Anaphylactoid_Syndrome_Amniotic_Fluid_Embolism.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Anaphylactoid Syndrome/Amniotic Fluid Embolism ID - 1688196 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688196/all/Anaphylactoid_Syndrome_Amniotic_Fluid_Embolism PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -