1. Prof. Dr. Bahaa Ewiss Professor of Ansthesia & Intensive Care Unit Ain Shams university

2. Introduction Amniotic fluid embolism is pure unpreventable, unpredictable & incompletely understood syndrome with potentially lethal complication ( mortality rate up to 85%). So since it is rapid, progressive & with lethal complication, so the diagnosis is very difficult & by exclusion.

3. It was 1st described by Brazilian medical journal in 1926, then diagnosed in 1941 by finding fetal debris in maternal lungs & Finally, in 1966, fetal debris were found in maternal lungs, kidneys, spleen. The pulmonary artery contains layers of pink strips of squames, derived from the amniotic fluid.

4. Pathophysiology Amniotic fluid + fetal debris Utero placental membrane leakage Maternal circulation Leukotriens & PGs Genesis of the syndrome

5. Predisposing factors Age: > 35 years old Amniocentesis Artificial rupture of membrane Cervical ulceration C.S. Eclampsia Fetal macrosomia Fetal distress Medical induction of labor Instrumentation Multiparicicty Placenta previa Polyhydramnios Uterine rupture

6. Presentation In case of vaginal delivery or C.S. under spinal anesthesia: Acute unexplained hypotension Desaturation, hypoxia, bronchospasm, …. In case of C.S. under G.A. : Unexplained hypotension, hypoxia, coagulopathy

7. Cardiac presentation Biphasic Short & rapid Long & slow progressive Right ventricular failure Pulmonary hypertension Pumonary edema HypoxiaMortality 50 % Left ventricular failure Hypotension Pumonary congestion Right ventricular failure Presentation cont….

8. Morbidity of the condition DIC Heart failure Renal failure Neurological ( convulsion) Post arrest complications

9. Monitoring Basic: ECG NIBP SO2 Capnography Advanced: T.E.E. Invasive blood pressure Pulmonary artery catheter CVP

10. Investigations “ non specific “ CBC : there is a marked decrease in the platelet levels Fibrinogen: there is a decrease in the level FDPs: there is an significant increase in the level D.dimer : ????

11. Management Delivery may increase the survival of both the baby & his mother

12. Management cont….. According to CPR guideline of pregnant women Oxygenation E.T.T Mechanical ventialtion

13. Cardio vascular management If the patient arrests CPR must be started (according to the international guidelines) Adequate Oxygenation and early intubation should be considered Supportive therapy Vasopressor Nor adrenaline, dopamine, dobutamine Management cont…..

14. Other line of management Haemofiltration Plasma exchange ECMO Cell salvage Management of DIC Ventilator assisted devices

15. Q1 :What about the role of heparin single dose?? Q2: What about corticosteroid IV?? Frequently asked questions

16. Conclusion As it is rapid, progressive with lethal complications so we should be minded about amniotic fluid embolism & rapid interference. Good monitoring of the patient during labor, C.S. or in the recovery is mandatory. Amniotic fluid embolism should be considered in case of rapid progressive hypotension, desaturation & hypoxia. Rapid delivery of the baby. CPR as soon as possible.