1. Amniotic Fluid Embolism Women ’ s Hospital School of Medicine Zhejiang University Wang Zhengping

2. Definition Amniotic Fluid Embolism is a complex disorder during labor characterized by amniotic fluid entering into the maternal circulation which causes acute pulmonary embolism, shock, DIC, acute renal failure or abrupt death.

3. overview An devastating complication during labor Mortality: up to 60%~80% May occur in the first and second trimester abortions Recently, it is also termed “anaphylactoid syndrome of pregnancy”

4. Why amniotic fluid can enter into the maternal circulation?

5. Etiology :Three factors There is a breach in vein or blood sinus at the trauma site of cervix and the body of uterine Higher pressure of amniotic cavity Disruption of fetal membrane amniotic fluid enters into the maternal circulation through the breached vein and blood sinus

6. What would happen after the amniotic fluid enter into the maternal circulation

7. pathophysiology Pulmonary artery hypertension Allergic shock DIC Acute renal failure(ARF) Amniotic fluid → inferior vena → atrio dextro → right ventricle → pulmonary artery

8. Clinical presentation Acute amniotic fluid embolism: occur acutely Pulmonary artery hypertension/ Shock Hemorrhage due to DIC Acute renal failure Typical: three phages Atypical: Bulk colporrhagia shock (occur mainly after delivery)

9. Diagnosis According to the typical clinic manifestation, we can make the preliminary diagnosis and save the patients immediately While saving the patients do the necessary auxiliary examination, including: a. Collecting blood from arteria pulmonalis and inferior vena, and finding components of amniotic fluid b. The basis of laboratory examination for DIC c. ECG d. X-ray e. Autopsy

10. Basis of laboratory examination for DIC PLT ＜ 100 ╳ 10 9 /L or it was gradually decrease fibrinogen <1.5g/L PT >15 s plasm protamine paracoagulation test (+) Obtrite RBC in blood smear

11. Management Improve hypoxia Anti-anaphylacic shock Prevent DIC and acute renal failure(ARF) Prevent infection

12. Treatment Anticonvulsive drug Oxygenation Aminophylline Narceine Atropine phentolamine 1 、 Disengage pulmonary hypertension, improve hypoxia:

13. 2 、 Anti-anaphylacic Glucocorticosteroid Treatment Hydrocortisone Dexamethasone

14. 3 、 Anti-shock Transfusion Angiotensin Treat heart failure Cure acidemia Treatment

15. 4 、 Prevent and cure DIC Use decoagulant and heparin as early as possible Treatment

16. 5 、 Prevent or cure ARF and infection Prevent ARF: aware of urinary volume Furosemide Prevent infection using antibiotic drug with low toxicity Treatment

17. antepartum intrapartum post partum amnionic fluid embolism drug treatment Forcep delivery postpartum hemorrhage uterectomy Without postpartum hemorrhage Go on the expectant treatment cesarean section delivery Without hemorrage Go on the expectant treatment Treatment 6 、 Obstetric management Cervical apertura is not open or not fully open Cervical apertura is fully dilatting

18. Artificial rupture of membrane without stripping of membrane Don’t conduct artificial rupture of membrane when uterine is constricting Master the indication of oxytocin application Protect the vessel during the caesarean section Avoid precipitate labor, birth trauma, rupture of uterus, cervical laceration Aware of the predisposing factor Prevention