By Lynn Razzano, RN, MSN, ONCC

The Boston Herald recently reported that 32-year old Colleen Celia on January 15, 2014, shortly after giving birth to her fourth child.  The young mother died from amniotic fluid embolism, where amniotic fluid enters the mother’s bloodstream.

After reading about yet another who dies after childbirth, I felt the clinical need to write this article. I honestly had not heard of this before and consider myself an expert on VTE and the prevention of the occurrence. Having done some considerable work with the release of the new OB VTE Safety Recommendations with the OB team of experts, I think this condition is worthy of researching and gaining knowledge. There is really very little written on the subject and I wanted to find out the incidence as well as any alert criteria and prevention modalities that would save a future mother from succumbing from such an rare condition.

I hope I do justice to explaining what Amniotic Fluid Embolism is and increase awareness of this condition with OB clinicians across the country. Another goal I have is to empower and engage pregnant women by educating them on this diagnosis so they may speak up with their respective OB clinicians and be a safety vehicle for their own welfare.

An amniotic fluid embolism is a rare but serious condition that occurs when amniotic fluid — the fluid that surrounds a baby in the uterus during pregnancy — or fetal material, such as hair, enters the maternal bloodstream.  There is some information, in addition, that points to the possibility of meconium being released into the mother’s system.

An amniotic fluid embolism is most likely to occur during childbirth or immediately afterward, which is the immediate post partum period.  This identifies to possible alerts as to the time frame of intense observations or monitoring that should occur with the OB patient.

Not surprising, an amniotic fluid embolism is difficult to diagnose which leads to clinical challenges while critical time may be wasted. In terms of patient education, OB clinicians should be teaching them. If your doctor suspects you might have an amniotic fluid embolism, you’ll need immediate treatment to prevent potentially life-threatening complications.

What are the symptoms the patient would display or exhibit if a pending amniotic fluid embolism is suspected. The urgent nature and important fact is – amniotic fluid embolism develops suddenly and rapidly.

Signs and symptoms of an amniotic fluid embolism might include:

• Sudden shortness of breath
• Excess fluid in the lungs (pulmonary edema)
• Sudden low blood pressure
• Sudden circulatory failure (cardiovascular collapse)
• Life-threatening problems with blood clotting (disseminated intravascular coagulopathy)
• Altered mental status, such as anxiety
• Nausea or vomiting
• Chills
• Rapid heart rate or disturbances in the rhythm of the heart rate
• Fetal distress, such as a slow heart rate
• Seizures
• Coma

Preparation for monitoring these above symptoms could be developed into a safety checklist that clinicians could have on the patient board or reduce and carry a pocket size version easily accessible to them. All emergency equipment should be on hand and easily available so as to manage, abort symptoms,, before any undue harm to the OB patient.

What Causes Amniotic Fluid Embolism to present itself and what is the significance clinically? :

It is not a comforting fact that amniotic fluid embolism occurs as this isn’t well understood and due to its supposed rareness is not well researched.

An amniotic fluid embolism occurs when amniotic fluid or fetal material enters the maternal bloodstream, possibly by passing through tears in the fetal membranes. It’s likely that amniotic fluid contains components that cause an inflammatory reaction and activate clotting in the mother’s lungs and blood vessels. This should be a red alert to the clinician and activate a proactive treatment and prevention plan.

However, amniotic fluid embolisms are rare — and it’s likely that some amniotic fluid commonly enters the maternal bloodstream during delivery without causing problems. It’s not clear why in some cases this leads to an amniotic fluid embolism.

Further research on what causes amniotic fluid embolisms is needed.

Due to the rarity of Amniotic fluid embolisms, it is difficult to identify risk factors. It’s estimated that there are between 1 and 12 cases of amniotic fluid embolism for every 100,000 deliveries.

Frequency

United States

Incidence of AFE is estimated at 1 case per 8,000-30,000 pregnancies. The true incidence is unknown because of inaccurate diagnoses and inconsistent reporting of nonfatal cases.

International

Incidence is similar to that of the United States.

Mortality/Morbidity

• Maternal mortality approaches 80%.
• Mortality was 61% in the US national registry, which listed 46 cases.
• AFE is the cause of 5-10% of maternal mortality in the United States.
• Of patients with AFE, 50% die within the first hour of onset of symptoms. Of survivors of the initial cardiorespiratory phase, 50% develop a coagulopathy.

Research suggests that several factors might be linked to an increased risk of an amniotic fluid embolism, however, including:

• Advanced maternal age. If you’re 35 or older at the time of your child’s birth, you might be at increased risk of an amniotic fluid embolism.
• Placenta problems. If there are abnormalities in your placenta you might be at increased risk of an amniotic fluid embolism. Abnormalities might include the placenta partially or totally covering the cervix (placenta previa) or the placenta peeling away from the inner wall of the uterus before delivery (placental abruption). There may be disruption in the physical barriers between mother and baby.
• Preeclampsia. If you have preeclampsia including high blood pressure and excess protein in the urine after 20 weeks of pregnancy there might be an increased risk of developing an amniotic fluid embolism.
• Medically induced labor. Limited research suggests that certain labor induction methods are associated with an increased risk of amniotic fluid embolism. Research on this link, however, is conflicting with no firm clinical consensus.
• Operative delivery. Having a C-section, a forceps delivery or a vacuum extraction might increase your risk of an amniotic fluid embolism.  It’s not clear, however, whether operative deliveries are true risk factors for amniotic fluid embolisms or are used after the condition develops to ensure a rapid delivery.
• Genetics. Some experts believe that genetics might play a role in determining a woman’s risk of amniotic fluid embolism.

Complications

An amniotic fluid embolism can cause serious complications for mother and baby.

If you have an amniotic fluid embolism, you’re at increased risk of:

• Brain injury. Low blood oxygen can cause permanent, severe neurological damage or brain death.
• Lengthy hospital stay. Women who survive an amniotic fluid embolism often require treatment in the intensive care unit and depending on the extent of their complications may necessitate weeks or months in the hospital.
  • This increases cost expenditures in terms of transfer to a higher level of acuity and a longer length of stay.

It’s estimated that amniotic fluid embolisms cause up to 10 percent of maternal deaths in developed countries. Death can occur within an hour of the start of symptoms.

An amniotic embolism, places the unborn baby at increased risk of a brain injury due to a lack of oxygen, which may prove fatal.

Clinical considerations for managing amniotic fluid embolism suspicion might include:

• Standards: Use of the new OB VTE Safety Recommendations would provide the assessment process and earlier recognition to manage the patient and provide the required intervention. The most significant course of clinical action that is critical is for “early on” detection of an possible amniotic fluid embolism is consistent and complete baseline assessment of OB VTE risk factors on all patients. In particular the VTE risk factors that have been identified above and common to the OB patient.
• Clinician Education: Due to the rare nature of the condition, there needs to be vigilant education with clinicians and patients. Accountability and responsibility is still a clinical expectation even when a condition is termed rare- this does not prevent the jurisprudence that is still a clinical expectation for maximum OB patient safety.
• Recommendations: Develop patient safety recommendations using the symptoms detailed above to serve as a clinical guide in assessing patients for suspicion or alert to potential amniotic fluid embolism. See the new OB VTE Safety Recommendations as an example of recommendations.
• Monitoring: Ensure increased patient monitoring is provided to a patient that may have one or more of the high risk factors for developing amniotic fluid embolism.
• Training: Ensure there is adequate cross trained skills and competencies from both OB nurses to Critical care nurses who need the specific nuances and clinical algorithms to care for the critical OB patient.
• Patient Awareness: Consistently educate and engage the pregnant woman in the condition and provide opportunities to have the patient be their own safety advocate. This will go far in preventing mortality or complications.

For additional knowledge and clinical guidance on this rare condition, amniotic fluid embolism, please read the paper, by Katherine J. Perozzi, RN, MSN and Nadine C. Englert, RN, MSN., “Amniotic Fluid Embolism An Obstetric Emergency” in Critical Care Nurse,

For a discussion about the heightened risk of blood clots in pregnant women, please listen to this clinical education podcast with Colleen Lee MS, RN (Maternal/Perinatal Patient Safety Officer, Montefiore Medical Center) on the PPAHS YouTube Channel.

 

• Blood Clots
• Practices & Tips