**5. Clinical presentation**

The classic presentation of AFE is often described as an acute onset of respiratory distress, hypoxia, hypotension (including cardiac arrest), seizures, and DIC either during labor, during delivery, or in the immediate postpartum period. If AFE occurs during labor, electronic fetal heart tracings frequently demonstrate acute changes characteristic of fetal hypoxia. There is often a rapid progression from the time of onset of the initial signs and symptoms to end organ damage and death. Severe consumptive coagulopathy is seen in only two obstetric conditions, AFE and massive placental abruption [4]. DIC is present in approximately 80% of patients with AFE and may develop at any time; however, half of affected patients develop coagulopathy within 4 hours of initial symptoms [2].

### **6. Management**

The management of women diagnosed with AFE is centered on supportive care. Unfortunately, even with prompt recognition and appropriate treatment, maternal morbidity and mortality remain high. The Society for Maternal-Fetal Medicine (SMFM) recommends a multidisciplinary team approach consisting of anesthesiology, critical care medicine, respiratory therapy, and maternal-fetal

medicine [6]. Treatment is initially focused on maternal cardiopulmonary stabilization with a goal to limit end organ damage [2]. Intravenous access with two large bore IVs should be obtained in anticipation of the need for aggressive fluid resuscitation. Hypotension is corrected with optimization of preload via rapid infusion of isotonic crystalloid and colloid solutions [4, 8, 9]. Transthoracic or transesophageal echocardiography is helpful to guide fluid therapy [4–6, 9]. Placement of an arterial line and pulmonary catheter if feasible is also useful. In addition to IVF resuscitation, transfusions of packed red blood cells are necessary to aid in hypotension as well as restoration of oxygen carrying capacity. The use of vasopressors and or inotropic support is often necessary. A central line should be placed for infusion of vasopressors as well as monitoring. Following stabilization of the patient, admission to an intensive care unit is recommended for close monitoring. Initial laboratory testing should include a CBC, arterial blood gas, electrolytes, and a coagulation panel.
