**7. Outcomes**

*Clinical Management of Shock - The Science and Art of Physiological Restoration*

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

Acute hypoxia is frequently the first sign of AFE and has been reported to be present in >90% of patients according to the AFE National Registry [2]. Maternal oxygenation should be monitored by pulse oximetry. The degree of respiratory compromise will determine the approach for oxygen delivery. Regardless of the route of delivery, oxygen should be administered immediately and judiciously.

The early phase of AFE often consists of right ventricular failure which can be identified with the use of transthoracic or transesophageal echocardiography [9, 13]. Findings of echocardiography may include a dilated right ventricle and a collapsed left ventricle with leftward deviation of the interventricular septum [9, 13]. Cardiopulmonary resuscitation (CPR) should be initiated immediately with priority given to high-quality chest compressions before rescue breaths [6]. Standard basic life support (BLS) and advanced cardiac life support (ACLS) protocols should also be initiated [1, 6]. If the fetus is undelivered and has reached a gestational age of potential viability (≥23 weeks), immediate delivery is indicated [1, 2, 6]. Preparation for a perimortem cesarean section should occur simultaneously with the initiation of CPR [1, 10]. The undelivered patient should be placed in a left lateral tilt that displaces the uterus to avoid compression of the aorta and IVC [2, 6]. Patients that progress to cardiac arrest have a dismal prognosis

Intubation is often necessary but may not be required in all cases.

compared to their counterparts with AFE that do not develop cardiac arrest.

care for monitoring during the hemorrhagic phase of AFE [17].

Hemorrhage with DIC requires initiation of a massive transfusion protocol. Correcting the coagulopathy may require aggressive repletion of red blood cells and blood products, fresh frozen plasma, platelets, and/or cryoprecipitate. Consideration should be given to arterial catheterization if possible, which allows for accurate blood pressure monitoring as well as blood sampling [5]. The use of recombinant factor VIIa has been reported in the literature, though data on its use is limited and conflicting. Research suggests that the use of recombinant factor VIIa most likely should be reserved for cases where conventional resuscitative measures fail [1]. Increasing evidence suggests the use of thrombelastometry for early identification of patients with AFE but also to guide management, providing a point of

**136**

a coagulation panel.

**6.2 Cardiac arrest**

**6.3 Coagulopathy**

**6.1 Hypoxia**

Mortality associated with amniotic fluid embolism appears to have declined which is likely associated with early diagnosis as well as improvements in critical care [4, 5, 9]. Disease severity (i.e., the presence or absence of cardiac arrest) is closely related to prognosis. Mortality rates vary greatly depending upon criteria used for diagnosis of AFE but have been reported as high as 60–70% [1, 9, 14]. The use of population-based studies appears to provide the best available evidence of the mortality rate associated with AFE. Analysis of a collection of 9 populationbased studies published since 1999 which included more than 17 million births in 8 countries and 751 cases of amniotic fluid embolism revealed an overall mortality rate of 20.3% [7]. Morbidity, however, remains extremely high and can include serious neurologic impairment, renal failure, cardiac failure, arrhythmias, and myocardial infarction [5, 9].

Although limited data is available, neonatal survival rates are reported in the range of 70% [4, 5, 9]. Survival is dependent upon timing of delivery relative to onset of symptoms. Neonates delivered prior to onset of symptoms or soon after onset of symptoms have lower rates of morbidity and mortality.

There is no data to suggest that survivors of AFE have an increased risk of recurrence in a subsequent pregnancy. However, the risk of recurrence is unknown. There have been published case reports of successful pregnancies following an AFE.
