**33. Management**

92 Pulmonary Embolism

Adjusted odds ratio (95% confidence interval)

Cohort) (Kramer et al., 2006)

presentation 8.6 (4.3–17.4) – noncephalic presentation

3.5 (2.3–5.5)

Eclampsia 11.5 (2.8–46.9) 29.1 (7.1–119.3) Fetal distress 1.7 (1.2–2.5) 1.5 (1.0–2.2)

found the most common presenting signs and symptoms were hypotension and signs of non-reassuring fetal status (100%), pulmonary edema or respiratory symptoms (93%), cardiac arrest (87%), cyanosis (83%), and coagulopathy (83%). A majority develop seizures, encephalopathy and permanent neurological sequelae [85], due to cerebral ischemia and anoxia. The clinical course seems to have phases that are likely temporally related to

Table 8. Risk factors associated with an increased risk of AFE in two large registries.

Induced abortion (Grimes & Schulz, 1985; Guidotti et al.,

Transabdominal amniocentesis (Hasaart & Essed, 1983; Paterson et al.,

Blunt abdominal trauma (Judich et al., 1998; Olcott et al., 1973)

Manual removal of placenta (Manchanda & Sriemevan, 2005)

Surgical trauma (Pluymakers et al., 2007)

foeticide (Edwards & Davies, 2000; Shojai et al., 2003) Intrapartum amnioinfusion (Dorairajan & Soundararaghavan, 2005;

Removal of cervical sutures (Haines & Wilkes, 2003; Margan et al., 1984)

The diagnosis of AFE is "clinical" and one of exclusion. AFE should be suspected if a woman experiences one or more of the following during late pregnancy or within 48 hours of delivery: acute or sudden onset of hypotension and/or cardiac arrest, hypoxemia,

1977)

1981; Lawson et al., 1990)

Maher et al., 1994)

Forcep delivery 5.9 (3.4–10.3) 4.3 (1.9–6.6) Vacuum delivery 2.9 (1.6–5.3) 1.9 (1 –3.7) Abr ptio placen a --- 8.0 (4.0–15.9) Placenta previa ---- 30.4 (15.4–60.1)

Maternal age 35 years 1.9 (1. –2.7) 2.2 (1.5–2. )

Abenhaim et al ( American Cohort) (Abenhaim et al., 2008)

5.7 (3.7–8.7)

Characteristics Kramer et al ( Canadian

Cesarean delivery 12.5 (7.9 –19.9) - cephalic

Abruptio placenta or placenta previa

pathophysiologic changes (Clark, 1990).

Table 9. Procedures associated with AFE.

**32. Diagnosis** 

There is no specific treatment for AFE. The condition can be neither predicted nor prevented. The principles of management of AFE are mainly supportive, ie, to restore and maintain hemodynamic stability, to correct hypoxia and maintain adequate oxygenation, correction of coagulopathy with blood products as necessary and to deliver the fetus promptly at the earliest sign of maternal or fetal distress. Given sudden or hyperacute manner of presentation, prompt and aggressive response from the treating clinician is a must. As the diagnosis is not always clear from the onset of collapse, the role of diagnostic tests is to exclude conditions that can be treated specifically such as, Thrombotic PE which is more common compared to AFE. Hypoxia must be corrected promptly as significant proportions of survivors have residual neurological impairment due to cerebral anoxia (Moore & Baldisseri, 2005). Hypotension and shock should be aggressively treated with intravenous fluids, vasopressors and ionotropes as necessary. Since clinical manifestations are biphasic and complex, invasive hemodynamic monitoring is essential. Additional data from trans-thoracic or trans-esophageal echocardiography may be useful (James et al., 2004; Koegler et al., 1994; Stanten et al., 2003; van Haeften et al., 1989; Verroust et al., 2007). Administration of blood component is considered the first line treatment for coagulopathy associated with AFE. DIC is frequently associated with severe hemorrhage, so transfusion of packed red blood cells is a priority to maintain adequate tissue oxygenation. Uterine atony with DIC is a dangerous complication that might require immediate surgical intervention such as, hysterectomy.

As AFE occurred during labor in a predominant number of cases, immediate delivery of fetus by means of caesarian section is mandatory to prevent fetal hypoxic damage and to facilitate resuscitation (Davies & Harrison, 1992; Prasad & Howell, September 2001). Advanced cardiac life support (ACLS) protocol should be followed in case of cardiac arrest. The goal of drug therapy is to restore normal maternal hemodynamics in conjunction with the delivery of the fetus as soon as possible after the onset of asystole or malignant arrhythmia. During resuscitation, the uterus should be displaced to the left to avoid compression of the large vessels and improve venous return.
