Amniotic Embolism Research Articles

Novel Approach to Identify Severe Maternal Morbidity Clusters: A Latent Class Analysis.

Whether clusters exist within severe maternal morbidity (SMM), a set of life-threatening heterogeneous conditions, is not known. Our primary objective was to identify SMM clusters using a data-driven clustering technique, their associated predictors and outcomes. From 2008 to 2017, we used a delivery database supplemented by state data and medical record abstraction from a single institution in Pennsylvania. To identify SMM clusters, we applied latent class modeling that included 23 conditions defined by 21 Centers for Disease Control SMM indicators, intensive care unit (ICU) admission, or prolonged postpartum length of stay. Logistic regression models estimated risk for SMM clusters and associations between clusters and maternal and neonatal outcomes. Among 97,492 deliveries, 2.7% (N = 2,666) experienced SMM by any of the 23 conditions. Four clusters were identified as archetypes of SMM. Deliveries labeled as Hemorrhage (37.7%, N = 1,004) were characterized by blood transfusions and sickle cell anemia; Critical Care (28.1%, N = 748) by ICU admission and amniotic embolism; Vascular (24.5%, N = 654) by cerebrovascular conditions; and Shock (9.8%, N = 260) by ventilatory support and shock. Hypertensive disorders of pregnancy, depression, and Medicaid insurance were associated with Shock cluster. People in all clusters had a high risk of maternal death within 1 year (odds ratio: 12.0, 95% confidence interval: 6.2-23). Infants born to those in the shock cluster had the highest odds of neonatal death, low Apgar scores, and neonatal ICU admission. We identified four novel SMM clusters that may help understand the collection of conditions defining SMM, underlying pathways and the importance of comorbidities such as depression and social determinants of health markers that amplify the well-established risk factors for SMM such as hypertensive disorders of pregnancy. · A total of 2.7% of deliveries experienced SMM events.. · There are four distinct SMM clusters: Hemorrhage, Critical Care, Vascular, and Shock.. · Not all SMM clusters bear the same risk for adverse perinatal outcomes..

TEMPORARY REMOVAL: Mortalité maternelle en France, 2016–2018, fréquence, causes et profil des femmes

Objective: To describe, for the 2016-2018 period, the frequency, causes and risk factors of maternal deaths in France.Method: Data from the National Confidential Enquiry into Maternal Deaths for 2016-2018Results: For 2016-2018, 272 maternal deaths occurred in France, i.e a maternal mortality ratio of 11,8 per 100,000 live births (95% CI 10,4-13,3), and 8.5 (IC 95 % 7,4-9,8) for maternal mortality up to 42 days. Compared to women aged 20-24, the risk of maternal death is multiplied by 2.6 for women aged 35-39, by 5 for women aged 40 and over. Obese women are twice as frequent among maternal deaths (26%) than in the general population of parturients (11%). There are territorial disparities -the maternal mortality ratio in the French overseas departments is 2 times higher than in metropolitan France (significant difference but smaller than in 2013-2015)-, and social disparities -the mortality of migrant women remains higher than that of women born in France, particularly for women born in sub-Saharan Africa whose risk is 3 times higher than that native women. One in three women who died (34%) had socio-economic vulnerability versus 22% in the overall population of parturients.Among causes of maternal deaths, the predominant role of psychiatric conditions (mostly suicides) is confirmed for the period 2016-2018, leading cause of maternal mortality considered up to 1 year (17%), MMR of 1.9 /100,000 NV. i.e. approximately one death from psychiatric causes every 3 weeks. Cardiovascular diseases are the second leading cause of maternal mortality up to one year (14%) and the leading cause up to 42 days (16%), with 1.3 deaths per 100,000 NV. Amniotic embolism ranks as the third cause (8%) (2nd cause, 11%, for MM limited to 42 days), i.e. MMR of 0.9 per 100,000 NV. After a regular decline over the last decade, maternal mortality from obstetric hemorrhage is at a stable level compared to the previous triennium 2013-2015, MMR of 0.9/100,000 NV, i.e 5th cause of MM up to one year (7%) and 4th cause of MM up to 42 days.Conclusion: The overall national maternal mortality ratio does not show a downward trend, even with constant surveillance method. Territorial inequalities persist but change in their magnitude and in the regions concerned. The profile of the causes of maternal mortality up to one year of the pregnancy end shows the leading role of suicides and cardiovascular diseases, which illustrates that the health of pregnant women or those who have recently given birth is not limited to the obstetric domain, and highlights the importance of multidisciplinarity in the management and organization of care for women in this period

Mortalité maternelle par embolie amniotique en France 2016–2018

Amniotic embolism remains the 3rd leading cause of maternal death in France, with 21 maternal deaths over the 2016–2018 triennium. The women who died were more likely to be obese (25%), to benefit from induction of labor (71%) and be cared in a maternity hospital <1500 deliveries/year (45%), compared with the reference population (ENP 2016). The symptom occurred mainly during labor (95%) and the course was rapid, with a symptom-to-fatality interval of 4hours 45minutes (min: 25minutes – max: 8 days). Preventability was proposed for 35% of the deaths assessed, with areas for improvement identified in terms of technical skills (haemostasis procedures, management of polytransfusion), non-technical skills (communication) and health care organization (human resources, vital emergency plan, wide access to PSL). An autopsy was performed in 38% of deaths.

The Right Time for Certification

The Right Time for Certification

Massive platelet-rich thrombus formation in small pulmonary vessels in amniotic fluid embolism: an autopsy study.

To identify pulmonary/uterine thrombus formation in amniotic fluid embolism (AFE). Retrospective, observational. Nationwide. Eleven autopsy cases of AFE and control cases. We assessed pulmonary and uterine thrombus formation and thrombus area in AFE and pulmonary thromboembolism (PTE) as a control. The area of platelet glycoprotein IIb/IIIa, fibrin, neutrophil elastase, citrullinated histone H3 (a neutrophil extracellular trap marker) and mast cell chymase immunopositivity was measured in 90 pulmonary emboli, 15 uterine thrombi and 14 PTE. Pathological evidence of thrombus formation and its components in AFE. Amniotic fluid embolism lung showed massive thrombus formation, with or without amniotic emboli in small pulmonary arteries and capillaries. The median pulmonary thrombus size in AFE (median, 0.012 mm2 ; P < 0.0001) was significantly smaller than that of uterine thrombus in AFE (0.61 mm2 ) or PTE (29 mm2 ). The median area of glycoprotein IIb/IIIa immunopositivity in pulmonary thrombi in AFE (39%; P < 0.01) was significantly larger than that of uterine thrombi in AFE (23%) and PTE (15%). The median area of fibrin (0%; P < 0.001) and citrullinated histone H3 (0%; P < 0.01) immunopositivity in pulmonary thrombi in AFE was significantly smaller than in uterine thrombi (fibrin: 26%; citrullinated histone H3: 1.1%) and PTE (fibrin: 42%; citrullinated histone H3: 0.4%). No mast cells were identified in pulmonary thrombi. Amniotic fluid may induce distinct thrombus formation in the uterus and lung. Pulmonary and uterine thrombi formation may contribute to cardiorespiratory collapse and/or consumptive coagulopathy in AFE.

AMNIOTIC FLUID EMBOLISM: ABOUT A CASE

Amniotic fluid embolism is a rare and unpredictable complication of childbirth.with about fifteen cases per year in France, but very serious with maternal mortality that can vary from 20 to 60% , associating severe cardiovascular collapse, acute respiratory distress syndrome and hemorrhage with disseminated intravascular coagulation (DIC). As soon as the diagnosis is mentioned, management must be multidisciplinary and intensive. Amniotic embolism is responsible for such significant neonatal mortality. Over the past ten years, the maternal-fetal prognosis seems to have improved thanks to progress in standardized multidisciplinary care at the delivery site. We report a case of amniotic fluid embolism which occurred during fetal extraction during caesarean section.

Fatal amniotic fluid embolism: incidence, risk factors and influence on perinatal outcome.

This study aimed to estimate the incidence of fatal amniotic fluid embolism, describe its risk factors, and analyze perinatal outcomes. Maternity cases and newborn records of amniotic fluid embolism were collected from the Zhejiang Maternal Surveillance System from October 2006 to October 2019. This study strictly limited the diagnostic criteria for AFE and excluded suspicious cases in order to minimize false-positive AFE cases. The risk factors of fatal amniotic fluid embolism and the relationship between perinatal prognosis and AFE were investigated using logistic regression analysis, estimating the adjusted odds ratios (aORs) and 95% confidence intervals (CIs). 149 cases of amniotic fluid embolism were registered, of which 80 cases were fatal. The estimated fatal AFE incidence was 0.99 per 100,000. The occurrence of fatal AFE was significantly correlated with spontaneous vaginal delivery (aOR 12.3, 95% CI 3.3-39.2) and cardiac arrest (aOR 64.8, 95% CI 14.6-287.8). The average diagnosis time of fatal AFE is 85.51min, and the peak period of female death is 1-12h after the onset of the disease, accounting for 60% (48/80) of cases. Fatal amniotic embolism is a cause of intrauterine fetal death and fetal death during delivery (aOR 11.957, 95% CI 1.457-96.919; aOR 13.152, 95% CI 1.636-105.723). Of the 149 confirmed AFE cases, 11 cases of stillbirth occurred, 12 cases were stillborn, and 7 cases of neonatal death were reported. The perinatal mortality rate was 202 per 1000. Early detection, diagnosis, and treatment of amniotic fluid embolism are essential to avoiding fatal AFE. Clinicians should fully evaluate the pros and cons of choosing the delivery method for pregnant women. When cardiac arrest occurs in women with amniotic fluid embolism, obstetricians should be particularly careful and provide timely and effective treatment to minimize the fatality rate. The outcome of AFE is not only related to maternal survival but also plays a decisive role in the prognosis of the infant over the perinatal period.

Extracorporeal Membrane Oxygenation Utility in Postpartum Patients.

Although extracorporeal membrane oxygenation (ECMO) has been used in many different populations, its use in pregnant or postpartum patients has not been widely studied. This article reviews the ECMO experience in this population at a large urban hospital. Electronic medical records for all pregnant or postpartum patients who required ECMO between 2012 and 2019 were retrospectively reviewed. Data on clinical characteristics, outcomes, and complications were gathered. Comparisons between survivors and nonsurvivors were completed. Ten postpartum patients were identified. The patients presented as follows: four with cardiac arrest, one with a massive pulmonary embolism, three with acute respiratory distress syndrome (ARDS), one with combined ARDS and cardiogenic shock, and one with suspected amniotic embolism. Survival to decannulation was 70%, and survival to discharge was 60%. When comparing survivors vs. nonsurvivors, ECMO survivors tended to have shorter support times vs. nonsurvivors. Otherwise, no differences were noted in age, mechanical ventilation time, or length of stay. Disseminated intravascular coagulation was a common phenomenon in this patient cohort. After initiation of ECMO, elevated serum lactate levels, lower systolic blood pressure, and acute renal failure were predictors of mortality. In a single institution at a large metroplex, we present data regarding the use of ECMO in postpartum patients. ECMO can be successfully used in selected postpartum patients with severe cardiac or respiratory dysfunction. Multidisciplinary collaboration on a regular basis will streamline the ECMO referral in a timely manner. Furthermore, larger studies are indicated to understand the utility of ECMO in larger cohorts.

Extracorporeal Membrane Oxygenation Utility in Postpartum Patients

Although extracorporeal membrane oxygenation (ECMO) has been used in many different populations, its use in pregnant or postpartum patients has not been widely studied. This article reviews the ECMO experience in this population at a large urban hospital. Electronic medical records for all pregnant or postpartum patients who required ECMO between 2012 and 2019 were retrospectively reviewed. Data on clinical characteristics, outcomes, and complications were gathered. Comparisons between survivors and nonsurvivors were completed. Ten postpartum patients were identified. The patients presented as follows: four with cardiac arrest, one with a massive pulmonary embolism, three with acute respiratory distress syndrome (ARDS), one with combined ARDS and cardiogenic shock, and one with suspected amniotic embolism. Survival to decannulation was 70%, and survival to discharge was 60%. When comparing survivors vs. nonsurvivors, ECMO survivors tended to have shorter support times vs. nonsurvivors. Otherwise, no differences were noted in age, mechanical ventilation time, or length of stay. Disseminated intravascular coagulation was a common phenomenon in this patient cohort. After initiation of ECMO, elevated serum lactate levels, lower systolic blood pressure, and acute renal failure were predictors of mortality. In a single institution at a large metroplex, we present data regarding the use of ECMO in postpartum patients. ECMO can be successfully used in selected postpartum patients with severe cardiac or respiratory dysfunction. Multidisciplinary collaboration on a regular basis will streamline the ECMO referral in a timely manner. Furthermore, larger studies are indicated to understand the utility of ECMO in larger cohorts.

Editorial from Editor-in-Chief: Amniotic Pulmonary Embolism and the Respiratory System: Management Trends and Future Options

Editorial from Editor-in-Chief: Amniotic Pulmonary Embolism and the Respiratory System: Management Trends and Future Options

Blood Cell Salvage During Cesarean Delivery

Abstract Objective To review the use of blood cell salvage performed during cesarean delivery. Methods A retrospective review of the case notes of 107 patients who underwent blood cell salvage during cesarean delivery. A total of 102 women at high risk of hemorrhage were prepared preoperatively for cell salvage. A second group of 5 patients had cell salvage initiated intraoperatively owing to unexpected severe hemorrhage. Results Of the 107 patients, 36 (33.6%) were re-infused with salvaged blood. There were no reported incidents of amniotic embolization or hemolytic disease. Of the 31 patients for whom cell salvage was prepared preoperatively, only 6 patients required transfusion of banked blood. In elective procedures, patients were re-infused with salvaged blood averaging 28% of the volume of blood lost, without complications. Conclusion Cell salvage was acceptable, beneficial, and without adverse events in both high-risk elective cesareans and emergency cesareans for unexpected hemorrhaging. The skills refined during use of cell salvage in elective cesareans were crucial for successful implementation during emergency situations.

Medical Responsibility in the Operating Room: The Example of an Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) continues to be one of the most feared complications of pregnancy. A healthy 32-year-old woman died during delivery after a normal 39-week third pregnancy. The family filed a complaint with a criminal court as the causes of death appeared unclear. No risk factor associated with AFE was identified. Clinical presentation was typical, including sudden onset of cardiovascular and respiratory symptoms. Autopsy confirmed the histological diagnosis of amniotic embolism and excluded an iatrogenic cause of death or anesthetic malpractice. This article highlights the value of both antemortem records and histological features in establishing the diagnosis of AFE and demonstrates the fundamental importance of autopsy in an unexpected death related directly or indirectly to a medical procedure.

87: Can the presence of amniotic emboli in the myometrial vasculature be interpreted as a sign of amniotic fluid embolism?

87: Can the presence of amniotic emboli in the myometrial vasculature be interpreted as a sign of amniotic fluid embolism?

Blood cell salvage during cesarean delivery

Objective To review the use of blood cell salvage performed during cesarean delivery. Methods A retrospective review of the case notes of 107 patients who underwent blood cell salvage during cesarean delivery. A total of 102 women at high risk of hemorrhage were prepared preoperatively for cell salvage. A second group of 5 patients had cell salvage initiated intraoperatively owing to unexpected severe hemorrhage. Results Of the 107 patients, 36 (33.6%) were re-infused with salvaged blood. There were no reported incidents of amniotic embolization or hemolytic disease. Of the 31 patients for whom cell salvage was prepared preoperatively, only 6 patients required transfusion of banked blood. In elective procedures, patients were re-infused with salvaged blood averaging 28% of the volume of blood lost, without complications. Conclusion Cell salvage was acceptable, beneficial, and without adverse events in both high-risk elective cesareans and emergency cesareans for unexpected hemorrhaging. The skills refined during use of cell salvage in elective cesareans were crucial for successful implementation during emergency situations.

Maternal deaths: A 22-year forensic retrospective study (1987–2009)

The death of a pregnant woman is dramatic for her family as for the medical staff and the entire society. How can this mortality be reduced? In order to determine the epidemiology and causes of maternal mortality in a French population, we carried out a retrospective study of all obstetrical deaths autopsied in a French forensic pathology department between 1987 and 2009. We studied all the cases in which a woman was pregnant or had delivered in the 42 days prior to death, whichever the manner of death was. During this 22-year period, 36 obstetrical deaths were autopsied out of 7,705 autopsies in total (0.47% of cases). The average age at death was 29.5 (17 to 39 years old). The majority of deaths (69.4%) was of natural origin ( n = 25), 16.7% were homicides ( n = 6), 8.3% were suicides ( n = 3), and 5.6% were accidental ( n = 2). Most of deaths (30.6%) occurred during delivery ( n = 11), with an equivalent repartition during the three quarters (19.4% per period, i.e. n = 7) and 11.1% during post-partum time ( n = 4). Causes of natural deaths were amniotic emboli ( n = 5) followed by cerebral or aortic arterial rupture ( n = 4), uterine rupture ( n = 3), delivery hemorrhage ( n = 3), infection ( n = 3), cardiomyopathy ( n = 3), extra-uterine pregnancy accident ( n = 2), pulmonary embolism ( n = 2) and anesthesia complication ( n = 1). These results gave us the opportunity to suggest original prevention and screening acts that may be of interest for the public health policy and forensic physician practices. First, we insist on the search for preliminary pathology and risk factors: tobacco (nicotinic intoxication), alcoholism, drug-addiction and psychological weakness. Second, a systematic electrocardiogram (ECG) at the beginning of pregnancy would help in the detection of an existing cardiomyopathy, while keeping in mind that it is not sufficient to eliminate any cardiac risk. Lastly, any symptom usually considered as ordinary may correspond to a serious complication of pregnancy. La mort d’une femme enceinte est dramatique, tant pour sa famille que pour le personnel médical et la société toute entière. Comment cette mortalité peut-elle être réduite ? Pour déterminer l’épidémiologie et les causes de mortalité maternelle dans une population française, nous avons effectué une étude rétrospective de toutes les morts obstétriques autopsiées dans un département de médecine légale français entre 1987 et 2009. Nous avons étudié tous les cas dans lesquels une femme était enceinte ou avait accouché dans les 42 jours avant la mort, quelle que soit la cause du décès maternel. Pendant cette période de 22 ans, 36 morts obstétriques ont été constatées sur la totalité des 7705 autopsies effectuées (0,47 % de cas). L’âge moyen lors du décès était de 29,5 ans (17 à 39 ans). La majorité des décès (69,4 %) était d’origine naturelle ( n = 25), 16,7 % étaient des homicides ( n = 6), 8,3 % étaient des suicides ( n = 3) et 5,6 % étaient accidentels ( n = 2). La plupart des décès (30,6 %) sont arrivés pendant l’accouchement ( n = 11), avec une répartition équivalente pendant les trois trimestres de grossesse (19,4 % par période, c’est-à-dire ( n = 7) et 11,1 % pendant le délai de postpartum ( n = 4). Les causes de morts naturelles étaient des embolies amniotiques ( n = 5) suivies par la rupture artérielle cérébrale ou aortique ( n = 4), une rupture utérine ( n = 3), une hémorragie d’accouchement ( n = 3), une infection ( n = 3), une cardiomyopathie ( n = 3), un accident de grossesse extra-utérin ( n = 2), une embolie pulmonaire ( n = 2) et une complication d’anesthésie ( n = 1).

Factors Associated with Maternal Mortality in Nyakabande Subcounty, Kisoro District in Uganda

Pregnancy and childbirth should be viewed as a happy and joyous event but the majority of women who become pregnant experience pain, fear, suffering and even death. About one million women are estimated to get pregnant every year. Out of these, at least 1600 women die every day from pregnancy-related complications and childbirth. Of all maternal deaths that occur globally, 99% are in developing countries compared to 1% that occurs in developed countries (WHO, 1996; UNICEF 1996; CARE, 1998). Uganda is a developing country with a very high maternal mortality rate. The revised UNICEF/WHO 1990 global, regional and individual country estimations maternal mortality rates put the Ugandan rate at 1200 maternal deaths per 100,000 live births. The study was conducted in Nyakabande Sub County in Kisoro district in South Western Uganda to establish the main factors associated with maternal mortality. The study also sought to identify the socio-economic, cultural, physical and health care factors associated with maternal mortality. Data was obtained from the office of the District Director of Health Services (DDHS) from 1998—2002, health units, health workers and pregnant women by means of pre-tested questionnaires and focus group discussion guides. The study was descriptive and cross-sectional in nature. The population under study included women of reproductive age, pregnant women, nurses and midwives. The main causes of maternal deaths (N = 29) were malaria in pregnancy (34.9%), post-partum haemorrhage (17.4%) purpueral sepsis (17.4%), cerebral malaria (4.3%). Amniotic embolism (4.3%) pulmonary embolism (4.3%) pre-eclampsia (4.3%) HIV in pregnancy (4.3%). There were frequent deaths among women with the third to sixth pregnancy: 3—4 pregnancies (30.4%), 5—6 pregnancies (26.1%). Most of the maternal deaths occurred in the age group of 20—29 years (52.2%). The findings indicate a high maternal mortality in Nyakabande Sub-county that is related to several personal, socio-economic and health care factors.

Embolie de liquide amniotique : évolution favorable d'une CIVD isolée et diagnostic biologique précoce

Amniotic embolism is a sudden, unexpected and devastating complication of pregnancy. The diagnosis is usually made on the basis of clinical presentation after excluding differential diagnosis or at autopsy in the event of death of the parturient. We need to develop simple, non-invasive, sensitive tests for a reliable and early diagnosis. We report the case of a 34-year-old woman, who presented soon after delivery, an isolated disseminated intravascular coagulation with severe haemorrhage, an haemostatic hysterectomy was required. A 3370 g child was delivered by caesarean section. The patient survived without sequelae. The diagnosis of amniotic embolism was established by the presence of amniotic cells in the maternal central venous blood as well as in the bronchoalveolar fluid.

Maternal mortality during hospital admission for delivery: a retrospective analysis using a state-maintained database.

This study reports the overall age- and race-specific delivery mortality ratios from January 1984 to December 1997 and medical and demographic risk factors associated with maternal death during hospital admission for delivery. We performed a retrospective case control study using patient records from a state-maintained anonymous database of all nonfederal Maryland hospitals that performed deliveries from 1984 to 1997. Variables studied included patient demographics and International Classification of Diseases, 9th Revision, Clinical Modification, diagnosis, and procedure codes. Mortality was the outcome variable. Of the 822,591 hospital admissions for delivery during the 14-yr study period, there were 135 deaths. The overall delivery mortality ratio was 16.4. The most common diagnoses associated with mortality during hospital admission for delivery included preeclampsia/eclampsia (22.2%), postpartum hemorrhage/obstetric shock (22.2%), pulmonary complications (14%), blood clot and/or amniotic embolism (8.1%), and anesthesia-related complications (5.2%). The identification of medical and demographic risk factors may have significant implications creating initiatives aimed at decreasing the public health burden associated with maternal mortality. This study reports the medical and demographic risk factors associated with maternal death during hospital admission for delivery by using a state-maintained database. This information could prove useful in the creation of initiatives aimed at decreasing the public health burden associated with maternal mortality.

An Anesthetic Experience of Amniotic Embolism after Normal Delivery: A case report

Amniotic embolism is a fatal disease with an abrupt onset and rapidly deteriorating clinical course. Its clinical features are various and the prediction of its occurrence is very difficult. Understanding its pathogenetic mechanisms has increased over the past two decades. We report on a case of amniotic embolism along with its full clinical manifestations after a normal delivery in the young primigravida. (Korean J Anesthesiol 1999; 37: 536∼542)

Prédiction au moyen des potentiels évoqués endogènes et exogènes de l’évolution favorable d’un coma prolongé

A neurophysiological follow-up (EEG, exogenous and endogenous evoked potentials--EP) was performed over a 4-month period in a patient who presented a long-lasting coma following a cardiac arrest and an amniotic embolism. A pure anoxic aetiology was ruled out starting from the second day on the basis of a dissociation between mildly altered flash visual EP and markedly altered somatosensory EP, indicating focal brain-stem pathology. Endogenous EP reappeared after 12 days. This patient recovered consciousness after 51 days. Despite the absence of MRI abnormalities, we put forward the hypothesis that a brain-stem embolism had, in fact, worsened the clinical picture of an actually moderate anoxia. This case exemplifies the interest of an integrated neurophysiological approach (EEG, exogenous three-modality EP and endogenous EP) in the early evaluation of coma. It also illustrates the complement between structural imaging and functional assessment of the nervous system.