Echocardiography findings in amniotic fluid embolism: a systematic review of the literature.

PURPOSE: Amniotic fluid embolism (AFE) is a leading cause of obstetrical cardiac arrest and maternal morbidity. The pathogenesis of hemodynamic collapse is thought to be from right ventricular (RV) failure; however, there is a paucity of data documenting echocardiography findings in this population. We undertook a systematic review of the literature to evaluate the echocardiography findings in patients with AFE. SOURCES: We retrieved all case reports and case series reporting AFE in Embase and MEDLINE from inception to 20 November 2021. Studies reporting AFE diagnosed by fulfilling at least one of three different proposed AFE criteria and echocardiography findings during hospitalization were included. Patient and echocardiographic data were retrieved, and univariate logistic regression analysis was performed for outcomes of interest. Bias was assessed using the Joanna Briggs Institute clinical appraisal tool for case series. PRINCIPAL FINDINGS: Eighty publications reporting on 84 patients were included in the final review. Fifty-five out of 82 patients with data (67%) showed RV dysfunction, including 11/82 (13%) with biventricular dysfunction; 14/82 (17%) had normal systolic function. No data on RV or left ventricular function were reported for two patients. The presence of RV dysfunction on echocardiography was associated with cardiac arrest (odds ratio [OR], 3.66; 95% confidence interval [CI], 1.39 to 9.67; P = 0.009), and a composite risk of cardiac arrest, maternal death or use of extracorporeal membrane oxygenation (OR, 3.86; 95% CI, 1.43 to 10.4; P = 0.007). A low risk of bias was observed in 15/84 (18%) cases. CONCLUSIONS: Right ventricular dysfunction on echocardiography is a common finding in AFE and is associated with a high risk of cardiac arrest. The finding of RV dysfunction on echocardiography may help diagnose AFE and help triage the highest risk patients with AFE. STUDY REGISTRATION: PROSPERO (CRD42021271323); registered 1 September 2021.

RéSUMé: OBJECTIF: L'embolie amniotique (EA) est l'une des principales causes d'arrêt cardiaque obstétrical et de morbidité maternelle. Il est présumé que la pathogenèse du choc hémodynamique provient d'une défaillance ventriculaire droite (VD). Cependant, il y a peu de données documentant les constatations de l'examen échocardiographique dans cette population. Nous avons effectué une revue systématique des données probantes visant à évaluer l'utilité de l'échocardiographie chez les patientes atteintes d'embolie amniotique. SOURCES: Nous avons évalué tous les rapports de cas et séries de cas rapportant une EA dans les bases de données Embase et MEDLINE de leur création jusqu'au 20 novembre 2021. Les études rapportant une EA diagnostiquée en remplissant au moins l'un des trois critères d'EA proposés et les résultats échocardiographiques pendant l'hospitalisation ont été incluses. Les données sur les patientes et échocardiographiques ont été colligées, et une analyse de régression logistique univariée a été effectuée pour les issues cliniques d'intérêt. Le risque de biais a été évalué à l'aide de l'outil d'évaluation clinique de l'Institut Joanna Briggs pour les séries de cas. CONSTATATIONS PRINCIPALES: Quatre-vingts publications incluant 84 patientes ont été incluses dans la revue finale. Cinquante-cinq des 82 patientes présentant des données (67 %) avaient une dysfonction du VD incluant 11/82 (13 %) avec une dysfonction biventriculaire. Quatorze patientes sur 82 (17 %) avaient une fonction systolique normale. Aucune donnée sur la fonction du ventricule droit ou gauche n'a été rapportée pour deux patientes. La présence d'une dysfonction du VD à l'échocardiographie était associée à un arrêt cardiaque (rapport de cotes [RC], 3,66; intervalle de confiance à 95 % [IC], 1,39 à 9,67; P = 0,009), et à un risque composite d'arrêt cardiaque, de décès maternel ou d'utilisation de l'oxygénation par membrane extracorporelle (ECMO) (RC, 3,86; IC 95 %, 1,43 à 10,4; P = 0,007). Un faible risque de biais a été observé dans 15/84 (18 %) des cas. CONCLUSION: La dysfonction ventriculaire droite à l'échocardiographie est une constatation courante dans l'embolie amniotique et est associée à un risque élevé d'arrêt cardiaque. La découverte d'une dysfonction du VD à l'échocardiographie peut aider à diagnostiquer l'embolie amniotique et à identifier les patientes atteintes d'embolie amniotique les plus à risque. ENREGISTREMENT DE L'éTUD: PROSPERO (CRD42021271323); enregistrée le 1er septembre 2021.

Placental mesenchymal dysplasia complicated with sudden fetal demise and amniotic fluid embolism: a case report.

BACKGROUND: Placenta mesenchymal dysplasia (PMD) is a rare placental anomaly associated with various fetal and maternal complications. Whether close ultrasound surveillance can prevent intrauterine fetal demise (IUFD) in patients with PMD is still under investigation. Amniotic fluid embolism (AFE) is a rare, lethal, and unpredictable maternal complication that has never been described in association with PMD. Here, we report a case of PMD, in which the fetus eventually demised in utero despite weekly color Doppler monitoring, and the mother subsequently encountered AFE during delivery. CASE PRESENTATION: A 43-year-old woman who had received three frozen embryo transfer, was found to have a singleton pregnancy with an enlarged multi-cystic placenta at 8 weeks' gestation. Fetal growth restriction (FGR) was noted since the 21stweek. The fetus eventually demised in-utero at 25 weeks despite weekly color Doppler surveillance. Cesarean section was performed under general anesthesia due to placenta previa totalis and antepartum hemorrhage. During surgery, the patient experienced a sudden blood pressure drop and desaturation followed by profound coagulopathy. AFE was suspected. After administration of inotropic agents and massive blood transfusion, the patient eventually survived AFE. PMD was confirmed after pathological examination of the placenta. CONCLUSIONS: While FGR can be monitored by color Doppler, our case echoed previous reports that IUFD may be unpreventable even under intensive surveillance in PMD cases. Although AFE is usually considered unpredictable, PMD can result in cumulative risk factors contributing to AFE. Whether a specific link exists between the pathophysiology of PMD and AFE requires further investigation.

The role of echocardiography in amniotic fluid embolism: a case series and review of the literature.

PURPOSE: Amniotic fluid embolism (AFE) is a rare, but often fatal condition characterized by sudden hemodynamic instability and coagulopathy occurring during labour or in the early postpartum period. As the mechanisms leading to shock and the cardiovascular effects of AFE are incompletely understood, the purpose of this case series is to describe how AFE presents on echocardiography and review limited reports in the literature. CLINICAL FEATURES: We describe three cases of AFE at the Jewish General Hospital, a tertiary care centre in Montreal, Canada. All cases met the Clark diagnostic criteria, which comprise 1) sudden cardiorespiratory arrest or both hypotension and respiratory compromise, 2) disseminated intravascular coagulation, 3) clinical onset during labour or within 30 min of delivery of the placenta, and 4) absence of fever. Two patients had a cardiac arrest and the third developed significant hypotension and hypoxia. In all patients, point-of-care echocardiography at the time of shock revealed signs of right ventricular failure including a D-shaped septum, acute pulmonary hypertension, and right ventricular systolic dysfunction. CONCLUSION: This case series and literature review of AFE emphasizes the importance of echocardiography in elucidating the etiology of maternal shock. The presence of right ventricular failure may be considered an important criterion to diagnose AFE.

RéSUMé: OBJECTIF: L'embolie de liquide amniotique (ELA) est une complication rare mais souvent fatale caractérisée par une instabilité hémodynamique et une coagulopathie soudaines survenant pendant le travail obstétrical ou au début de la période postpartum. Étant donné que les mécanismes menant au choc et les effets cardiovasculaires de l'ELA ne sont que partiellement compris, le but de cette série de cas était de décrire comment l'ELA apparaît à l'échocardiographie et de passer en revue les rares comptes rendus dans la littérature. CARACTéRISTIQUES CLINIQUES: Nous décrivons trois cas d'ELA survenus à l'Hôpital général juif, un centre tertiaire de soins à Montréal, au Canada. Tous les cas remplissaient les critères diagnostiques de Clark, qui comportent 1) un arrêt cardiorespiratoire soudain ou une hypotension accompagnée d'une détresse respiratoire, 2) une coagulation intravasculaire disséminée, 3) une apparition clinique pendant le travail obstétrical ou dans un délai de 30 minutes suivant la délivrance du placenta, et 4) l'absence de fièvre. Deux patientes ont subi un arrêt cardiaque et le tiers des patientes ont manifesté une hypotension et une hypoxie significatives. Chez toutes les patientes, l'échocardiographie au chevet au moment du choc a révélé des signes d'insuffisance ventriculaire droite, y compris un septum en forme de D, une hypertension pulmonaire aiguë et une dysfonction systolique ventriculaire droite. CONCLUSION: Cette série de cas et revue de littérature de l'ELA souligne l'importance de l'échocardiographie pour élucider l'étiologie du choc maternel. La présence d'une insuffisance ventriculaire droite peut être considérée un critère important pour diagnostiquer une ELA.

Case report of amniotic fluid embolism coagulopathy following abortion; use of viscoelastic point-of-care analysis.

BACKGROUND: Amniotic fluid embolism (AFE) is a rare, life threatening obstetric complication, often associated with severe coagulopathy. Induced abortions are extremely safe procedures however complications including AFE can occur. CASE PRESENTATION: A 29-year-old previously healthy woman, gravida 1 para 0, presented for a scheduled second trimester induced abortion via dilation and evacuation at 22-weeks gestation. The case was complicated by a suspected AFE with associated profound coagulopathy. Viscoelastic point-of-care coagulation analysis was used to successfully and swiftly guide management of her coagulopathy. CONCLUSION: AFE can occur in the setting of induced abortion. This case report suggests viscoelastic point-of-care coagulation analyzers may aid in the management of pregnancy-related coagulopathy by providing faster coagulation assessment than laboratory testing, and facilitating timely, targeted management of coagulopathy.

Amniotic fluid embolism: principles of early clinical management.

Amniotic fluid embolism is an uncommon, but potentially lethal, complication of pregnancy. Because amniotic fluid embolism usually is seen with cardiac arrest, the initial immediate response should be to provide high-quality cardiopulmonary resuscitation. We describe key features of initial treatment of patients with amniotic fluid embolism. Where available, we recommend performing transthoracic or transesophageal echocardiography as soon as possible because this is an easy and reliable method of identifying a failing right ventricle. If such failure is identified, treatment that is tailored at improving right ventricular performance should be initiated with the use of inotropic agents and pulmonary vasodilators. Blood pressure support with vasopressors is preferred over fluid infusion in the setting of severe right ventricular compromise. Amniotic fluid embolism-related coagulopathy should be managed with hemostatic resuscitation with the use of a 1:1:1 ratio of packed red cells, fresh frozen plasma, and platelets (with cryoprecipitate as needed to maintain a serum fibrinogen of >150-200 mg/dL). In cases that require prolonged cardiopulmonary resuscitation or, after arrest, severe ventricular dysfunction refractory to medical management, consideration for venoarterial extracorporeal membrane oxygenation should be given.

Beyond Pulmonary Embolism; Nonthrombotic Pulmonary Embolism as Diagnostic Challenges.

Nonthrombotic pulmonary embolism (NTPE) is less well understood and is encountered less frequently than pulmonary embolism from venous thrombosis. NTPE results from embolization of nonthrombotic material to the pulmonary vasculature originating from many different cell types as well as nonbiologic or foreign materials. For many radiologists NTPE is a challenging diagnosis, presenting nonspecific or unusual imaging findings in the setting of few or unusual clinical signs. The aim of this paper is to review the pathophysiology of diverse causes of NTPE, which should aid radiologists to better understand and, more importantly, diagnose these infrequent events.

Koagulopatia ze zuzycia jako wiodacy objaw zatoru plynem owodniowym -opis przypadku.

Amniotic fluid embolism is a rare and diagnostically challenging obstetric disease of high mortality rate. We present a case of a 33-year old parturient after vaginal birth, who presented with severe hemorrhagic shock with low platelet count and coagulopathy resistant to treatment with plasma, platelets and coagulation factors and despite of surgical management of bleeding. Laboratory findings revealed consumptive coagulopathy. Other symptoms included dyspnea and atelectatic changes on chest x-ray, together with augmentation of the heart with no proof of ventricular insufficiency in echocardiographic examination. The suspected reason of these alterations was amniotic fluid embolism. The patient survived and came back to her usual activity after 22 days of treatment.

Paradoxical amniotic fluid embolism presenting before caesarean section in a woman with an atrial septal defect.

We present a case of presumed amniotic fluid embolism in a 33-year-old parturient at 30 weeks of gestation, which occurred just before she was due to receive spinal anaesthesia for urgent caesarean section. While sitting, the woman suddenly lost consciousness, started having convulsions and finally suffered cardiorespiratory collapse. She was resuscitated and a live baby was delivered by emergency caesarean section. An echocardiogram performed postoperatively showed a large atrial septal defect and severe right ventricular dysfunction with moderate pulmonary hypertension. Paradoxical amniotic fluid embolism was diagnosed. After extubation she was aphasic and had a right hemiparesis. She made a good recovery and was discharged from hospital 24 days later, at which time she had a slight weakness on her right side. Three months later she had a normal gait with no obvious neurological deficit.

Echocardiographically detected mass "in transit" in early amniotic fluid embolism.

BACKGROUND: Amniotic fluid embolism is a catastrophic illness related to the passage of fetal material into the pulmonary circulation causing cardiovascular collapse. CASE: A 29-year-old female sustained cardiopulmonary arrest during delivery presumably due to amniotic fluid embolism. A right atrial mass "in transit" was detected by echocardiography. It had an appearance and pattern of motion that was suggestive of a gelatinous consistency and is likely to have been an amniotic fluid embolus. There was also evidence of acute right ventricular overload. CONCLUSION: We recommend that echocardiography be considered early on such conditions to gain more insight into the pathogenesis of this complication.

Massive amniotic fluid embolism: diagnosis aided by emergency transesophageal echocardiography.

A 36-year-old woman was hospitalized at term and in labor at 3-cm cervical dilatation. The early labor course was remarkable only for oxytocin augmentation and combined spinal-epidural analgesia. Eight hours after admission, tetanic uterine contractions ensued, followed by persistent fetal bradycardia. An emergency cesarean section was performed and a viable male infant was delivered. Intraoperatively, a placental abruption was identified, and disseminated intravascular coagulation and persistent hypotension developed despite resuscitative efforts. Transesophageal echocardiography revealed normal left ventricular contractility and gross enlargement of the right ventricle and main pulmonary trunk, consistent with acute right ventricular pressure overload and underloading of the left ventricle. Despite resuscitative efforts, the patient died three hours postoperatively. Autopsy showed extensive microvascular plugging of the pulmonary capillaries by fetal cells in all lung fields. This is a rare case of amniotic fluid embolism diagnosed in part and managed pre-mortem with transesophageal echocardiography and confirmed by autopsy findings.