Anesthesia Considerations 

Amniotic Fluid Embolism 

 

 

Considerations 

 

• Life threatening condition with multi-system derangements:

  • CNS: seizures, coma

  • Cardiovascular: hypotension, cardiovascular collapse, biventricular failure  

  • Respiratory: pulmonary edema, ARDS 

  • Hematological: coagulopathy 

• Pregnancy considerations (difficult intubation, aspiration, ↓ time to desaturation, aortocaval compression, 2 patients)

• Need for immediate cardiopulmonary resuscitation & correction of coagulopathy 

• Need for multidisciplinary management including the ICU 

 

 

Clinical Features (tend to happen suddenly) 

 

• Premonitory symptoms (restlessness, agitation, numbness, tingling) 

• Hypotension, biphasic cardiovascular collapse:

  • First phase (initial 15-30 min):  RV failure & acute pulmonary hypertension

  • Second phase: LV failure 

• Hypoxemia, respiratory failure 

• Coagulopathy 

• Seizures/coma 

 

 

Management 

 

• Call for help, code blue

• If cardiac arrest → follow ACLS guidelines with obstetrical modifications:

  • Supradiaphragmatic IV 

  • Left uterine displacement

  • Chest compressions higher on sternum than usual

  • Early intubation 

  • Prepare for peri-mortem cesarean section; if no ROSC within 4 minutes of resuscitation, aim for delivery within 5 minutes of resuscitation

• Ventilate/oxygenate: intubate, 100% O2 

• Fluid resuscitate in increments, avoid fluid overload that may lead to pulmonary edema or RV over-distension  

• Support circulation with vasopressors initially, may need inotropes in 2nd phase:

  • Start with norepinephrine 

  • Add inodilators if needed: dobutamine, milrinone 

• Establish invasive monitoring: arterial line, central venous access & CVP monitoring 

• Call for transesophageal echocardiography

• Treat coagulopathy:

  • Initiate massive hemorrhage protocol 

  • Correct INR/PTT & platelets 

  • Ensure normothermia & normocalcemia 

• Fetus management:

  • Institute fetal monitoring 

  • Deliver fetus if fetal distress or maternal cardiopulmonary arrest 

• Post resuscitation care in ICU 

 

 

Differential Diagnosis 

 

• Obstetrical:

  • Placental abruption 

  • Eclampsia

  • Uterine rupture or laceration 

  • Uterine atony 

  • Peripartum cardiomyopathy 

• Non-obstetrical:

  • Myocardial infarction

  • Pulmonary embolism

  • Sepsis 

  • Anaphylaxis 

  • Venous air embolism 

  • Transfusion reaction 

• Anesthetic: 

  • High neuraxial 

  • Local anesthetic toxicity 

  • Medication error