Amniotic fluid embolism is a dangerous complication during childbirth. It involves amniotic fluid being washed into the mother’s bloodstream.
What is amniotic fluid embolism?
Amniotic fluid embolism is also known as amniotic infusion syndrome. This refers to a special type of embolism that occurs during the birth process. During delivery, amniotic fluid from the uterus enters the bloodstream of the pregnant woman. This results in the obstruction of capillaries or pulmonary arterioles, which in turn affects the blood clotting system. Amniotic fluid embolism rarely occurs. However, it usually takes a severe course and can end in death for the affected woman. In the event of survival, there is a risk of brain damage to both mother and child. Amniotic fluid embolism is rare. According to estimates, this special form of embolism occurs in only 2 to 8 cases per 100,000 births. In 25 to 34 percent of all affected women, death occurs in the first hour. Only 16 to 20 percent survive the amniotic fluid embolism. In 70 percent of all cases, the embolism already manifests itself during birth. Nineteen percent suffer the complication during a cesarean section and 11 percent during a vaginal birth. The child is also threatened by amniotic fluid embolism. Thus, about half of all affected babies die.
Causes
The exact causes of amniotic fluid embolism could not be precisely determined until now. It represents a special form of pulmonary embolism. The contact of amniotic fluid components with the mother’s bloodstream is responsible. Since the onset of rupture of the membranes occurs at the same time in most cases, some physicians suspect this to be a possible trigger of the embolism. On the other hand, there are numerous reactions that clearly exceed an ordinary embolism. In the course of amniotic fluid embolism, the amniotic fluid may enter the venous system of the pregnant woman through an open area of the placenta. Sometimes, however, injuries to the cervical blood vessels or the venous plexus of the uterus are also the cause of amniotic fluid penetration. From the venous system, amniotic fluid penetrates to the pulmonary arteries. It also enters the body’s circulation through shunts within the lungs. The exact mechanisms that promote the development of amniotic fluid embolism are not well understood. Moreover, not every contact between amniotic fluid, as well as its components, and the mother’s circulation results in a dangerous embolism. There are some risk factors that can trigger the development of amniotic fluid embolism. These include all diseases or processes from which increased labor is triggered. Typical risk factors include rupture of the membranes, uterine rupture, injuries during delivery such as a cervical tear or vaginal tear, cesarean section, and vaginal surgical delivery. Other possible triggers include injury to the uterine venous plexus, premature detachment of the placenta, intrauterine amniotic death, or administration of contraceptives.
Symptoms, complaints, and signs
The diagnosis of amniotic fluid embolism must be made quickly because of the dangerous nature of the complication. The condition is initially manifested by preliminary signs such as difficulty breathing, tremors, a feeling of cold, and impaired sensation in the fingers. Affected women also experience nonspecific anxiety and inner restlessness, often associated with nausea and vomiting. These initial signs usually occur suddenly and persist for a few minutes to four hours before the acute symptoms set in. In the early stages, patients show symptoms such as seizures and dyspnea with cyanosis. Shock signs such as circulatory distress or even loss of consciousness also occur. In more than half of the women, chest pain is also present. If this first stage is survived, the second stage is bleeding and finally hemorrhagic shock, which is manifested by dizziness and circulatory collapse, among other symptoms, and is often fatal. In the late stage of amniotic fluid embolism, a respiratory distress syndrome develops, in the course of which pulmonary edema develops. Accompanying hyperfibrinolysis occurs, often resulting in multiorgan failure. The individual phases of the disease merge smoothly into one another and occur within a period of a few hours.In the unborn child, the reduced oxygen supply leads to cardiac arrhythmias and ultimately to death. In addition, patients usually notice unusually strong contractions. The affected mother also suffers from confusion, anxiety and convulsions. Eventually, she loses consciousness. Sometimes vomiting or chills also occur. In severe cases, there is a threat of respiratory and circulatory arrest.
Course
Amniotic fluid embolism progresses in two phases:
During the first phase, there is obstruction of the arterial pulmonary pathway for which the components of the amniotic fluid are responsible. This results in vasoconstriction (vasoconstriction) and pulmonary hypertension. The blockage of the pulmonary vessels reduces the filling pressure and cardiac output. This results in cardiogenic shock. The second phase occurs after 30 minutes to three hours. During this phase, severe bleeding occurs due to generalized coagulation and consumption coagulopathy. The mother may die because of this due to hemorrhagic shock. In addition, a respiratory distress syndrome including pulmonary edema is seen. Not infrequently, the shock results in fatal multiorgan failure.
Complications
If amniotic fluid embolism is not diagnosed and treatment therefore fails to occur, the risk of death is 100 percent. The only possibility of survival – for both mother and newborn child – lies in intensive medical treatment. In this case, the diagnosis must be made very quickly. Without rapid intervention, there will be respiratory distress, shock, which in turn will result in circulatory arrest. The entry of the amniotic fluid – including solid components – into the maternal bloodstream causes sepsis. This poisoning affects the entire body. Without treatment, the woman’s body collapses in a very short time, due to multi-organ failure. The disease itself is not treatable, only its symptoms. Due to reduced oxygen supply and failure of the circulatory system as well as the immune system, neurological damage is the most common complication. This affects both the mother and the child. Tissue in the throat can be injured as a complication of the intubation needed – to ensure breathing. Numerous drugs are administered to counteract heart failure and an immunological defense reaction. These can produce side effects and in turn lead to organ damage. To increase the chances for mother and child, an emergency cesarean section is usually performed. As a complication, further bleeding of the uterus and adaptation problems (lack of breathing, cardiac arrhythmia) of the newborn can occur. If the amniotic fluid embolism develops during pregnancy and this necessitates an emergency cesarean section, complications may arise for the premature baby. These manifest as difficulties in adaptation and often organ insufficiencies.
When should you see a doctor?
A pregnant woman should generally see a doctor if she feels that something is wrong with her or her baby. If there is a diffuse feeling of complications, unusual changes or anxiety, a doctor should be consulted for checkups. If there are signs such as confusion, a persistent feeling of stress, malaise or general weakness, consultation with a physician is required. Repeated vomiting throughout the day or during delivery, headache, nausea or a strong sensation of cold, are considered unusual and should be clarified. If there are chills or an elevated body temperature, a physician is needed. If decreased breathing, intermittent breathing or respiratory arrest occurs, a doctor’s visit is needed as soon as possible. There is a threat of a life-threatening condition for the expectant mother as well as the child. In case of circulatory problems, high blood pressure or a pulse that can hardly be felt, a doctor should be called. Discoloration of the skin, swelling or other skin changes should be presented to a doctor. Blue discoloration of the skin is of particular concern. If it occurs, a doctor should be consulted immediately. If the birth takes place in an inpatient setting, the signs are usually observed by the obstetricians and reported to a physician immediately. In the case of a home birth, the expectant mother and those present are subject to an increased duty of care and must respond immediately.
Treatment and therapy
It is not possible to treat amniotic fluid embolism causally or specifically. Thus, symptomatic intensive medical therapy is usually given. The aim is to stabilize the condition of the affected mother. For most patients, the attending physician inserts a hollow plastic probe through the nose or mouth. From there, he places the tube in the trachea to provide artificial respiration. The patient receives an infusion to counteract the drop in blood pressure. She is also given drugs to prevent right heart failure. Glucocorticoids are also administered. If the patient’s condition can be stabilized, a vaginal delivery can be performed. If, on the other hand, there is no improvement after about five minutes, an emergency cesarean section must be performed to save the child. In this way, the mother’s chances for cardiopulmonary resuscitation are greater. After the baby is born, the mother is given the hormone oxytocin by infusion to prevent atonic postpartum hemorrhage. Oxytocin is usually combined with the cervical alkaloid methylergometrine. These drugs can be used to promote uterine contraction, which leads to a decrease in bleeding.
Outlook and prognosis
The timing of interdisciplinary care for the pregnant woman is critical in determining prognosis. With a prompt diagnosis and immediate comprehensive medical treatment, the health condition of the expectant mother can be stabilized. There is a good prognosis outlook for both the mother and the child. However, the more time passes, the more likely a life-threatening condition will occur. The pregnant woman is at risk of shock, respiratory distress, and circulatory arrest. Her life and that of the unborn child are thus acutely endangered. Once sepsis has set in, the prognosis worsens within minutes. If the child is already at a stage of development at which it is capable of surviving, a Caesarean section is initiated immediately in many cases. This puts the child’s life out of danger and it receives intensive medical care for the first days or weeks of life. Subsequent sequelae must be evaluated on an individual basis. If the pregnancy is advanced, the newborn can often be discharged from treatment after a few weeks, free of symptoms. The mother of the child is treated symptomatically, since there is no therapeutic form of amniotic fluid embolism. If the symptoms regress, there is also a good chance of recovery. Nevertheless, there is a possibility that in many cases consequential damages will develop as a result of the medical treatment. These include lifelong organic disorders.
Prevention
There are no preventive measures to prevent amniotic fluid embolism.
Follow-up care
In the case of amniotic fluid embolism, there are usually no special aftercare options available to the affected person. However, these are also not necessary, since amniotic fluid embolism must primarily be treated directly by a medical professional in order to prevent the death of the child and that of the mother. In the process, there can be no self-healing. If this complaint is not treated in time, the mother usually dies from this complication. In this case, the treatment is carried out directly during the birth by means of a surgical intervention. In any case, the mother must rest and take care of her body after the operation. Efforts or other stressful activities should be avoided in any case. Sporting activities should also be avoided in any case. In many cases, even after the treatment of amniotic fluid embolism, it is necessary to be examined by a doctor, since the disease can also damage the heart. In general, therefore, the heart should be examined regularly. Often, the patient is also dependent on taking medication. In this case, regular intake should be ensured. If the amniotic fluid embolism is treated in time, the life expectancy of the mother and the child is not reduced.
What you can do yourself
Self-help is not possible in case of amniotic fluid embolism, only immediate intensive medical care can save the life of mother and child, unrecognized and untreated amniotic fluid embolism will inevitably lead to death.If the pregnant woman suddenly experiences shortness of breath and signs of shock, blue discoloration of the skin and partial confusion, an amniotic fluid embolism is urgently suspected. Reactions in amniotic fluid embolism are usually more severe than in a normal embolism, but not all symptoms need to occur together. Individual symptoms may also be absent. If there is a suspicion of an amniotic fluid embolism based on individual symptoms, medical help is required immediately. If the woman is already in hospital or in another medical facility, help can be given quickly from there and the vital measures can be initiated. The necessary help from home is more problematic, since it is not recognizable for the layman which illness it is. For this reason, it is necessary to immediately alert the emergency physician when individual signs appear, who will then arrange for the patient to be admitted to a hospital. This is the only way to save the life of mother and child in case of amniotic fluid embolism.
