Anaphylactoid syndrome of pregnancy Amniotic Fluid Embolism

This is a complication of labor or Cesarean delivery giving rise to peripartum collapse as a result of embolization of amniotic fluid and possibly fetal squamous cells into the maternal circulation. The syndrome may be rapidly lethal in women who develop severe pulmonary hypertension and cardiac arrest. Those who survive for longer periods develop an anaphylactoid type of response to the presence of amniotic fluid in the circulation (Clark etal., 1995).

The clinical syndrome is diagnosed every 1 in 8000 to 1 in 80,000 pregnancies. A national registry of cases that has been opened in the USA is currently the most authoritative source of information about this condition. The condition usually presents during labor but may occur at the time of Cesarean delivery or immediately after birth. There are no demographic predisposing factors and obstetric practices, such as prior amniotomy and oxytocin administration do not seem to influence the risk of developing amniotic fluid embolus. The onset of the condition is abrupt and hypotension is universally present. Most patients develop pulmonary edema with cyanosis and a profound coagulopathy which should immediately give rise to a suspicion of the diagnosis.

The single most common initial presenting symptom, however, in antenatal patients is seizure activity. This may lead to confusion with eclampsia, which is a far more frequent cause of seizures.

The patients who survive the initial embolus and who develop the anaphylactoid picture have markedly depressed left ventricular function. Cardiac electromechanical dissociation may develop and there is a high risk of cardiopulmonary arrest.

The prognosis is poor; in the American national registry, 61% of the patients died and only 15% survived neurologically intact. Diagnosis must be prompt and continuous vigorous resuscitation will be needed immediately. Intensive care is mandatory and inotropic support is necessary from the beginning. Hemorrhage should be anticipated and hypovolemia is also likely to be a problem as a result of postpartum hemorrhage or bleeding after Cesarean section. Continuous transfusion with blood and coagulation factors will be necessary and obstetric intervention in the form of oxytocic drugs and hysterectomy may be necessary to control bleeding. Although not currently studied or reported, in those cases with overwhelming coagulopathy treatment with recombinant activated Factor VII may be a last resort therapy (Bouwmeester et al., 2003; Danilos et al., 2003).

Intubation and mechanical ventilation along with pulmonary artery catheterization are likely adjuncts to intensive care management.

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