Incidence, risk factors, management and outcomes of amniotic‐fluid embolism: a population‐based cohort and nested case–control study

Fitzpatrick, KE; Tuffnell, Derek; Kurinczuk, JJ; Knight, Marian

doi:10.1111/1471-0528.13300

Cited by 87 publications

(93 citation statements)

References 25 publications

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“…This represents only a summary of key points; many more specific messages for care are reported in the publications about individual conditions and these should be referred to for further detail. 54,71,72,181,220,221 The incidence of the specific morbidities most commonly leading to maternal death in the UK We examined the incidence of AFE, severe maternal sepsis, uterine rupture, HELLP syndrome and placenta accreta/increta/percreta. Because the studies conducted were national cohort or case-control studies, we were able to estimate incidence of each condition with a relatively high degree of precision.…”

Section: Key Findings and Implications For Practice Or Policymentioning

confidence: 99%

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight

Acosta

Brocklehurst

et al. 2016

Programme Grants Appl Res

101

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BackgroundStudies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision.ObjectivesTo (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts.MethodsMixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group.SettingMaternity units in all four countries of the UK.ParticipantsWomen with near-miss maternal morbidities, their partners and comparison women without severe morbidity.Main outcome measuresThe incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches.ResultsWomen and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services.LimitationsThis programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded.ConclusionsImplementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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Section: Key Findings and Implications For Practice Or Policymentioning

confidence: 99%

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight

Acosta

Brocklehurst

et al. 2016

Programme Grants Appl Res

101

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“…On the grounds of previous data, the rate of perinatal mortality seemed to range between 7% and 38%, but it has been recently estimated to be 6.7% in the UK. This datum is still significantly higher than the national perinatal mortality rate of 0.75% [5,7].…”

Section: Epidemiologymentioning

confidence: 70%

“…However, a lower incidence (1.7 per 100 000 births) has been reported in a prospective population-based study, collecting data of 7001438 maternities in the period between 1 February 2005 and 31 January 2014 in the United Kingdom [5].…”

Section: Epidemiologymentioning

confidence: 95%

“…As compared to AFE being diagnosed before or at delivery, diagnosis of AFE in the postpartum period seems to predispose significantly to perinatal death, need for intensive neonatal care and major complications [5].…”

Section: Epidemiologymentioning

confidence: 99%

“…abortion), blunt abdominal trauma or amniocentesis [3,13]. Several risk factors may predispose to AFE, including maternal age ≥ 35 years, placenta previa and multiple pregnancies [5,12]. Additionally, instrumental vaginal and caesarean deliveries are associated with the occurrence of AFE post-natally [5].…”

Section: Pathogenesis and Pathophysiologymentioning

confidence: 99%

See 2 more Smart Citations

Amniotic Fluid Embolism: An Update of the Evidence

Piva¹,

Scutiero²,

Greco³

2016

Med Toxicol Clin Forens Med (5)

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This article reviews the current evidence on amniotic fluid embolism (AFE), focusing on epidemiology, pathogenesis, clinical presentation, diagnosis and treatment. AFE is a rare and life-threatening obstetric condition, occurring in 2 to 8 per 100 000 births. With a mortality of 0.5 to 1.7 deaths per 100,000 deliveries in the developed world and 1.9 to 5.9 deaths per 100,000 deliveries in the developing world, it is among the leading direct causes of maternal death. Furthermore, persistent neurological impairment has been reported in 6-61% of survivors. Even though there is no shared pathogenetic theory for AFE, the transfer of amniotic fluid components in the maternal circulation may lead either to an inflammatory-mediated anaphylactoid response or to complement activation. There is great variability in the presentation of AFE from classical cardiopulmonary collapse with coagulopathy to minor and subclinical presentations. In severe cases, AFE should be distinguished from other acute and life-threatening emergencies, such as pulmonary embolism, myocardial infarction and peripartal cardiomyopathy. Thus, the diagnosis is one of exclusion, very often on post-mortem report. In fact, several diagnostic biomarkers have been proposed, but they have not been established in routine clinical diagnosis. Prompt recognition of the symptoms and immediate interdisciplinary management are pivotal for prognosis. The traditional treatment is supportive and aimed at treating cardiovascular, pulmonary, and coagulation derangements. Recently, novel treatment strategies have been proposed in the field of invasive hemodynamic support and C1 esterase inhibitors represent a potential therapeutic option. However, due to the lack of specific diagnostic tests, the difficulty of establishing the diagnosis and excluding competing diagnoses, and the complex treatment required, AFE still remains a major clinical challenge. Keywords:Amniotic fluid embolism; Maternal death; Pregnancy; Embolism How this fits in with quality in primary care? What do we know?Amniotic fluid embolism (AFE) is a rare and devastating obstetrical condition characterized by a grim prognosis in terms of survival and morbidity. In the absence of reliable diagnostic markers, the diagnosis is based on the clinical presentation and it is one of exclusion. The traditional treatment is supportive. What does this paper add?This paper reviews recent epidemiological data, current evidence about the pathophysiological mechanisms involved in AFE and focuses on novel treatment strategies.

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Association of Pregnancy Characteristics and Maternal Mortality With Amniotic Fluid Embolism

et al. 2022

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ImportanceAmniotic fluid embolism (AFE) is an uncommon pregnancy complication but is associated with high maternal mortality. Because of the rarity of AFE, associated risks factors and maternal outcomes have been relatively understudied.ObjectiveTo examine the clinical, pregnancy, and delivery characteristics and the maternal outcomes related to AFE in a recent period in the US.Design, Setting, and ParticipantsThis retrospective cohort study examined hospital deliveries from January 1, 2016, to December 31, 2019, from the Healthcare Cost and Utilization Project’s National Inpatient Sample.Main Outcomes and MeasuresThe primary outcome was clinical, pregnancy, and delivery characteristics of AFE, assessed with a multivariable binary logistic regression model. The coprimary outcome was failure to rescue, defined as maternal mortality after AFE. Associations with other severe maternal morbidity indicators and failure to rescue per clinical and pregnancy characteristics were also assessed.ResultsA total of 14 684 135 deliveries were examined, with AFE diagnosed in 880 women, corresponding to an incidence rate of 6.0 per 100 000 deliveries. The cohort-level median patient age was 29 years (IQR, 25-33 years). In a multivariable analysis, (1) patient factors of older age, Asian and Black race, Western US region, pregestational hypertension, asthma, illicit substance use, and grand multiparity; (2) pregnancy factors of placental accreta spectrum (PAS), placental abruption, uterine rupture, polyhydramnios, chorioamnionitis, preeclampsia, fetal growth restriction, and fetal demise; and (3) delivery factors of early gestational age, cervical ripening, cesarean delivery, operative delivery, and manual removal were associated with AFE. Among these characteristics, PAS had the largest association with AFE (adjusted odds ratio [aOR], 10.01; 95% CI, 7.03-14.24). When stratified by the PAS subtypes, more severe forms of PAS had a greater association with AFE (aOR for increta and percreta, 17.35; 95% CI, 10.21-28.48; and aOR for accreta, 7.62; 95% CI, 4.83-12.01). Patients who had AFE were more likely to have coagulopathy (aOR, 24.68; 95% CI, 19.38-31.44), cardiac arrest (aOR, 24.56; 95% CI, 17.84-33.81), and adult respiratory distress syndrome (aOR, 10.72; 95% CI, 8.09-14.20). The failure-to-rescue rate after AFE was 17.0% overall. However, the failure-to-rescue rate exceeded 30% when AFE co-occurred with other severe maternal morbidity indicators: 45.8% for AFE, cardiac arrest, and coagulopathy; 43.2% for AFE, shock, and cardiac rhythm conversion; and 38.6% for AFE, cardiac arrest, coagulopathy, and shock. The failure-to-rescue rate after AFE also exceeded 30% when AFE occurred in the setting of placental pathology: 42.9% for AFE and PAS and 31.3% for AFE and placental abruption.Conclusions and RelevanceThis contemporaneous, national-level analysis validated previously known risk factors for AFE and confirmed the dismal outcomes of pregnancy complicated by AFE. The association between PAS and AFE, which was not previously reported, warrants further investigation.

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Incidence, risk factors, management and outcomes of amniotic‐fluid embolism: a population‐based cohort and nested case–control study

Cited by 87 publications

References 25 publications

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Amniotic Fluid Embolism: An Update of the Evidence

Association of Pregnancy Characteristics and Maternal Mortality With Amniotic Fluid Embolism

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