[Maternal mortality due to Amniotic Fluid Embolism in France 2016-2018]. / Mortalité maternelle par embolie amniotique en France 2016­2018.

Amniotic embolism remains the 3rd leading cause of maternal death in France, with 21 maternal deaths over the 2016-2018 triennium. The women who died were more likely to be obese (25%), to benefit from induction of labor (71%) and be cared in a maternity hospital <1500 deliveries/year (45%), compared with the reference population (ENP 2016). The symptom occurred mainly during labor (95%) and the course was rapid, with a symptom-to-fatality interval of 4hours 45minutes (min: 25minutes - max: 8 days). Preventability was proposed for 35% of the deaths assessed, with areas for improvement identified in terms of technical skills (haemostasis procedures, management of polytransfusion), non-technical skills (communication) and health care organization (human resources, vital emergency plan, wide access to PSL). An autopsy was performed in 38% of deaths.

Amniotic fluid embolism: 20-year incidence and case-fatality trends in the United States.

OBJECTIVE: To estimate incidence and case-fatality rates of amniotic fluid embolism (AFE) and to examine their temporal trends. STUDY DESIGN: Population-based retrospective cohort study using the 2000-2019 Health Care Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS). Annual population rates were estimated using HCUP-NIS specific weighting. Descriptive analyses and logistic regression described trends within the cohort. RESULTS: Over the study period, AFE incidence rate remained stable (mean 4.9 cases/100,000 deliveries) and the case-fatality rate declined (mean 17.7 %,95 % CI 16.40-10.09). Highest AFE incidence rates and fatality rates were in women ≥ 35 years, African-Americans, and in urban-teaching hospitals. AFE mortality rates decreased among Hispanics. CONCLUSION: AFE rates remained stable and fatality rates declined over time. Highest rates of AFE occurrence and death were in women who typically have greater risk of experiencing adverse obstetrical outcomes. Continued research into early diagnostic methods and effective treatments are needed to further improve AFE incidence and mortality rates.

Amniotic fluid embolism: a reappraisal.

OBJECTIVES: Using cases from our own experience and from the published literature on amniotic fluid embolism (AFE), we seek to improve on existing criteria for diagnosis and discern associated risk factors. Additionally, we propose a novel theory of pathophysiology. METHODS: This retrospective case review includes eight cases of AFE from two hospital systems and 21 from the published literature. All cases were evaluated using the modified criteria for research reporting of AFE by Clark et al. in Am J Obstet Gynecol, 2016;215:408-12 as well as our proposed criteria for diagnosis. Additional clinical and demographic characteristics potentially correlated with a risk of AFE were included and analyzed using descriptive analysis. RESULTS: The incidence of AFE was 2.9 per 100,000 births, with five maternal deaths in 29 cases (17.2 %) in our series. None of the cases met Clark's criteria while all met our criteria. 62.1 % of patients were over the age of 32 years and two out of 29 women (6.9 %) conceived through in-vitro fertilization. 6.5 % of cases were complicated by fetal death. Placenta previa occurred in 13.8 %. 86.2 % of women had cesarean sections of which 52.0 % had no acute maternal indication. CONCLUSIONS: Our criteria identify more patients with AFE than others with a low likelihood of false positives. Clinical and demographic associations in our review are consistent with those previously reported. A possible relationship between cesarean birth and risk of AFE was identified using our criteria. Additionally, we propose a new hypothesis of pathophysiology.

Fatal amniotic fluid embolism: incidence, risk factors and influence on perinatal outcome.

PURPOSE: This study aimed to estimate the incidence of fatal amniotic fluid embolism, describe its risk factors, and analyze perinatal outcomes. METHODS: Maternity cases and newborn records of amniotic fluid embolism were collected from the Zhejiang Maternal Surveillance System from October 2006 to October 2019. This study strictly limited the diagnostic criteria for AFE and excluded suspicious cases in order to minimize false-positive AFE cases. The risk factors of fatal amniotic fluid embolism and the relationship between perinatal prognosis and AFE were investigated using logistic regression analysis, estimating the adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: 149 cases of amniotic fluid embolism were registered, of which 80 cases were fatal. The estimated fatal AFE incidence was 0.99 per 100,000. The occurrence of fatal AFE was significantly correlated with spontaneous vaginal delivery (aOR 12.3, 95% CI 3.3-39.2) and cardiac arrest (aOR 64.8, 95% CI 14.6-287.8). The average diagnosis time of fatal AFE is 85.51 min, and the peak period of female death is 1-12 h after the onset of the disease, accounting for 60% (48/80) of cases. Fatal amniotic embolism is a cause of intrauterine fetal death and fetal death during delivery (aOR 11.957, 95% CI 1.457-96.919; aOR 13.152, 95% CI 1.636-105.723). Of the 149 confirmed AFE cases, 11 cases of stillbirth occurred, 12 cases were stillborn, and 7 cases of neonatal death were reported. The perinatal mortality rate was 202 per 1000. CONCLUSIONS: Early detection, diagnosis, and treatment of amniotic fluid embolism are essential to avoiding fatal AFE. Clinicians should fully evaluate the pros and cons of choosing the delivery method for pregnant women. When cardiac arrest occurs in women with amniotic fluid embolism, obstetricians should be particularly careful and provide timely and effective treatment to minimize the fatality rate. The outcome of AFE is not only related to maternal survival but also plays a decisive role in the prognosis of the infant over the perinatal period.

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.

Association of Pregnancy Characteristics and Maternal Mortality With Amniotic Fluid Embolism.

Importance: Amniotic 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. Objective: To examine the clinical, pregnancy, and delivery characteristics and the maternal outcomes related to AFE in a recent period in the US. Design, Setting, and Participants: This 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 Measures: The 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. Results: A 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 Relevance: This 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.

Amniotic fluid embolism - implementation of international diagnosis criteria and subsequent pregnancy recurrence risk.

OBJECTIVES: An international diagnostic criterion for amniotic fluid embolism (AFE) diagnosis has recently been published. Data regarding subsequent pregnancies is scarce. We sought to implement recent diagnostic criteria and detail subsequent pregnancies in survivors. METHODS: A case series of all suspected AFE cases at a tertiary medical center between 2003 and 2018 is presented. Cases meeting the diagnostic criteria for AFE were included. Clinical presentation, treatment, and outcomes described. Pregnancy outcomes in subsequent pregnancies in AFE survivors detailed. RESULTS: Between 2003 and 2018 14 women were clinically suspected with AFE and 12 of them (85.71%) met the diagnostic criteria for AFE. Three cases occurred during midtrimester dilation and evacuation procedures, and the remaining occurred in the antepartum period. Of the antepartum cases, mode of delivery was cesarean delivery or vacuum extraction for expedited delivery due to presentation of AFE in 8/9 cases (88.88%). Clinical presentation included cardiovascular collapse, respiratory distress and disseminated intravascular coagulopathy (DIC). Heart failure of varying severity was diagnosed in 75% (9/12) cases. Composite maternal morbidity was 5/12 (41.66%), without cases of maternal mortality. 11 subsequent pregnancies occurred in four AFE survivors. Pregnant women were followed by a high-risk pregnancy specialist and multidisciplinary team if pregnancy continued beyond the early second trimester. Six pregnancies resulted in a term delivery. No recurrences of AFE were documented. CONCLUSIONS: Use of a diagnostic criterion for diagnosis of AFE results in a more precise diagnosis of AFE. Nevertheless, the accuracy of clinical diagnosis is still high. Subsequent pregnancies were not associated with AFE recurrence.

Maternal cardiac arrest: a retrospective analysis.

OBJECTIVES: To describe the characteristics and factors which may influence the maternal outcomes of maternal cardiac arrest (MCA). DESIGN: Retrospective analysis of cases. SETTING: China. POPULATION OR SAMPLE: A total of 61 MCA patients admitted or transferred to The Third Affiliated Hospital of Guangzhou Medical University from January 2000 to December 2019. METHODS: Clinical data for MCA were analysed retrospectively. The indicators included maternal age; BMI; gestational age; antenatal examination; income; MCA cause and place; cardiopulmonary resuscitation (CPR); mode of delivery; maternal prognosis; and neonatal outcome. MAIN OUTCOME MEASURES: The impact of case characteristics on maternal prognosis of MCA. RESULTS: The hospital received 61 patients with MCA, 36 of whom died (mortality 59.0%, 95% CI 46.3-71.7%). MCA was predominantly caused by treatable complications. Those who died were more likely to have collapsed in the ICU. CONCLUSIONS: Regular antenatal examination and early intervention can reduce the incidence of adverse pregnancy outcomes. The location of MCA occurred may be related to maternal prognosis. The leading causes of MCA were postpartum haemorrhage and amniotic fluid embolism. TWEETABLE ABSTRACT: A retrospective analysis describes the correlation between case characteristics of MCA and maternal outcomes.

[Maternal deaths due to amniotic fluid embolism. Results from the French confidential enquiry into maternal deaths, 2010-2012]. / Mortalité maternelle par embolie amniotique. Résultats de l'ENCMM, France 2010­2012.

Amniotic fluid embolism (AFE) is an unpredictable, dreadful complication of pregnancy or childbirth. EA typically includes in the same lapse of time respiratory, haemodynamic, neurological and hemorrhagic symptoms (from early and severe coagulopathy). Immediate supportive treatment by a multidisciplinary team is the cornerstone of the management. Between 2010 an 2012 in France, 24 deaths were related to AFE giving a maternal mortality ratio of 1/100,000 live births (CI 95% 0.6-1.4). AFE ranks as the second leading cause of direct maternal death. Eight cases over 23 were classified as having some degree of substandard care. Substandard care included delays in performing aggressive surgical treatment or delays in the diagnosis and the treatment of the coagulopathy. Learning points focus on the importance to pay attention on premonitory symptoms, to early assess the clotting status and to train in multidisciplinary team.

[Maternal death by venous thromboembolic disease]. / Morts maternelles par thromboembolies veineuses.

Pregnancy and postpartum are very high-risk periods for venous thromboembolism events (TEE), which seems to extend far beyond the classical 6-8 weeks after childbirth. Pulmonary embolism (PE) is one of the 3 main causes of direct maternal death in western countries. Between 2010 an 2012 in France, 24 deaths were related to PE giving a maternal mortality ratio of 1/100,000, which is not different from the former report (2007-2009). PE is responsible of 9% of maternal deaths, in equal position with postpartum hemorrhage and amniotic fluid embolism. Four deaths (16%) occurred after pregnancy interruption (1 abortion, 3 medical interruptions), 7 (30%) during ongoing pregnancy (before 22 weeks of pregnancy) and 13 (54%) in the postpartum period (9 to 60 days after childbirth). Among these deaths, 9 occurred in extra hospital setting (at home or in the street). Fifty percent of these deaths seem to be avoidable, as it was in the former report. Main avoidability criteria were: diagnostic delay; mobilization before effective anticoagulation of proximal deep venous thrombosis; insufficient preventive treatment with low molecular weight heparin [duration and/or dose (obesity)]; unjustified induction of labor. Analyzing those deaths allow to remind that in case of high suspicion of TEE, effective anticoagulation should be started without delay, and that angio-TDM is not contraindicated in pregnant women. Low molecular weight heparin regiment should be adapted to real weight. Monitoring of anti-Xa activity, if not routinely recommended, is probably useful in case of obesity or renal insufficiency. Anticipating birth by induction of labor, in the absence of abnormal fetal heart rhythm, should not delay effective anticoagulation of near-term TEE.

Acute Respiratory Distress Syndrome in Pregnant Women.

OBJECTIVE: To estimate the rate of acute respiratory distress syndrome (ARDS) in pregnant patients as well as to investigate clinical conditions associated with mortality. METHODS: We used the Nationwide Inpatient Sample from 2006 to 2012 to identify a cohort of pregnant patients who underwent mechanical ventilation for ARDS. A multivariate model predicting in-hospital mortality was created. RESULTS: A total of 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Samples were analyzed. There were 2,808 pregnant patients with ARDS who underwent mechanical ventilation included in the cohort. The overall mortality rate for the cohort was 9%. The rate of ARDS requiring mechanical ventilation increased from 36.5 cases (95% confidence interval [CI] 33.1-39.8) per 100,000 live births in 2006 to 59.6 cases (95% CI 57.7-61.4) per 100,000 live births in 2012. Factors associated with a higher risk of death were prolonged mechanical ventilation (adjusted odds ratio [OR] 1.69, 95% CI 1.25-2.28), renal failure requiring hemodialysis (adjusted OR 3.40, 95% CI 2.11-5.47), liver failure (adjusted OR 1.71, 95% CI 1.09-2.68), amniotic fluid embolism (adjusted OR 2.31, 95% CI 1.16-4.59), influenza infection (OR 2.26, 95% CI 1.28-4.00), septic obstetric emboli (adjusted OR 2.15, 95% CI 1.17-3.96), and puerperal infection (adjusted OR 1.86, 95% CI 1.28-2.70). Factors associated with a lower risk of death were: insurance coverage (adjusted OR 0.56, 95% CI 0.37-0.85), tobacco use (adjusted OR 0.53, 95% CI 0.31-0.90), and pneumonia (adjusted OR 0.70, 95% CI 0.50-0.98). CONCLUSION: In this nationwide study, the overall mortality rate for pregnant patients mechanically ventilated for ARDS was 9%. The rate of ARDS requiring mechanical ventilation increased from 36.5 cases (95% CI 33.5-41.8) per 100,000 live births in 2006 to 59.6 cases (95% CI 54.3-65.3) per 100,000 live births in 2012.

Serendipitous Signs, Symptoms, Laboratory Parameters, and Instrumental Patterns of Amniotic Fluid Embolism: Lessons from an Analysis of Case Reports.

Objective: Serendipitous Signs, Symptoms, Laboratory Parameters, and Instrumental Patterns of Amniotic Fluid Embolism: Lessons from an Analysis of Case Reports. Study Design: Wide analysis of the case reports on AFE published from 1990 to 2014. A scoring system for quantifying the relevance was attributed to each sign, symptom, laboratory parameter, and instrumental abnormal pattern in AFE cases. Principal component rotated factor analysis was used to reduce data. The residual signs, symptoms, and laboratory and instrumental parameters were introduced in a multivariable logistic regression model (dependent variable: survival). Results: AFE, clinically, has at least 2 serendipitous symptoms (restlessness and confusion, at rates between 10­15%) and a serendipitous laboratory parameter (rise in C-reactive protein blood levels, between 2­3%). Fatal AFE cases relate mostly to the severity of cardiac and pulmonary impairment, rather than with restlessness, confusion, and rise in C-reactive protein. Conclusion: The hypothesis that AFE has atypical behavior should be retained; the extent to which serendipitous findings of AFE relate to AFE outcomes is uncertain.

Amniotic fluid embolism: update and review.

PURPOSE OF REVIEW: This article reviews our current understanding of amniotic fluid embolism (AFE), specifically the pathogenesis, treatment strategies, potential diagnostic tests and future therapeutic interventions for AFE. RECENT FINDINGS: The incidence and case mortality of AFE varies widely because of heterogeneous diagnostic criteria and varying reporting mechanisms across the world. Amniotic fluid embolism is thought to be caused by abnormal activation of immunologic mechanisms following entry of fetal antigens into maternal circulation. Mast cell degranulation and complement activation may play a role in this anaphylactoid or systemic inflammatory response syndrome. Development of serum biomarkers and immune-histochemical staining techniques to aid diagnosis and develop treatments are under development and evaluation. Treatment of AFE is supportive and directed at treating cardiovascular, pulmonary, and coagulation derangements. Treatment for coagulopathy (fresh frozen plasma, cryoprecipitate/fibrinogen concentrate, and antifibrinolytics) should be initiated promptly. Recombinant factor VIIa may lead to increased mortality and should not routinely be used. C1 esterase inhibitors may be a potential therapeutic option. SUMMARY: AFE is a devastating obstetric complication that requires early and aggressive intervention with optimal cardiopulmonary resuscitation, as well as hemorrhage and coagulopathy management. Biomarkers offer promise to aid the diagnosis of AFE, and immunomodulation may provide future therapeutic interventions to treat this lethal condition.

Current status of pregnancy-related maternal mortality in Japan: a report from the Maternal Death Exploratory Committee in Japan.

OBJECTIVE: To clarify the problems related to maternal deaths in Japan, including the diseases themselves, causes, treatments and the hospital or regional systems. DESIGN: Descriptive study. SETTING: Maternal death registration system established by the Japan Association of Obstetricians and Gynecologists (JAOG). PARTICIPANTS: Women who died during pregnancy or within a year after delivery, from 2010 to 2014, throughout Japan (N=213). MAIN OUTCOME MEASURES: The preventability and problems in each maternal death. RESULTS: Maternal deaths were frequently caused by obstetric haemorrhage (23%), brain disease (16%), amniotic fluid embolism (12%), cardiovascular disease (8%) and pulmonary disease (8%). The Committee considered that it was impossible to prevent death in 51% of the cases, whereas they considered prevention in 26%, 15% and 7% of the cases to be slightly, moderately and highly possible, respectively. It was difficult to prevent maternal deaths due to amniotic fluid embolism and brain disease. In contrast, half of the deaths due to obstetric haemorrhage were considered preventable, because the peak duration between the initial symptoms and initial cardiopulmonary arrest was 1-3 h. CONCLUSIONS: A range of measures, including individual education and the construction of good relationships among regional hospitals, should be established in the near future, to improve primary care for patients with maternal haemorrhage and to save the lives of mothers in Japan.

Severe placental abruption: clinical definition and associations with maternal complications.

BACKGROUND: Placental abruption traditionally is defined as the premature separation of the implanted placenta before the delivery of the fetus. The existing clinical criteria of severity rely exclusively on fetal (fetal distress or fetal death) and maternal complications without consideration of neonatal or preterm delivery-related complications. However, two-thirds of abruption cases are accompanied by fetal or neonatal complications, including preterm delivery. A clinically meaningful classification for abruption therefore should include not only maternal complications but also adverse fetal and neonatal outcomes that include intrauterine growth restriction and preterm delivery. OBJECTIVES: The purpose of this study was to define severe placental abruption and to compare serious maternal morbidity profiles of such cases with all other cases of abruption (ie, mild abruption) and nonabruption cases. STUDY DESIGN: We performed a retrospective cohort analysis using the Premier database of hospitalizations that resulted in singleton births in the United States between 2006 and 2012 (n = 27,796,465). Severe abruption was defined as abruption accompanied by at least 1 of the following events: maternal (disseminated intravascular coagulation, hypovolemic shock, blood transfusion, hysterectomy, renal failure, or in-hospital death), fetal (nonreassuring fetal status, intrauterine growth restriction, or fetal death), or neonatal (neonatal death, preterm delivery or small for gestational age) complications. Abruption cases that did not qualify as being severe were classified as mild abruption cases. The morbidity profile included amniotic fluid embolism, pulmonary edema, acute respiratory or heart failure, acute myocardial infarction, cardiomyopathy, puerperal cerebrovascular disorders, or coma. Associations were expressed as rate ratios with 95% confidence intervals that were derived from fitting log-linear Poisson regression models. RESULTS: The overall prevalence rate of abruption was 9.6 per 1000, of which two-thirds of cases were classified as being severe (6.5 per 1000). Serious maternal complications occurred in 15.4, 33.3, and 141.7 per 10,000 among nonabruption cases and mild and severe abruption cases, respectively. In comparison with no abruption, the rate ratio for serious maternal complications were 1.52 (95% confidence interval, 1.35-1.72) and 4.29 (95% confidence interval, 4.11-4.47) in women with mild and severe placental abruption, respectively. Rate ratios for the individual complications were 2- to 7-fold higher among severe abruption cases. Furthermore, the rate ratios for serious maternal complications among severe abruption cases compared with mild abruption cases was 3.47 (95% confidence interval, 3.05-3.95). This association was considerably stronger for virtually all maternal complications among cases with severe abruption compared with mild abruption. Annual rates of mild and severe abruption were fairly constant during the study period. Although the maternal complication rate among non-abruption births was stable from 2006-2012, the rate of complications among mild abruption cases dropped from 2006-2008 and then leveled off thereafter. In contrast, the rate of serious complications among severe abruption cases remained fairly stable from 2006-2010 and increased sharply thereafter. CONCLUSIONS: Severe abruption was associated with a distinctively higher morbidity risk profile compared with the other 2 groups. The clinical characteristics and morbidity profile of mild abruption were more similar to those of women without an abruption. These findings suggest that the definition of severe placental abruption based on the proposed specific criteria is clinically relevant and may facilitate epidemiologic and genetic research.

Amniotic fluid embolism: an Australian-New Zealand population-based study.

BACKGROUND: Amniotic fluid embolism (AFE) is a major cause of direct maternal mortality in Australia and New Zealand. There has been no national population study of AFE in either country. The aim of this study was to estimate the incidence of amniotic fluid embolism in Australia and New Zealand and to describe risk factors, management, and perinatal outcomes. METHODS: A population-based descriptive study using the Australasian Maternity Outcomes Surveillance System (AMOSS) carried out in 263 eligible sites (>50 births per year) covering an estimated 96% of women giving birth in Australia and all 24 New Zealand maternity units (100% of women giving birth in hospitals) between January 1 2010-December 31 2011. A case of AFE was defined either as a clinical diagnosis (acute hypotension or cardiac arrest, acute hypoxia and coagulopathy in the absence of any other potential explanation for the symptoms and signs observed) or as a post mortem diagnosis (presence of fetal squames/debris in the pulmonary circulation). RESULTS: Thirty-three cases of AFE were reported from an estimated cohort of 613,731women giving birth, with an estimated incidence of 5.4 cases per 100,000 women giving birth (95% CI 3.5 to 7.2 per 100,000). Two (6%) events occurred at home whilst 46% (n = 15) occurred in the birth suite and 46% (n = 15) in the operating theatre (location not reported in one case). Fourteen women (42%) underwent either an induction or augmentation of labour and 22 (67%) underwent a caesarean section. Eight women (24%) conceived using assisted reproduction technology. Thirteen (42%) women required cardiopulmonary resuscitation, 18% (n = 6) had a hysterectomy and 85% (n = 28) received a transfusion of blood or blood products. Twenty (61%) were admitted to an Intensive Care Unit (ICU), eight (24%) were admitted to a High Dependency Unit (HDU) and seven (21%) were transferred to another hospital for further management. Five woman died (case fatality rate 15%) giving an estimated maternal mortality rate due to AFE of 0.8 per 100,000 women giving birth (95% CI 0.1% to 1.5%). There were two deaths among 36 infants. CONCLUSIONS: A coordinated emergency response requiring resource intense multi-disciplinary input is required in the management of women with AFE. Although the case fatality rate is lower than in previously published studies, high rates of hysterectomy, resuscitation, and admission to higher care settings reflect the significant morbidity associated with AFE. Active, ongoing surveillance to document the risk factors and short and long-term outcomes of women and their babies following AFE may be helpful to guide best practice, management, counselling and service planning. A potential link between AFE and assisted reproductive technology warrants further investigation.

Embolismo de líquido amniótico: mitos y realidades etiopatogénicas de un síndrome potencialmente fatal / Amniotic fluid embolism: etiopathogenic realities and myths of a potentially fatal syndrome

Fundamento: el embolismo de líquido amniótico es un síndrome catastrófico que ocurre durante el trabajo de parto, el parto o inmediatamente. De incidencia variable, es la segunda causa de muerte materna en muchas partes del mundo y que reporta tasas de hasta un 60 por ciento en países desarrollados. En las últimas dos décadas un trabajo de investigación más riguroso ha mejorado enormemente la comprensión de esta condición.Objetivo: exponer los elementos más recientes que intentan explicar la etiología y la fisiopatología del embolismo de líquido amniótico.Método: se realizó una revisión en 32 bibliografías entre revistas y textos clásicos, a través de la biblioteca virtual cubana, Lilacs, PubMed y Medline.Desarrollo: la embolia de líquido amniótico es, desde un punto de vista fisiopatológico, parecida al síndrome de respuesta inflamatoria sistémica, común en condiciones tales como choque séptico, en el que una respuesta anormal del huésped es la principal responsable de las manifestaciones clínicas. La teoría bimodal es la regla: una fase temprana caracterizada por vasoespasmo e hipertensión pulmonar y fallo ventricular derecho; otra tardía donde prima el fallo ventricular izquierdo, el edema pulmonar, el shock y los trastornos de la coagulación.Conclusiones: la base fisiopatológica de toda esta secuencia de alteraciones hemodinámicas parece implicar una secuencia compleja de reacciones resultantes de la activación anormal de sistemas mediadores pro inflamatorios similares a los presentes en el síndrome de respuesta inflamatoria sistémica, que sigue al casi universal paso de antígenos fetales a la circulación materna durante el proceso de parto(AU)

Background: amniotic fluid embolism is a catastrophic syndrome that takes place during the onset of labor or during the labor. This syndrome of variable incidence is the second cause of maternal death in many regions of the world. Rates up to 60 percent are reported in developed countries. A more rigid investigation has greatly increased the comprehension of this condition in the last two decades.Objective: to set out the most recent elements that try to explain the etiology and physiopathology of amniotic fluid embolism.Method: a review of 32 bibliographies, including journals and classic texts, was made through the Cuban virtual library, Lilacs, PubMed and Medline.Development: amniotic fluid embolism is, from the physiopathological point of view, similar to the systemic inflammatory response syndrome, and it is common in conditions like septic shock, in which the abnormal response of the host is the main responsible for the clinical manifestations. Bimodal theory is the rule: an early stage characterized by vasospasm and pulmonary hypertension and heart failure; and a late stage where left heart failure, pulmonary edema, shock and coagulation disorders predominate.Conclusions: the physiopathological basis of this sequence of hemodynamic changes seems to entail a complex sequence of reactions that result from the abnormal activation of proinflammatory mediator systems, similar to those present in the systemic inflammatory response syndrome that follows the almost universal flow of fetal antigens to the maternal circulation during labor(AU)

The impact of socioeconomic position on severe maternal morbidity outcomes among women in Australia: a national case-control study.

OBJECTIVE: Studies in other developed countries have suggested that socioeconomic position may be a risk factor for poorer pregnancy outcomes. This analysis aimed to explore the independent impact of socioeconomic position on selected severe maternal morbidities among women in Australia. DESIGN: A case-control study using data on severe maternal morbidities associated with direct maternal death collected through the Australasian Maternity Outcomes Surveillance System. SETTING: Australia. POPULATION: 623 cases, 820 controls. METHODS: Logistic regression analysis to investigate differences in outcomes among different socioeconomic groups, classified by Socio-Economic Indexes for Areas (SEIFA) quintile. MAIN OUTCOME MEASURES: Severe maternal morbidity (amniotic fluid embolism, placenta accreta, peripartum hysterectomy, eclampsia or pulmonary embolism). RESULTS: SEIFA quintile was statistically significantly associated with maternal morbidity, with cases being twice as likely as controls to reside in the most disadvantaged areas (adjusted OR 2.00, 95%CI 1.29-3.10). Maternal age [adjusted odds ratio (aOR) 2.20 for women aged 35 or over compared with women aged 25-29, 95%CI 1.64-3.15] and previous pregnancy complications (aOR 1.30, 95%CI 1.21-1.87) were significantly associated with morbidity. A parity of 1 or 2 was protective (aOR 0.58, 95%CI 0.43-0.79), whereas previous caesarean delivery was associated with maternal morbidity (aOR 2.20 for women with one caesarean delivery, 95%CI 1.44-2.85, compared with women with no caesareans). CONCLUSION: The risk of severe maternal morbidity among women in Australia is significantly increased by social disadvantage. This study suggests that future efforts in improving maternity care provision and maternal outcomes in Australia should include socioeconomic position as an independent risk factor for adverse outcome.

Amniotic fluid embolism: antepartum, intrapartum and demographic factors.

OBJECTIVE: To describe the incidence, antepartum, intrapartum and postpartum risk factors, and mortality rate of amniotic fluid embolism (AFE). METHODS: We used 2001-2007 California health discharge data to identify cases of AFE by ICD-9 codes. RESULTS: Of 3,556,567 deliveries during the time period, we identified 182 cases of AFE, resulting in a population incidence of 5.1 in 100,000. Twenty-four of the cases resulted in death, giving a case fatality rate of 13.2%. Non-Hispanic blacks had a higher than 2-fold odds of developing AFE. AFE increased significantly with maternal age, most significantly after age 39. Cardiac disease had a nearly 70-fold higher association with AFE, cerebrovascular disorders had a 25-fold higher association, while conditions such as eclampsia, renal disease, placenta previa and polyhydramnios had nearly 7- to 13-fold higher associations. Classical cesarean delivery, abruption placentae, dilation and curettage, and amnioinfusion were all procedures highly associated with AFE. CONCLUSION: Several antepartum and peripartum conditions and procedures are associated with significantly higher risks of amniotic fluid embolism. This information may contribute to a better understanding of the pathophysiology of AFE and potentially help identify those at the highest risk of developing this morbid condition.