Patient handout

Amniotic Fluid Embolism (AFE)

PRODUCTION

1. Your condition

This handout is for amniotic fluid embolism (afe). Your care team identified this based on: sudden cardiovascular collapse (sbp < 90 / map < 65 / cardiac arrest) + hypoxia (spo2 < 90 / cyanosis / dyspnea) during labor, delivery, or within 30 min postpartum — gateway clinical feature (clark 2016 pmid 27372270).

Other reasons your team may use this plan: sudden onset severe dyspnea + altered mental status / agitation / seizure-like activity in labor or immediate postpartum — early prodrome (clark 2016 pmid 27372270; smfm 9 pacheco 2016 pmid 26987420); sudden onset dic features (fibrinogen < 200, platelets < 100, prolonged pt/aptt, oozing iv sites, surgical-site / uterine bleeding) in immediate temporal association with delivery — clark 2016 criterion 2 (pmid 27372270); maternal cardiac arrest in 3rd trimester (≥ 20–24 wk by fundal height) with no clear cause — perimortem cesarean within 4–5 min indication (aha 2015 maternal arrest pmid 26443610; aha 2024 update).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
epinephrine	1 mg IV/IO q3–5 min during cardiac arrest	IV/IO	q3–5 min during arrest	AHA 2020 ACLS standard; left-uterine displacement maintained throughout; perimortem cesarean if no ROSC in 4–5 min
amiodarone	300 mg IV/IO bolus for VF/pulseless VT; 150 mg IV/IO repeat if refractory	IV/IO	bolus, may repeat × 1	AHA 2020 ACLS — shockable rhythm management

Plan: AFE acute resuscitation — ATLS/ACLS + perimortem cesarean + pulmonary vasodilators + vasoactive support + massive transfusion + ECMO consideration (Clark 2016 PMID 27372270 + SMFM 9 Pacheco 2016 PMID 26987420 + AHA 2015 maternal arrest PMID 26443610 + ELSO 2020 obstetric ECMO + ESC Pregnancy 2018 PMID 30165544)

3. When to call your provider

Contact your care team if any of the following happen:

New mental health crisis (PHQ-9 ≥ 15 or suicidal ideation or PTSD impairment) → urgent mental health referral
Newborn high-risk features (persistent feeding issues, neurodevelopmental concerns) → urgent peds visit
New cardiac symptoms (dyspnea, edema, palpitations) → cardiology urgent visit
New bleeding / bruising / coagulopathy → hematology urgent visit
Persistent cognitive / neurologic deficits → neurology + neuropsychology + rehabilitation escalation

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Amniotic fluid embolism at presentation — sudden cardiopulmonary collapse + hypoxia ± DIC during labor / delivery / immediate postpartum within 30 min (Clark 2016 criteria PMID 27372270) — life-threatening; immediate ATLS + ACLS framework + left-uterine displacement + multidisciplinary team activation (OB + anesthesia + critical care + cardiothoracic / ECMO + neonatology + hematology); do NOT delay treatment for confirmatory imaging — diagnosis is clinical(life-threatening)
Maternal cardiac arrest in 3rd trimester (GA ≥ 20–24 wk by fundal height) with no immediate response to ACLS — life-threatening; perimortem cesarean within 4–5 min improves both maternal venous return + fetal outcomes (AHA 2015 maternal arrest PMID 26443610; AHA 2024 update); do NOT delay for confirmatory imaging or fetal viability assessment(life-threatening)
AFE phase 2 — overt DIC + active obstetric hemorrhage (uterine atony, surgical-site bleeding, oozing IV sites, mucosal bleeding) — life-threatening; massive transfusion protocol 1:1:1 PRBC:FFP:platelets + cryoprecipitate 10 units if fibrinogen < 200 + tranexamic acid 1 g IV within 3 h + factor VIIa or PCC per hematology consult; surgical hemostasis if uncontrolled (uterotonics + tamponade + B-Lynch + uterine artery ligation + hysterectomy)(life-threatening)
AFE phase 1 — acute pulmonary HTN + right ventricular failure pattern on echocardiogram (dilated RV + flattened septum) + profound hypoxia — life-threatening; inhaled nitric oxide 20–40 ppm first-line + sildenafil 20–40 mg PO/NG q4–8h + milrinone 0.25–0.5 mcg/kg/min IV + epoprostenol inhaled or IV; norepinephrine for systemic hypotension + dobutamine for low CO; refractory → VA-ECMO consideration(life-threatening)
AFE phase 2 — LV failure + pulmonary edema + cardiogenic shock (typically after phase 1 RV failure resolves but LV dysfunction emerges) — life-threatening; inotropes (dobutamine or milrinone) + cautious diuresis + vasoactive support; avoid fluid overload; mechanical ventilation with optimised PEEP; ECMO consideration if refractory(life-threatening)
Refractory AFE cardiopulmonary collapse despite max NE + AVP + milrinone + iNO + epoprostenol + MTP — life-threatening; VA-ECMO consideration as bridge to recovery; multidisciplinary decision (critical care + cardiothoracic + OB + ethics); mortality on ECMO still ~ 50% but recovery is genuinely achievable in select cases (ELSO 2020 obstetric ECMO registry + Sharma 2017 PMID 25248040)(life-threatening)
AFE survivor with hypoxic-ischemic encephalopathy (HIE) — post-ROSC persistent coma, focal neurologic deficits, or cognitive impairment — severe; targeted temperature management 32–36°C × 24 h if comatose immediately post-ROSC (AHA 2020); neurology + neuropsychology consultation + multimodal prognostication at 72 h post-rewarming; rehabilitation services (PT, OT, speech) as recovery progresses; family + ethics support
Broad differential evaluation in parallel with resuscitation — pulmonary embolism (CT-PA + d-dimer + echo RV strain pattern), septic shock (fever ≥ 38.0°C excludes AFE per Clark 2016 criterion 4; blood cultures + procalcitonin), anaphylaxis (allergen trigger + skin findings + tryptase + epinephrine response), eclampsia (HTN + seizure + pre-eclampsia history + magnesium response), peripartum cardiomyopathy with cardiogenic shock, acute MI / SCAD, tension pneumothorax, total spinal anesthetic, uterine rupture, placental abruption with DIC — severe; do NOT delay resuscitation for confirmatory imaging — treat empirically based on temporal association + DIC + cardiopulmonary collapse pattern; CT-PA only if patient stable enough + AFE / PE ambiguity persists

5. Follow-up

6-wk postpartum visit + AFE-specific anticipatory guidance. Survivors at risk for hypoxic-ischemic encephalopathy → neurology + neuropsychology evaluation; rehabilitation services as needed. Mental health screen — high risk for peripartum PTSD (PCL-5) + postpartum depression (EPDS) given catastrophic peripartum event. Subsequent-pregnancy counseling: recurrence rare (~ 1%; AFE Registry data); NOT a contraindication to pregnancy but high-risk MFM coordination + delivery at tertiary center with on-call critical care + ECMO capability. Newborn outpatient peds 24–48 h post-discharge + developmental tracking for first year (high CP / BPD risk if hypoxic-ischemic exposure). Cardiothoracic / pulmonology follow-up if RV recovery incomplete. Hematology follow-up if persistent coagulopathy. Family + psychosocial support; survivor support groups (AFE Foundation).

6. Sources

Guideline: Clark SL et al — Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies (Am J Obstet Gynecol 2016 PMID 27372270) — canonical clinical diagnostic criteria anchor + SMFM Consult Series 9 — Amniotic fluid embolism: diagnosis and management (Pacheco LD, Saade G, Hankins GDV; Am J Obstet Gynecol 2016 PMID 26987420) + Conde-Agudelo A, Romero R (Am J Obstet Gynecol 2009 PMID 19879393) — epidemiology + outcomes anchor + Knight M et al, UKOSS (Obstet Gynecol 2010 PMID 20410762) — UK national surveillance + Clark SL (Am J Obstet Gynecol 1995 PMID 7726251) — original anaphylactoid hypothesis + AHA 2015 maternal arrest (Jeejeebhoy FM et al, Circulation 2015 PMID 26443610; AHA 2024 update) — perimortem cesarean within 4–5 min + ELSO 2020 obstetric ECMO registry + Sharma NS et al (ASAIO J 2015 PMID 25248040) — ECMO in pregnancy/postpartum series (incl AFE) + Rezai S et al (Case Rep Obstet Gynecol 2017 PMID 29430313) — A-OK proposed empiric combination + Pacheco LD et al (Am J Obstet Gynecol 2016 PMID 26348379) — massive transfusion protocols in obstetrics + WOMAN trial Shakur 2017 (PMID 28456509) — TXA in PPH + ESC Pregnancy 2018 (Regitz-Zagrosek V et al PMID 30165544) — pulmonary vasodilator + RV support framework