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Grand Rounds

Amniotic Fluid Embolism: What are the Outcomes and Maternal Mortality Rates?

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BACKGROUND AND PURPOSE:

  • Mazza et al. (JAMA Network Open, 2022) examined the clinical, pregnancy, and delivery characteristics and maternal outcomes related to amniotic fluid embolism (AFE)

METHODS:

  • Retrospective cohort study
  • Population
    • Vaginal or cesarean deliveries from January 2016, to December 2019
    • Data obtained from the Healthcare Cost and Utilization Project’s National Inpatient Sample (NIS)
    • NIS represents hospital discharge data for more than 90% of the US population | Survey weights based on a random sampling of 20% of hospitalized patients annually
  • Exposure
    • AFE
  • Study design
    • The role of AFE on outcomes was assessed using a  logistic regression model
  • Primary outcome
    • Clinical, pregnancy and delivery characteristics of AFE
    • Maternal mortality after AFE
  • Secondary outcomes
    • Severe maternal morbidity indicators
    • Maternal mortality per clinical and pregnancy characteristics

RESULTS:

  • 14,684,135 deliveries
    • Median age: 29 (IQR, 25 to 33 years)
  • AFE diagnoses: 880
    • Incidence rate: 6.0 per 100,000 deliveries
  • In the multivariable analysis the following factors were associated with AFE
    • Patient factors
      • Older age | Asian and Black race | Western US region | Pregestational hypertension | Asthma | Illicit substance use | Grand multiparity
    • Pregnancy factors
      • Placental accreta spectrum (PAS) | Placental abruption | Uterine rupture | Polyhydramnios | Chorioamnionitis | Preeclampsia | Fetal growth restriction | Fetal demise
    • Delivery factors
      • Early gestational age | Cervical ripening | Cesarean delivery | Operative delivery | Manual removal
  • Among these, placental accreta spectrum had the largest association with AFE
    • Adjusted odds ratio (aOR) 10.01 (95% CI, 7.03 to 14.24)
  • When stratified by the PAS subtypes, more severe forms of PAS had a greater association with AFE
    • Increta and percreta: aOR 17.35 (95% CI, 10.21 to 28.48)
    • Accreta: aOR 7.62 (95% CI, 4.8 to 12.01)
  • Patients who had AFE were more likely to experience
    • Coagulopathy
      • aOR 24.68 (95% CI, 19.38 to 31.44)
    • Cardiac arrest
      • aOR 24.56 (95% CI, 17.84 to 33.81)
    • Adult respiratory distress syndrome
      • aOR 10.72 (95% CI, 8.09 to 14.20)
  • The maternal mortality rate after AFE: 17.0%
  • This rate exceeded 30% when AFE co-occurred with other severe maternal morbidity indicators
    • AFE, cardiac arrest, and coagulopathy: 45.8%
    • AFE, shock, and cardiac rhythm conversion: 43.2%
    • AFE, cardiac arrest, coagulopathy, and shock: 38.6%
  • The maternal mortality rate also exceeded 30% when AFE occurred in the setting of placental pathology
    • AFE and PAS: 42.9%
    • AFE and placental abruption: 31.3%

CONCLUSION:

  • In this population, AFE occurred in 6.0 of every 100,000 deliveries
  • Risk factors associated with AFE were identified
    • Placenta accreta spectrum had the largest association with AFE
  • Maternal mortality after AFE was high at 17.0%
    • This rate increased if AFE co-occurred with other maternal morbidity indicators or placental pathology
  • The authors state

It is unknown whether adherence to the Society for Maternal-Fetal Medicine checklist for initial management of AFE is associated with improved maternal outcome

Other studies suggested the importance of high-quality cardiopulmonary resuscitation; correction of coagulopathy, including tranexamic acid use; and extracorporeal membrane oxygenation use for AFE management, but these procedures were not assessed in this study

Learn More – Primary Sources:

Association of Pregnancy Characteristics and Maternal Mortality With Amniotic Fluid Embolism

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Related ObG Topics:

What is the Validity of the SMFM/AFE Foundation Amniotic Fluid Embolism Criteria in a Population-based Cohort?
Pregnancy-Related Deaths in the U.S.: How Many are Preventable?
CDC Reports: US Maternal Mortality Rates for 2020

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