Available online 20 April 2023, 102597

Author links open overlay panel, , , , , , , , ABSTRACTOBJECTIVE

Amniotic fluid embolism (AFE) is a rare life-threatening complication in obstetrics, but the diagnosis lacks a consensual definition. The objective of this study was to compare two different AFE classification systems by analysing the AFE cases from two university hospitals.

MATERIAL AND METHODS

In this retrospective study, all patients with a strong suspicion of AFE between 2014 and 2021 at two university hospitals, LMU Women's University Hospital Munich, and Women's University Hospital Basel, were included. Patient records were checked for the ICD-10 code O88.1 (AFE). Diagnoses were confirmed through clinical findings and/or autopsy. The presence of the diagnostic criteria of the Society of Maternal Fetal Medicine (SMFM) and the AFE Foundation (AFEF) and of a new framework by Ponzio-Klijanienko et al. from Paris, France, were checked and compared using Chi-square-test.

RESULTS

Within our study period, 38,934 women delivered in the two hospitals. Six patients had a strong suspicion of AFE (0.015%). Only three of six patients (50%) presented with all the four diagnostic criteria of the SMFM/AFEF framework. All six patients met the criteria of the modified “Paris AFE framework”.

CONCLUSION

Using the “Paris AFE framework” based exclusively on clinical criteria can help clinicians to diagnose AFE, anticipate the life-threatening condition of the patient and prepare immediately for best clinical care.

Section snippetsINTRODUCTION

Amniotic fluid embolism (AFE) is a rare and unpredictable complication in obstetrics and has still a high maternal mortality rate [1]. Few obstetricians will have to treat a patient with AFE as the reported incidence is between 2-8:100,000 births [2,3]. This underlines the need for clear diagnostic criteria to help manage this rare condition.

First described by Meyer in 1926 [4], the clinical entity was established according to autopsies from Steiner and Lushbaugh in 1941 [5]. The name “AFE”

STUDY POPULATION AND PATIENT DATA

In this retrospective study, we screened all women who gave birth from January 1st, 2014 until December 31st, 2021 at two university hospitals: LMU Munich, Germany, Campus Innenstadt and University Hospital Basel, Switzerland. Both clinics are classified as perinatal centres of the highest level and treat women in all weeks of pregnancy without any restrictions.

We searched the digital patient records for the ICD-10 code O88.1 (AFE). The diagnosis of AFE had to be mentioned in the clinical file

OVERALL PATIENT CHARACTERISTICS

In total, 38,934 births took place in two large university hospitals from 2014 to 2021, 18,135 at Campus Innenstadt of LMU Munich and 20,799 at University Hospital Basel. Among all cases, we found six cases of AFE, which means 0.02% or 15.4/100,000 deliveries, four cases at LMU Munich and two cases at University Hospital Basel.

DETAILED ANALYSIS OF THE SIX AFE CASES

Each case of AFE at our institutions was a life-threatening condition for mother and child. In terms of overall survival, we have to report one maternal death (16.7%),

DISCUSSION

The reported incidence of AFE lies between 2-8:100,000 births according to the established literature [2,3]. In our collective, we found six cases in around 39,000 births which marks an incidence of 15:100,000 births. This corresponds to the numbers of Ponzio-Klijanienko et al. [18]. We suspect this higher incidence is caused by counting all cases, including survivors and not only fatal cases leading to autopsy, which has been done heterogeneously in different publications leading to lower

CONCLUSION

Clear diagnostic criteria which fit into the clinical setting help to diagnose more cases of AFE and to manage this rare condition, especially as it is a “once in a life-time event” for most of the treating medical staff. We confirmed that using the “Paris AFE framework” based exclusively on clinical criteria can help clinicians to diagnose AFE, anticipate the life-threatening condition of the patient and prepare immediately for best clinical care.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

Sven Mahner declares research funding, advisory board, honorary or travel expenses:  AbbVie, AstraZeneca, Clovis, Eisai, GlaxoSmithKline, Hubro, Medac, MSD, Novartis, Nykode, Olympus, PharmaMar, Pfizer, Roche, Sensor Kinesis, Teva, Tesaro. The other authors declare no conflict of interest.

ACKNOWLEDGEMENTS

Figure 1 was created with BioRender.com. We thank our colleague Heather Mullikin for her detailed review of the manuscript regarding wording and grammar.

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PE Steiner et al.Landmark article, Oct. 1941: Maternal pulmonary embolism by amniotic fluid as a cause of obstetric shock and unexpected deaths in obstetricsLandmark article, Oct. 1941: Maternal pulmonary embolism by amniotic fluid as a cause of obstetric shock and unexpected deaths in obstetrics

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SL. ClarkAmniotic fluid embolism

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