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For the parturient undergoing labor and delivery, amniotic fluid embolism (AFE) is a rare but potentially life-threatening emergency. AFE is caused by fetal components entering maternal circulation, producing massive broncho- and vasoconstriction, leading ultimately to cardiopulmonary arrest. AFE is characterized by coagulopathies and little response to classic resuscitation efforts. Atropine, ondansetron, and ketorolac (AOK) are common medications utilized by anesthesia providers in many routine scenarios. Each medication comes with potential side effects, but when administered in appropriate situations at recommended doses, they yield promising results. The combination of AOK has been found to protect and save patients experiencing an AFE not responding to advanced cardiopulmonary life support (ACLS). The AOK for AFE protocol should be utilized as soon as AFE is suggested to stabilize the patient and prevent any potential neurological deficits.

For the parturient undergoing labor and delivery, amniotic fluid embolism (AFE) is a rare but potentially life-threatening emergency. AFE is caused by fetal components entering maternal circulation, producing massive broncho- and vasoconstriction, leading ultimately to cardiopulmonary arrest. AFE is characterized by coagulopathies and little response to classic resuscitation efforts. Atropine, ondansetron, and ketorolac (AOK) are common medications utilized by anesthesia providers in many routine scenarios. Each medication comes with potential side effects, but when administered in appropriate situations at recommended doses, they yield promising results. The combination of AOK has been found to protect and save patients experiencing an AFE not responding to advanced cardiopulmonary life support (ACLS). The AOK for AFE protocol should be utilized as soon as AFE is suggested to stabilize the patient and prevent any potential neurological deficits. In this evidence-based case report, a 42-year-old female presented for a repeat cesarean section (CS) where the AOK for AFE protocol was utilized in a preventative manner.

Objective: To identify the lessons learned from women who died during pregnancy or childbirth in Lebanon between 2018 and 2020. Method: This is a case series and synthesis of maternal deaths between 2018 and 2020 that were reported by healthcare facilities to the Ministry of Public Health in Lebanon. The notes recorded from the maternal mortality review reports were analyzed using the “Three Delays” model to identify preventable causes and lessons learned. Results: A total of 49 women died before, during, or after childbirth, with hemorrhage being the most frequent cause (n = 16). The possible factors that would have prevented maternal deaths included a prompt recognition of clinical severity, availability of blood for transfusion and magnesium sulfate for eclampsia, adequate transfer to tertiary care hospitals comprising specialist care, and involvement of skilled medical staff in obstetric emergencies. Conclusion: Many maternal deaths in Lebanon are preventable. Better risk assessment, use of an obstetric warning system, access to adequately skilled human resources and medications, and improved communication and transfer mechanisms between private and tertiary care hospitals may avoid future maternal deaths.

Amniotic fluid embolism (AFE) is a catastrophic condition in the peripartum period and still remains as a leading cause of maternal death. Although over 80% of cases of AFE cases are accompanied by coagulopathy, the pathology of disseminated intravascular coagulation is not well understood not only because of its rarity but also because of the limited availability of laboratory testing in emergent clinical settings....

AIM: We aimed to evaluate the clinical usefulness of serum squamous cell carcinoma (SCC) antigen for the diagnosis of amniotic fluid embolism (AFE). METHODS: Sera and information of 20 patients with AFE (autopsy-proven AFE, four cases; clinical AFE, 16 cases) were obtained from the Japan Amniotic Fluid Embolism Registration Center at Hamamatsu University School of Medicine. As controls, we included 74 gestational-age-matched healthy women who gave birth to healthy newborns during the period from December 2012 to January 2014. Receiver-operator curves (ROC) were used to evaluate the diagnostic performance of SCC levels for prediction of AFE. RESULTS: Serum SCC antigen levels in women with autopsy-proven AFE (112.0 ± 169.4 ng/mL, P = 0.001) and clinical AFE (9.5 ± 10.3 ng/mL, P = 0.004) were significantly higher than those in healthy controls with normal delivery (4.4 ± 2.2 ng/mL). On ROC analysis, the optimal cut-off value for SCC antigen levels was 7.15 ng/mL, for which the sensitivity and specificity for AFE prediction was 60.0% and 89.2%, respectively (area under the ROC, 0.785; 95% confidence interval, 0.663-0.908; P < 0.001). CONCLUSION: Serum SCC antigen may be a promising predictor of the entry of amniotic fluid into the maternal circulation, potentially serving as a candidate marker for noninvasive diagnosis of AFE., 博士（医学）・乙第1436号・令和元年9月27日, © 2017 Japan Society of Obstetrics and Gynecology, This is the peer reviewed version of the following article: [https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/jog.13453], which has been published in final form at [https://doi.org/10.1111/jog.13453]. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.

Two types of amniotic fluid embolism (AFE) have been described : cardiopulmonary collapse type and disseminated intravascular coagulation (DIC) type, with the latter proposed as uterine type. This report describes a healthy 28-year-old woman who developed AFE during a cesarean section. Because of a previous cesarean section, the patient underwent an elective cesarean section, under combined spinal-epidural anesthesia, at 38 weeks of pregnancy. She began coughing 5 minutes after delivery of the fetus, subsequently becoming unconscious and developing glossoptosis and bradycardia. Her blood pressure decreased to 76/43 mmHg, and AFE was suspected. Her uterus was atonic, and she experienced persistent noncoagulant bleeding, with a final blood loss of 6300 ml. Considerable blood transfusion was required. The patient survived, and she and her baby were discharged without any sequelae on the eighth postoperative day. This patient met the Japanese criteria for clinical AFE, with an obstetrical DIC score of 21 meeting the criteria for obstetrical DIC. Early diagnosis and treatment likely resulted in patient survival.

Objective: Develop a core outcome set of international consensus definitions for severe maternal morbidities. Design: Electronic Delphi study. Setting: International. Population: Eight expert panels. Methods: All 13 high-income countries represented in the International Network of Obstetric Surveillance Systems (INOSS) nominated five experts per condition of morbidity, who submitted possible definitions. From these suggestions, a steering committee distilled critical components: eclampsia: 23, amniotic fluid embolism: 15, pregnancy-related hysterectomy: 11, severe primary postpartum haemorrhage: 19, uterine rupture: 20, abnormally invasive placentation: 12, spontaneous haemoperitoneum in pregnancy: 16, and cardiac arrest in pregnancy: 10. These components were assessed by the expert panel using a 5-point Likert scale, following which a framework for an encompassing definition was constructed. Possible definitions were evaluated in rounds until a rate of agreement of more than 70% was reached. Expert commentaries were used in each round to improve definitions. Main outcome measures: Definitions with a rate of agreement of more than 70%. Results: The invitation to participate in one or more of eight Delphi processes was accepted by 103 experts from 13 high-income countries. Consensus definitions were developed for all of the conditions. Conclusion: Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process. These should be used in national registrations and international studies, and should be taken up by the Core Outcomes in Women's and Newborn Health initiative. Tweetable abstract: Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process.

BACKGROUND: Intra-operative cell salvage is not routinely used during cesarean delivery because it is not cost-effective for patients at low risk of hemorrhage and there are theoretical concerns about amniotic fluid embolism. Some guidelines recommend using leukocyte depletion filters to decrease the risk of amniotic fluid embolism before re-infusing salvaged blood, but these filters are not available in Japan. We compared the efficacy and safety of leukocyte depletion and micro-aggregate filters in combination with intra-operative cell salvage during cesarean delivery.METHODS: Blood was collected in a Cell Saver 5 reservoir during cesarean delivery. Four samples were collected: pre-wash, post-wash, post-filtration with a leukocyte depletion filter and post-filtration with a micro-aggregate filter. Each sample was analyzed for amniotic fluid markers of zinc coproporphyrin-1 and sialyl-Tn, for fetal hemoglobin, and the sample underwent pathological examination for white blood cells and squamous cells. Post-filtration samples were compared using paired t-tests with P <0.05 indicating statistical significance.RESULTS: Zinc coproporphyrin-1 and sialyl-Tn were negative at almost all sample points. Squamous cells decreased by 59.1% post-wash and 91.2% post-filtration using a leukocyte depletion filter. Leukocyte depletion filters removed 99.7% of white blood cells and were more effective in removing white blood cells than micro-aggregate filters (P=0.02).CONCLUSION: Leucocyte depletion filters are more effective in removing white blood cells and squamous cells than micro-aggregate filters, and their introduction for intra-operative cell salvage during cesarean delivery should be considered in Japanese clinical practice., source:Elsevier, source:https://www.clinicalkey.jp/#!/content/playContent/1-s2.0-S0959289X1830462X?returnurl=null&referrer=null

Objective: Develop a core outcome set of international consensus definitions for severe maternal morbidities. Design: Electronic Delphi study. Setting: International. Population: Eight expert panels. Methods: All 13 high-income countries represented in the International Network of Obstetric Surveillance Systems (INOSS) nominated five experts per condition of morbidity, who submitted possible definitions. From these suggestions, a steering committee distilled critical components: eclampsia: 23, amniotic fluid embolism: 15, pregnancy-related hysterectomy: 11, severe primary postpartum haemorrhage: 19, uterine rupture: 20, abnormally invasive placentation: 12, spontaneous haemoperitoneum in pregnancy: 16, and cardiac arrest in pregnancy: 10. These components were assessed by the expert panel using a 5-point Likert scale, following which a framework for an encompassing definition was constructed. Possible definitions were evaluated in rounds until a rate of agreement of more than 70% was reached. Expert commentaries were used in each round to improve definitions. Main outcome measures: Definitions with a rate of agreement of more than 70%. Results: The invitation to participate in one or more of eight Delphi processes was accepted by 103 experts from 13 high-income countries. Consensus definitions were developed for all of the conditions. Conclusion: Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process. These should be used in national registrations and international studies, and should be taken up by the Core Outcomes in Women's and Newborn Health initiative. Tweetable abstract: Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process.

A 42-year-old woman diagnosed as marginal placenta previa underwent cesarean section and bilateral tubal ligation under general anesthesia in 37th gestational week. Uterine contraction after delivery was good, but atonic bleeding progressed during tubal ligation. Oxytocic drugs were ineffective. We suspected obstetrical DIC and started treatment for DIC immediately, but the bleeding lasted. After total hysterectomy, she had stable vital signs. She broke away from DIC immediately after surgery. Intraoperative findings were satisfied the criteria for clinical uterine type amniotic fluid embolism (AFE). Although AFE indicates a bad prognosis, we saved her without any sequelae.

Key Clinical Message: Hypofibrinogenemia is rare in pulmonary thromboembolism. A pregnant woman with dyspnea, abdominal pain, restlessness, agitation and protein S deficiency exhibited normal blood oxygenation and high D-dimer (370 mu g/mL) and undetectable fibrinogen levels in the blood. The pathogenesis responsible for present findings may have some features similar to amniotic fluid embolism.

Key Clinical Message: Hypofibrinogenemia is rare in pulmonary thromboembolism. A pregnant woman with dyspnea, abdominal pain, restlessness, agitation and protein S deficiency exhibited normal blood oxygenation and high D-dimer (370 mu g/mL) and undetectable fibrinogen levels in the blood. The pathogenesis responsible for present findings may have some features similar to amniotic fluid embolism.

Embólia plodovou vodou je nečakanou, vzácnou a dramatickou pôrodníckou komplikáciou s fatálnymi následkami. Ide o kritický stav, ktorý si vyžaduje ofenzívny anestéziologický postup a intenzívnu starostlivosť. Cieľom nášho príspevku je predstaviť kazuistiku pacientky s embóliou plodovej vody počas spontánneho pôrodu, na základe tejto kazuistiky opísať neodkladné ošetrovateľské intervencie v anestéziológii v súvislosti s touto komplikáciou a zároveň poukázať aj na nevyhnutnosť úzkej medziodborovej spolupráce., Amniotic fluid embolism is an unexpected, rare and dramatical obstetric complication which has fatal consequences. It is a critical state, which requires the intervention of Anaesthesia and intensive care. The objectives of this article are to present the case study about pacient with amniotic fluid embolism during the spontaneous childbirth. Another object is describe the urgent nursing intervencions in Anaesthetist related to this complication and to also point out the necessity narrow interdisciplinary cooperation.