Last updated on Fri, 06/08/2018 - 18:41
Highest mark: 8.3
This question relates to the critically ill obstetric patient.
a) List the diagnostic criteria for peri-partum cardiomyopathy. (30%marks)
With respect to amniotic fluid embolism (AFE):
i. List six important risk factors.(30% marks)
ii. Outline the important clinical features.(40% marks)
• Onset of heart failure in the last month of pregnancy or within 5 months post-partum
• Absence of an identifiable cause of heart failure
• Absence of recognizable heart disease prior to the last month of pregnancy
• LV systolic dysfunction demonstrated by classical echocardiographic criteria. The latter
may be characterized as an LV ejection fraction < 45%, fractional shortening < 30%, or
both, with or without an LV end-diastolic dimension 2.7 cm/m2 body surface area. (This
level of detail not expected)
i. List six important risk factors
• Precipitous or tumultuous labour.
• Advanced maternal age.
• Caesarean and instrumental delivery.
• Placenta previa and abruption.
• Grand multi-parity (≥5 live births or stillbirths),
• Cervical lacerations.
• Foetal distress.
• Medical induction of labour.
ii. Outline the important clinical features of amniotic fluid embolism
• The onset of the symptoms and signs of amniotic fluid embolism syndrome
(AFES) most commonly occurs during labour and delivery, or immediately
• Non-specific symptoms – chills, nausea, vomiting, agitation
• Hypotension due to cardiogenic shock
• Hypoxemia and respiratory failure
• Disseminated intravascular coagulation
• Coma or seizures
In actual fact there are several competing definitions, of which the college offers one which is probably the least vague. Here is a table from the ESC statement (Sliwa et al, 2010)
Characteristic features of peripartum cardiomyopathy (also from Sliwa et al):
- It is usually a postpartum process: only 9% present antepartum. NHL-BIOR definition calls it PPCM if it is one month before or five months after delivery, but the ESC people felt this (totally arbitrary) timeframe would lead to underdiagnosis.
- There is mainly LV dysfunction
- The LV is usually dilated (if it is dilated beyond 60mm, the chances of recovery are small)
- It usually gets better: An estimated 23%-54% of patients show complete recovery of their systolic function within 6 months.
To mix up the college answer with an article by Knight et al (2012)
- Precipitous or tumultuous labour.
- Ethnic minority background
- Emergency delivery
- Smoking during pregnancy
- Socioeconomic disadvantage
- Age over 35 (what the college describes as "advanced maternal age", otherwise known as "checkout time" )
- Caesarean and instrumental delivery.
- Placenta previa and abruption.
- Grand multi-parity (≥5 live births or stillbirths),
- Cervical lacerations.
- Foetal distress.
- Medical induction of labour.
Cardinal clinical features:
- Altered mental status
Other associated features are listed by Moore et al (2005):
- Foetal distress
- Nausea / vomiting
Moore, Jason, and Marie R. Baldisseri. "Amniotic fluid embolism." Critical care medicine 33.10 (2005): S279-S285.
Meyer, JR "Embolia pulmonar amnio caseosa". Brasil Medico. 1926; 2:301.
Attwood, H. D. "The histological diagnosis of amniotic‐fluid embolism." The Journal of Pathology 76.1 (1958): 211-215.
Steiner, Paul E., and Clarence Chancelum Lushbaugh. "Maternal pulmonary embolism by amniotic fluid: as a cause of obstetric shock and unexpected deaths in obstetrics." Journal of the American Medical Association 117.15 (1941): 1245-1254.
Tuffnell, D. J. "United Kingdom amniotic fluid embolism register." BJOG: An International Journal of Obstetrics & Gynaecology 112.12 (2005): 1625-1629.
Conde-Agudelo, Agustín, and Roberto Romero. "Amniotic fluid embolism: an evidence-based review." American journal of obstetrics and gynecology 201.5 (2009): 445-e1.
Tamura, Naoaki, et al. "Amniotic fluid embolism: Pathophysiology from the perspective of pathology." Journal of Obstetrics and Gynaecology Research43.4 (2017): 627-632.
Sideris, Ioannis G., and Kypros H. Nicolaides. "Amniotic fluid pressure during pregnancy." Fetal diagnosis and therapy 5.2 (1990): 104-108.
Uyeno, Doko. "The physical properties and chemical composition of human amniotic fluid." Journal of Biological Chemistry 37.1 (1919): 77-103.
Lim, Y., et al. "Recombinant factor VIIa after amniotic fluid embolism and disseminated intravascular coagulopathy." International Journal of Gynecology & Obstetrics 87.2 (2004): 178-179.
Davies, Sharon. "Amniotic fluid embolism and isolated disseminated intravascular coagulation." Canadian Journal of Anesthesia 46.5 (1999): 456-459.
Kaneko, Yuhko, et al. "Continuous Hemodiafiltration for Disseminated Intrav ascular Coagulation and Shock due to Amniotic Fluid Embolism: Report of a Dramatic Response." Internal medicine 40.9 (2001): 945-947.
Awad, I. T., and G. D. Shorten. "Amniotic fluid embolism and isolated coagulopathy: atypical presentation of amniotic fluid embolism." European journal of anaesthesiology 18.6 (2001): 410-413.
Waters, Jonathan H., et al. "Amniotic fluid removal during cell salvage in the cesarean section patient." The Journal of the American Society of Anesthesiologists 92.6 (2000): 1531-1536.
Knight, Marian, et al. "Incidence and risk factors for amniotic-fluid embolism."Obstetrics & Gynecology 115.5 (2010): 910-917.
Knight, Marian, et al. "Amniotic fluid embolism incidence, risk factors and outcomes: a review and recommendations." BMC pregnancy and childbirth12.1 (2012): 7.