⚡ Amniotic Fluid Embolism
IN REVIEWPENDING CLINICAL VERIFICATIONTIME-CRITICAL PROTOCOL
1 RECOGNIZE
- Sudden respiratory compromise, hypotension/cardiac arrest and/or major coagulopathy during labour, birth or the early postpartum period; consider AFE alongside haemorrhage, PE, anaphylaxis and other causes.
- AFE is a clinical diagnosis; no single laboratory test confirms or excludes it.
2 CALL FOR HELP
- Full obstetric, anaesthetic, resuscitation, blood-bank and critical-care response; assign a team leader and family-communication lead.
3 IMMEDIATE ACTION
- Support oxygenation and ventilation immediately; if arrested, standard high-quality ALS with pregnancy modifications and early resuscitative-hysterotomy preparation.
- Treat haemodynamic collapse with monitored vasopressor/inotropic support guided by physiology/echo; avoid reflex large fluid loads that worsen right/left ventricular failure.
- Assess coagulopathy early and activate major-haemorrhage support when bleeding/DIC is present, with fibrinogen, platelets and appropriate components.
- Do not delay support while seeking a confirmatory AFE test or administering an unproven “A-OK” drug cocktail.
Drug doses & preparation
Choose the regimen for the stated indication. Alternatives are not instructions to give every medicine. Check prior doses, contraindications, concentration and the response before repeating.
Adrenaline — cardiac arrestResuscitation Council UKchecked
Dose1 mg
RouteIV or IO
FrequencyEvery 3–5 min during CPR; immediately for non-shockable rhythm, after the third shock for shockable rhythm
DurationDuring ongoing resuscitation, until ROSC or team decision
PreparationUse a 1 mg/10 mL (0.1 mg/mL) resuscitation syringe. If using 1 mg/mL stock, 1 mL diluted to FINAL 10 mL gives 0.1 mg/mL; independently check. Flush the IV/IO line and continue compressions
Max dose1 mg each scheduled dose; do not confuse with 0.5 mg IM anaphylaxis treatment
- Indication: Maternal cardiac arrest following the adult ALS algorithm
Monitoring
- Rhythm checks, CPR quality, capnography and reversible causes; use usual defibrillation energy in pregnancy
Contraindications: Do not use an IM anaphylaxis approach to treat cardiac arrest; CPR/defibrillation are not delayed for drugs
Norepinephrine (noradrenaline) — MSF peripheral protocolMSFchecked
DoseStart 0.1 microgram/kg/min of NOREPINEPHRINE TARTRATE; increase by 0.05 microgram/kg/min as required
RouteIV infusion pump through a suitable monitored large vein
FrequencyContinuous infusion; MSF reassessment/titration every 10 min initially
DurationUntil perfusion and BP recover; taper gradually, do not stop abruptly
PreparationFor the cited stock 8 mg TARTRATE/4 mL (=4 mg BASE/4 mL): 2 mL contains 4 mg tartrate. Add 38 mL compatible fluid for FINAL 40 mL =100 micrograms TARTRATE/mL. Rate = dose × kg ×60 ÷100 mL/h; at 70 kg and 0.1, rate=4.2 mL/h
Max doseMSF peripheral protocol ceiling 1 microgram/kg/min TARTRATE; persistent/escalating shock requires ICU and central/arterial access planning
- Indication: Persistent shock while fluid responsiveness/source control are addressed; first-line vasopressor in maternal septic shock
Monitoring
- Continuous ECG, frequent BP (arterial when possible), perfusion and urine output; inspect peripheral site frequently for extravasation
- Clearly label SALT versus BASE: this MSF tartrate dose is twice the numerical BASE dose; NEVER copy its pump rate into a base-labelled concentration
Contraindications: Correct hypovolaemia in parallel; vasopressors do not replace haemorrhage control/blood replacement · Extravasation threatens tissue; use a dedicated monitored line, not an unobserved small distal cannula
4 INVESTIGATIONS (never delaying treatment)
- CBC/platelets, PT/APTT/fibrinogen, blood gas/lactate, ionised calcium, electrolytes and crossmatch; bedside echo to guide haemodynamic management when available.
5 DEFINITIVE MANAGEMENT
- Multidisciplinary critical care, haemostasis and cause reassessment; treat ventricular failure, respiratory failure and DIC according to the observed physiology.
- Expedite birth when indicated for maternal resuscitation/obstetric reasons; neonatal team provides a separate resuscitation pathway.
- Consider mechanical circulatory/extracorporeal support in an experienced centre for selected refractory failure.
6 ESCALATION
- ICU-level care for suspected AFE with cardiorespiratory compromise; early referral to a centre with appropriate circulatory/respiratory support if feasible.
7 POST-EVENT CARE
- Serial organ-function, coagulation and neurological assessment; coordinated rehabilitation and psychological support for survivors/families.
- Document the diagnostic reasoning, timeline and treatments and undertake multidisciplinary review.
Admission & discharge after the acute event
Care setting: Emergency admission; critical care and later ward/home transfer are separate steps
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Admit to the appropriate critical-care setting for respiratory/circulatory/neurological support and definitive investigation/treatment.
When clinic, day care or home care may be suitable
- An unresolved collapse, amniotic-fluid embolism or major organ dysfunction requires hospital care, not direct home discharge.
Before going home
- The cause and ongoing risks have been assessed, acute organ support is no longer required at the proposed destination and the receiving team can provide the agreed care.
- Before home discharge, organ recovery, function, oral treatment/nutrition, mobility and support are adequate, with rehabilitation/specialty follow-up for remaining impairment.
Discharge medicines and treatment changes
- Reconcile all temporary critical-care medicines, continuing prescriptions and indication-specific anticoagulation; document what stopped and why.
Tests, pending results and their reviewer
- Provide a structured critical-care-to-ward handover and assign outstanding diagnostic/organ tests; ward step-down is not itself clearance for home.
Home care and counselling
- Explain the illness/course, likely recovery issues and physical/emotional support; address infant care, bereavement or safeguarding needs when relevant.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Before each transfer | Name the receiving team, monitoring/rehabilitation plan and urgent escalation triggers. |
At booked post-critical-care/specialty and postnatal reviews | Review organ/function recovery, medicines, mental health and outstanding results. |
Return urgently
- Breathlessness, chest pain, collapse, confusion, seizures, heavy bleeding or recurrent severe illness requires emergency care.
Sources
SMFMcheckedResuscitation Council UKcheckedWHO / FIGO / ICM · Consolidated edition (supersedes fragmented prior guidance incl. 2012 PPH recs; incorporates 2017 TXA recs, 2018 uterotonics, 2023 blood-loss assessment/treatment bundle)summary checkedResuscitation Council UKcheckedMSFcheckedNICE · CG50, recommendationscheckedNICE · NG194, recommendationscheckedIndia MoHFW / NHM · LaQshya district-hospital SOP, linked editioncheckedWHO · 2022 official recommendation summarycheckedRCOG · Current public recovery informationchecked