Suspected AFE
Sudden cardiorespiratory collapse during labor or shortly after delivery
All Pathways
Obstetrics & GynecologyEmergency
Amniotic Fluid Embolism Management (SMFM 2016)
Amniotic Fluid Embolism Management (SMFM 2016): Suspected AFE → Classic Presentation → IMMEDIATE RESPONSE → A - Airway & Breathing → D - DIC/Coagulopath...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Classic Presentation
Recognize the clinical syndrome
- Sudden hypotension or cardiac arrest
- Hypoxia/respiratory distress
- Altered mental status/seizures
- Coagulopathy (may be delayed 10-30 min)
- Fetal bradycardia if undelivered
- Occurs during labor, cesarean, or <30 min postpartum
03Warning IMMEDIATE RESPONSE
Activate emergency response NOW
- Call CODE/Rapid Response
- Call for anesthesia, OB, ICU, neonatal team
- If cardiac arrest: Begin high-quality CPR
- Prepare for perimortem cesarean if undelivered
- Assign roles: compressions, airway, access, recorder
04Action A - Airway & Breathing
Secure airway and support oxygenation
- 100% FiO2
- Early intubation likely needed
- Positive pressure ventilation
- Target SpO2 >94%
- Avoid hyperventilation
05Action D - DIC/Coagulopathy Management
Anticipate and treat massive hemorrhage
- Activate Massive Transfusion Protocol
- 1:1:1 ratio (pRBC:FFP:Platelets)
- Cryoprecipitate: target fibrinogen >150-200 mg/dL
- TXA 1g IV (if within 3 hours)
- Point-of-care testing if available (TEG/ROTEM)
- Avoid hypothermia - use warmers
06Action Right Heart Failure Support
Initial phase often involves acute RV failure
- Avoid fluid overload (worsens RV)
- Consider inhaled nitric oxide
- Consider ECMO in refractory cases
- Inotropes: dobutamine, milrinone
- Cardiology/cardiac surgery consultation
07Action Consider ECMO
For refractory cardiogenic shock
- VA-ECMO for cardiogenic shock
- May bridge to recovery
- Requires specialized center
- Consider early transfer if available
- Survival reported with ECMO support
08Outcome ICU Admission
Continued intensive monitoring and support
- Invasive hemodynamic monitoring
- Serial labs: coags, lactate, organ function
- Neurologic assessment post-arrest
- Multidisciplinary team management
- Family support and communication
09Outcome Outcome & Documentation
Debrief and follow-up care
- Mortality 20-60% despite optimal care
- Survivors may have neurologic sequelae
- Document timeline and interventions
- Debrief with team
- Support for family regardless of outcome
10Action Hemorrhage Control
Manage uterine atony and surgical bleeding
- Uterotonics (oxytocin, methylergonovine, carboprost)
- Uterine massage
- Uterine tamponade balloon
- Consider B-Lynch suture
- Hysterectomy if refractory bleeding
- Damage control surgery if coagulopathic
- Path rejoins step 07Shared downstream outcome
11Decision Diagnosis is Clinical
No confirmatory test exists
- Exclude other causes: PE, MI, anaphylaxis, sepsis
- Hemorrhage/DIC supports diagnosis
- Fetal squamous cells in blood NOT diagnostic
- Consider differential: massive PE, aortic dissection
- Path rejoins step 08Shared downstream outcome
12Action C - Circulation
Hemodynamic support
- 2 large-bore IVs (14-16G)
- Epinephrine 1mg IV q3-5min if arrest
- Vasopressors: norepinephrine preferred
- AVOID excessive fluid (risk pulmonary edema)
- Target MAP >65 mmHg
- Consider arterial line, central access
- Path rejoins step 05Shared downstream outcome
13Warning Perimortem Cesarean Section
If undelivered and cardiac arrest - deliver within 5 minutes
- Start within 4 minutes of arrest
- Delivery by 5 minutes improves maternal/fetal outcomes
- Do NOT delay for sterile prep
- Delivery relieves aortocaval compression
- May improve maternal resuscitation success
- Continue CPR during and after cesarean
- Path rejoins step 05Shared downstream outcome
Guideline Source
SMFM Clinical Guideline #9: Amniotic Fluid Embolism
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- AFE is a clinical diagnosis - no confirmatory test
- Extremely rare (1:40,000) - unpredictable and unpreventable
- Mortality 20-60% even with optimal care
- Pathophysiology not fully understood
Applicable Regions
USEUGlobal
US: Based on SMFM 2016 guideline with 2021 checklist update
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Amniotic Fluid Embolism Management (SMFM 2016)?
The Amniotic Fluid Embolism Management (SMFM 2016) is a emergency clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on SMFM Clinical Guideline #9: Amniotic Fluid Embolism.
What guideline is the Amniotic Fluid Embolism Management (SMFM 2016) based on?
This algorithm is based on SMFM Clinical Guideline #9: Amniotic Fluid Embolism (DOI: 10.1016/j.ajog.2016.03.012).
What are the limitations of the Amniotic Fluid Embolism Management (SMFM 2016)?
Known limitations include: AFE is a clinical diagnosis - no confirmatory test; Extremely rare (1:40,000) - unpredictable and unpreventable; Mortality 20-60% even with optimal care; Pathophysiology not fully understood. Individual patient factors may require deviation from these recommendations.
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