Suspected amniotic fluid embolism (AFE)
Sudden collapse with hypotension or arrest and breathing difficulty in labour, at caesarean or within 30 min after delivery of the placenta.
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Obstetrics & GynecologyEmergency
Amniotic Fluid Embolism Management (SMFM 2016)
Amniotic Fluid Embolism Management (SMFM 2016): Suspected amniotic fluid embolism (AFE) → Call for help now: obstetric emergency (code) call → Recognise...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Warning Call for help now: obstetric emergency (code) call
Cardiac arrest: start CPR now. Call senior obstetrics, anaesthesia, ICU, neonatal team and blood bank; assign roles. Small or remote site: call the retrieval service now.
- Fundus at or above umbilicus (about 20 weeks or more): manual left uterine displacement
- Note the time of collapse; a timekeeper calls out each minute
- Activate the massive haemorrhage protocol early: DIC follows in most cases
03Action Recognise AFE: collapse, hypoxia, then bleeding (DIC)
AFE is a clinical diagnosis. Start treatment at once; do not wait for tests.
- Sudden hypotension or cardiac arrest with respiratory compromise
- Hypoxia, cyanosis or sudden breathlessness
- Seizures or reduced consciousness
- Fetal bradycardia if undelivered
- Coagulopathy (DIC) with bleeding follows in more than 80% of cases
- Onset in labour, at caesarean or within 30 min after the placenta; no fever
04Warning Check now: magnesium toxicity, local anaesthetic toxicity, bleeding
These need specific treatment. Check while CPR and resuscitation continue; do not delay CPR.
- On magnesium sulfate: stop the infusion. Arrest: calcium chloride 10% 5 to 10 mL IV, repeat if needed. No arrest: calcium gluconate 10% 10 mL IV over 10 min
- Collapse after an epidural or spinal dose: local anaesthetic toxicity (adult: 20% lipid emulsion 1.5 mL/kg IV bolus, then 15 mL/kg/h; repeat bolus up to twice at 5 min; max total 12 mL/kg) or high block
- Also consider: concealed or overt haemorrhage, anaphylaxis, PE, MI, sepsis, eclampsia
05Action Cardiac arrest: high-quality CPR and standard adult ALS
Pregnancy does not change ALS drugs, doses or shock energy. Keep manual left uterine displacement if fundus at or above umbilicus.
- Defibrillate VF or pulseless VT as usual
- Adrenaline 1 mg IV: non-shockable rhythm as soon as possible; shockable rhythm after the 2nd shock
- Repeat adrenaline 1 mg every second loop (about every 4 min)
- Airway by the most experienced operator; 100% oxygen
- Treat reversible causes (magnesium, local anaesthetic, bleeding)
06Warning Arrest, undelivered, fundus at or above umbilicus: resuscitative hysterotomy
No return of circulation (ROSC): start caesarean (perimortem) delivery within 4 min of arrest. Do it where the patient is. Neonatal team ready.
- Do not move to theatre unless it takes 1 to 2 min or less
- Continue CPR and uterine displacement until delivery
- Fully dilated and head crowning: operative vaginal birth is an option
07Action Not in arrest, still undelivered: senior obstetric decision on delivery
Resuscitate the mother first; this is the best way to protect the fetus. The senior obstetrician decides timing and mode of delivery from maternal and fetal condition.
- Keep manual left uterine displacement or left lateral tilt
- Neonatal team present for any delivery
- If cardiac arrest occurs: remove fetal monitors; resuscitative hysterotomy as above
08Action Airway and breathing: 100% oxygen, early intubation
RV failure: induction and positive-pressure ventilation can cause severe hypotension or arrest. Have a vasopressor ready.
- Pregnancy: difficult airway, fast desaturation, high aspiration risk
- Most experienced airway operator
- Avoid hypoxia; titrate ventilation to blood gases
09Action Circulation: vasopressors and inotropes, not large fluid volumes
Fluid boluses worsen right ventricular (RV) failure. Use blood products for volume, not crystalloid or colloid.
- 2 large-bore IV cannulas; arterial line; central access when possible
- Hypotension: vasopressor (e.g. noradrenaline); titrate to perfusion
- Echocardiography (TTE or TOE) early to guide therapy
- Doses: per anaesthesia or ICU protocol
10Action RV failure and pulmonary hypertension: inotrope and pulmonary vasodilator
RV failure and pulmonary hypertension are common in AFE. Anaesthesia, ICU or cardiology lead.
- Inotrope: dobutamine or milrinone
- Pulmonary vasodilator, e.g. inhaled nitric oxide
- Avoid fluid overload
- Do not use the atropine-ondansetron-ketorolac (A-OK) regimen routinely
11Action DIC and bleeding: massive haemorrhage protocol
Start early. Test coagulation at once and replace fibrinogen early.
- Send FBC, PT/INR, APTT, fibrinogen, blood gas with ionised calcium, crossmatch; ROTEM or TEG if available
- Tranexamic acid 1 g IV over 10 min (within 3 h of birth); repeat 1 g if bleeding continues after 30 min
- Keep fibrinogen at or above 2 g/L: cryoprecipitate or fibrinogen concentrate
- Ratio protocol: RBC:FFP:platelets not lower than 2:1:1; SMFM favours cryoprecipitate over FFP to limit volume
- Keep ionised calcium at or above 1 mmol/L and temperature above 35 °C; warm all fluids
- Consider repeat tests after every 4 units of red cells
12Action Uterine atony and surgical bleeding
Oxytocin first, by slow IV injection. Carboprost: avoid if hypoxic, asthmatic or in RV failure. Ergometrine: avoid in hypertension, pre-eclampsia or heart disease.
- Oxytocin 5 units by slow IV injection (a rapid bolus causes hypotension), then infusion
- Carboprost can cause bronchospasm and pulmonary vasoconstriction
- Misoprostol (up to 1000 microgram rectally) is an option
- Uterine massage, balloon tamponade, compression (B-Lynch) suture
- Hysterectomy early if bleeding continues; damage control surgery if coagulopathic
13Action Refractory shock or arrest: consider VA-ECMO
Consider VA-ECMO (or ECPR in arrest) even with coagulopathy. Call the ECMO centre or retrieval service early.
- Needs a specialist centre; plan transfer early
- Systematic review of 79 published cases: about 72% maternal survival with ECMO (reporting bias likely)
14Action Diagnosis is clinical: no test confirms or excludes AFE
Typical: arrest or hypotension with respiratory compromise, then overt DIC, without fever.
- Fetal squamous cells in maternal blood are not diagnostic
- Differentials: PE, MI, air embolism, high spinal block, sepsis, anaphylaxis, haemorrhage, eclampsia, local anaesthetic toxicity
- Suspected PE: do not give thrombolysis peripartum unless PE is life-threatening; major bleeding risk is high after birth
- Otherwise the same supportive care while you exclude others
15Outcome ICU: ongoing multidisciplinary care
ICU with obstetrics, anaesthesia, haematology and cardiology.
- Invasive haemodynamic monitoring; echocardiography
- Serial coagulation, fibrinogen, lactate, renal and liver function
- Post-arrest care and neurological assessment
- Watch for ongoing bleeding and DIC
16Outcome Debrief, support and report
Debrief the team soon after ICU transfer, or as soon as possible after a death.
- Psychological support for the patient, family and staff
- Document the timeline, drugs and blood products
- Report as a serious clinical incident per local policy
- SMFM suggests reporting to the AFE Foundation registry
Guideline Source
SMFM Clinical Guideline #9: Amniotic fluid embolism: diagnosis and management (2016; reaffirmed 2024)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Supportive care only: no specific treatment or diagnostic test for AFE
- Case fatality about 20% to 40% or more in classic cases, even with optimal care
- Rare: about 2 to 6 per 100,000 births; most units see one or two cases per decade
- Local massive haemorrhage, retrieval and ECMO protocols apply
Contraindicated Populations
Not pregnant and not recently postpartum (use standard adult ALS)
Applicable Regions
AUNZUSEUGlobal
AU: Resuscitation per ANZCOR 11.10 (pregnancy) and 11.5; transfusion per NBA critical bleeding guideline 2023; uterotonics per RANZCOG C-Obs 43.
US: SMFM Guideline #9 (2016, reaffirmed 2024) and SMFM AFE checklist (updated 2026).
Version 2Next review: 2027-09-30
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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: diagnosis and management (2016; reaffirmed 2024).
What guideline is the Amniotic Fluid Embolism Management (SMFM 2016) based on?
This algorithm is based on SMFM Clinical Guideline #9: Amniotic fluid embolism: diagnosis and management (2016; reaffirmed 2024) (DOI: 10.1016/j.ajog.2016.03.012).
What are the limitations of the Amniotic Fluid Embolism Management (SMFM 2016)?
Known limitations include: Supportive care only: no specific treatment or diagnostic test for AFE; Case fatality about 20% to 40% or more in classic cases, even with optimal care; Rare: about 2 to 6 per 100,000 births; most units see one or two cases per decade; Local massive haemorrhage, retrieval and ECMO protocols apply. Individual patient factors may require deviation from these recommendations.
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