Management of Amniotic Fluid Embolism

Date: March 19, 2025
Reason for Alert: To confirm the importance of focusing on maternal resuscitation prior to initiation of proposed or suggested treatments for suspected amniotic fluid embolism.

Potential risks of the stated issue: Amniotic fluid embolism (AFE) (also known as anaphylactoid syndrome of pregnancy), is a rare syndrome in which the pathophysiology is unclear but thought to be related to the release of trophoblasts or other material into the maternal circulation triggering a cascade of inflammatory and hemostatic reactions that may result in cardiopulmonary collapse during labor or immediately postpartum and disseminated intravascular coagulation (Combs et al., 2021; Shamshirsaz & Clark, 2016; Toledo, 2020).

Recommendations for practice:

  • AWHONN supports the Society for Obstetric Anesthesia (Pacheco et al., 2016), Society for Maternal Fetal Medicine (Combs et al., 2021), and American Association of Nurse Anesthesiology (2022) management recommendations of suspected AFE by that focus on maternal resuscitation including oxygenation, hemodynamic support, and correction of coagulopathy.
  • AWHONN also supports a multidisciplinary approach to the management of a patient with suspected AFE. The multidisciplinary team may include, but not limited to, obstetric, maternal fetal medicine, anesthesia, respiratory therapy, critical care, and nursing professionals.
  • AWHONN recognizes that the management of AFE is mostly supportive. Multiple treatments have been proposed or suggested in several case reports, but none have been accepted or supported by scientific evidence. Amongst these treatments for the management of AFE is the use of atropine, ondansetron, ketorolac (A-OK). Administration of these medications may be considered and utilized by some providers but should not supersede or distract from prioritizing effective resuscitative care. Further research and studies are needed for the use of A-OK.

Benefits of recommendations: Focusing on maternal resuscitation can help improve patient outcomes.

References and Resources:

American Association of Nurse Anesthesiology. (2022). Analgesia and anesthesia for the obstetric patient practice guidelines. https://issuu.com/aanapublishing/docs/analgesia_and_anesthesia_for_the_obstetric_patient?fr=sN2ZlNTU2NDAxMjU  

Combs, C., Montgomery, D., Toner, L., Dildy, G. (2021). Society for Maternal-Fetal Medicine Special Statement: Checklist for initial management of amniotic fluid embolism. American Journal of Obstetrics and Gynecology, 224(4). https://doi.org/10.1016/j.ajog.2021.01.001

Pacheco, L. D., Saade, G., Hankins, G. D., Clark, S. L., & Society for Maternal-Fetal Medicine (SMFM). (2016). Amniotic fluid embolism: Diagnosis and management. American Journal of Obstetrics and Gynecology, 215(2), B16-B24. https://doi.org/10.1016/j.ajog.2016.03.012

Shamshirsaz, A. A., & Clark, S. L. (2016). Amniotic Fluid Embolism. Obstetrics and gynecology clinics of North America, 43(4), 779–790. https://doi.org/10.1016/j.ogc.2016.07.001

Toledo, P. (2020). Embolic disorders. In D. H. Chestnut, C. A. Wong, L. C. Tsen, W. D., Ngan Kee, Y. Beilin, J. M. Mhyre, & B. T. Bateman (Eds.), Chestnut’s obstetric anesthesia principes and practices (6th ed., pp 937-955). Elsevier.

AFE Practice Alert (3/2025)