A rare obstetrical emergency

How can you break the news to a group of expectant family and friends waiting outside the delivery ward that their loved one, who had come into the hospital walking to give birth, has suddenly died in the process of childbirth owing

to an uncommon and unanticipated complication of pregnancy? How can anyone expect the loving husband and family to understand and accept such a tragic and unforeseen event? How could things have taken such a quick turn for the worst for a young woman who suffered no risks or showed any obvious signs?

Such tragedies are sometimes made possible by a condition known as amniotic fluid embolism. This is a unique event that occurs only in pregnant women. Sometimes, the strong uterine contractions near the end of pregnancy force the amniotic fluid—the fluid that surrounds the baby in the womb—into the uterine veins, causing blockage of the maternal circulation. This condition is characterised by the sudden onset of severe respiratory distress and hypotension, which can lead to maternal and fetal death.

The incidence of this rare event is roughly estimated to be between one in 8,000 and one in 80,000 pregnancies. And the maternal mortality rate therein could be as high as 80 percent, with 50 percent dying within the first hour of the onset of symptoms. Survival is rare and those that do survive have increased chances of neurological impairment. The survival rate of the newborn, on the other hand, is estimated to be about 70 percent. 

Amniotic fluid embolism is an event that is as unpreventable as it is unpredictable. There are no warning signs and the cause is unknown. Symptoms develop suddenly and progress rapidly.

Circumstances may be such that a pregnant woman, otherwise absolutely normal, in the late stages of labour, could suddenly develop difficulty in breathing, with hypotension, and may experience seizures, quickly followed by cardiac arrest. This is soon followed by massive hemorrhage associated with bleeding disorder, and then death. Most patients die within one hour of the onset of the condition. The symptoms of the condition are caused by amniotic fluid entering the blood stream. When the amniotic fluid or stray cells escape the placenta and enter the circulation in the mother’s bloodstream, it may cause allergy-like reactions leading to a host of complications. On the other hand, not every woman who has amniotic fluid in her bloodstream will suffer such an embolism.

Some of the signs and symptoms of amniotic fluid embolism include sudden anxiety, agitation, shortness of breath, low blood pressure, bluish discolouration of the skin and mucus membranes, cardiopulmonary arrest, problems to do with blood-clotting and convulsions. This complication of pregnancy can occur during both normal vaginal delivery and cesarean section, which means that it cannot be prevented by a planned cesarean section.

The treatment of amniotic fluid embolism comprises of the supportive treatment of the failing organs system. Patients are treated through a multidisciplinary approach in the intensive unit setup. Since there is no definite medicine or therapy that could prevent or treat the condition—only supportive care with aggressive treatment of multiple types of shock concurrently can help manage the symptoms. Despite improved modalities for diagnosing amniotic fluid embolism and better intensive care facilities in this age and time, the mortality rate is still very high.

Because of the unexpected nature of this health emergency, it may be very difficult for family and friends to come to terms with its consequences. Anger, regrets and accusations may be flung at each other and at health professionals, and extreme physical, emotional and financial stress experienced. But given how it is such a sudden and rare event with such a high mortality rate, one would do well to remember that the shock is felt equally by health providers as well as loved ones.