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Amniotic fluid embolism

London, UK

To the Editor:

Sharon Davies concludes that amniotic fluid embolus (AFE) is of uncertain etiology, of variable presentation and without a standardized means of confirming the diagnosis.¹ I suggest a step further: abandon the term altogether since the evidence that amniotic fluid has anything to do with the syndrome of (sometimes) catastrophic collapse that we (sometimes) call AFE is at best tenuous, as Davies has so comprehensively summarized in her review. I have suggested the term "sudden obstetric collapse syndrome" (SOCS) as a more appropriate description, characterised by sudden, severe cardiovascular collapse in a woman who is (or has recently been) pregnant, where no other explanation is considered likely.² This definition reflects what is currently known about the condition, which is not very much, and gets us away from an obsession with amniotic fluid that has as much evidence against it as there is for it.

References

1 Davies S. Amniotic fluid embolus: a review of the literature. Can J Anesth 2001; 48: 88–98.[Abstract/Free Full Text]

2 Yentis SM. Sudden obstetric collapse syndrome. Int J Obstet Anesth 1999; 8: 296.

Toronto, Ontario

I would like to thank Dr. Yentis for his interest in my review article.¹ Others have also suggested that the syndrome should be renamed.² This may be somewhat premature until more is known about this entity. As stated in my article, there is no evidence in the literature for the common misconception that the entrance of amniotic fluid into the maternal circulation is a routine occurrence. We have enough clinical examples and autopsy findings in the literature to show that amniotic fluid elements such as lanugo, vernix and mucin can be found in the systemic circulation in cases of unexpected maternal death with no other pathological findings or diagnosis. These elements are not described in the lungs of pregnant patients dying from other causes. I continue to believe that amniotic fluid embolus does exist, that it is a pathological entity and that clinically it is not an all or nothing phenomena, but a spectrum of disease. When a mother is exposed to amniotic fluid elements, the outcome may well depend on the degree her pathophysiological response as well as the antigenicity of the fluid itself. Dr. Yentis' term "sudden obstetrical collapse syndrome" only encompasses patients with catastrophic presentations and excludes those with varied presentations. At present, we lack accurate diagnostic tests to confirm or exclude the diagnosis in these mothers with atypical presentations. Therefore, future efforts should be directed towards more clearly delineating the presentation, pathogenesis, diagnosis and outcome of amniotic fluid embolus before abandoning the term altogether.

References

1 Davies S. Amniotic fluid embolus: a review of the literature. Can J Anesth 2001; 48: 88–98.

2 Clark Sl, Hankins GDV, Dudley DA, Dildy GA, Porter TF. Amniotic fluid embolism: analysis of the national registry. Am J Obstet Gynecol 1995; 172: 1158–69.[Medline]

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