Question 28

This question relates to the critically ill obstetric patient.

a) List the diagnostic criteria for peri-partum cardiomyopathy. (30%marks)

With respect to amniotic fluid embolism (AFE):

i.  List six important risk factors.(30% marks)

ii. Outline the important clinical features.(40% marks)


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College answer

• Onset of heart failure in the last month of pregnancy or within 5 months post-partum
• Absence of an identifiable cause of heart failure
• Absence of recognizable heart disease prior to the last month of pregnancy
• LV systolic dysfunction demonstrated by classical echocardiographic criteria. The latter 
may be characterized as an LV ejection fraction < 45%, fractional shortening < 30%, or 
both, with or without an LV end-diastolic dimension 2.7 cm/m2 body surface area. (This 
level of detail not expected)

i. List six important risk factors 
• Precipitous or tumultuous labour.
• Advanced maternal age.
• Caesarean and instrumental delivery.
• Placenta previa and abruption.
• Grand multi-parity (≥5 live births or stillbirths), 
• Cervical lacerations.
• Foetal distress.
• Eclampsia.
• Medical induction of labour.
• Polyhydramnios

ii. Outline the important clinical features of amniotic fluid embolism 
• The onset of the symptoms and signs of amniotic fluid embolism syndrome 
(AFES) most commonly occurs during labour and delivery, or immediately 
• Non-specific symptoms – chills, nausea, vomiting, agitation
• Hypotension due to cardiogenic shock
• Hypoxemia and respiratory failure
• Disseminated intravascular coagulation
• Coma or seizures



In actual fact there are several competing definitions, of which the college offers one which is probably the least vague. Here is a table from  the ESC statement (Sliwa et al, 2010)

definitions of peripartum cardiomyopathy


Characteristic features of peripartum cardiomyopathy (also from Sliwa et al):

  • It is usually a postpartum process: only 9% present antepartum. NHL-BIOR definition calls it PPCM if it is one month before or five months after delivery, but the ESC people felt this (totally arbitrary) timeframe would lead to underdiagnosis.
  • There is mainly LV dysfunction
  • The LV is usually dilated (if it is dilated beyond 60mm, the chances of recovery are small)
  • It usually gets better: An estimated 23%-54% of patients show complete recovery of their systolic function within 6 months.


To mix up the college answer with an article by Knight et al (2012)

  • Precipitous or tumultuous labour.
  • Ethnic minority background
  • Emergency delivery
  • Smoking during pregnancy
  • Diabetes
  • Socioeconomic disadvantage
  • Age over 35 (what the college describes as "advanced maternal age", otherwise known as "checkout time" )
  • Caesarean and instrumental delivery.
  • Placenta previa and abruption.
  • Grand multi-parity (≥5 live births or stillbirths), 
  • Cervical lacerations.
  • Foetal distress.
  • Eclampsia.
  • Medical induction of labour.
  • Polyhydramnios

Cardinal clinical features:

  • Shock
  • Hypoxia
  • Altered mental status
  • DIC

Other associated features are listed by Moore et al (2005):

  • Seizures
  • Confusion
  • Agitation
  • Foetal distress
  • Fever
  • Rigors
  • Nausea / vomiting
  • Headache


Moore, Jason, and Marie R. Baldisseri. "Amniotic fluid embolism." Critical care medicine 33.10 (2005): S279-S285.

Meyer, JR "Embolia pulmonar amnio caseosa". Brasil Medico. 1926; 2:301. 

Attwood, H. D. "The histological diagnosis of amniotic‐fluid embolism." The Journal of Pathology 76.1 (1958): 211-215.

Steiner, Paul E., and Clarence Chancelum Lushbaugh. "Maternal pulmonary embolism by amniotic fluid: as a cause of obstetric shock and unexpected deaths in obstetrics." Journal of the American Medical Association 117.15 (1941): 1245-1254.

Tuffnell, D. J. "United Kingdom amniotic fluid embolism register." BJOG: An International Journal of Obstetrics & Gynaecology 112.12 (2005): 1625-1629.

Conde-Agudelo, Agustín, and Roberto Romero. "Amniotic fluid embolism: an evidence-based review." American journal of obstetrics and gynecology 201.5 (2009): 445-e1.

Tamura, Naoaki, et al. "Amniotic fluid embolism: Pathophysiology from the perspective of pathology." Journal of Obstetrics and Gynaecology Research43.4 (2017): 627-632.

Sideris, Ioannis G., and Kypros H. Nicolaides. "Amniotic fluid pressure during pregnancy.Fetal diagnosis and therapy 5.2 (1990): 104-108.

Uyeno, Doko. "The physical properties and chemical composition of human amniotic fluid.Journal of Biological Chemistry 37.1 (1919): 77-103.

Lim, Y., et al. "Recombinant factor VIIa after amniotic fluid embolism and disseminated intravascular coagulopathy." International Journal of Gynecology & Obstetrics 87.2 (2004): 178-179.

Davies, Sharon. "Amniotic fluid embolism and isolated disseminated intravascular coagulation." Canadian Journal of Anesthesia 46.5 (1999): 456-459.

Kaneko, Yuhko, et al. "Continuous Hemodiafiltration for Disseminated Intrav ascular Coagulation and Shock due to Amniotic Fluid Embolism: Report of a Dramatic Response." Internal medicine 40.9 (2001): 945-947.

Awad, I. T., and G. D. Shorten. "Amniotic fluid embolism and isolated coagulopathy: atypical presentation of amniotic fluid embolism." European journal of anaesthesiology 18.6 (2001): 410-413.

Waters, Jonathan H., et al. "Amniotic fluid removal during cell salvage in the cesarean section patient.The Journal of the American Society of Anesthesiologists 92.6 (2000): 1531-1536.

Knight, Marian, et al. "Incidence and risk factors for amniotic-fluid embolism."Obstetrics & Gynecology 115.5 (2010): 910-917.

Knight, Marian, et al. "Amniotic fluid embolism incidence, risk factors and outcomes: a review and recommendations." BMC pregnancy and childbirth12.1 (2012): 7.