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)
• 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.
• Medical induction of labour.
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)
Characteristic features of peripartum cardiomyopathy (also from Sliwa et al):
To mix up the college answer with an article by Knight et al (2012)
Cardinal clinical features:
Other associated features are listed by Moore et al (2005):
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Tamura, Naoaki, et al. "Amniotic fluid embolism: Pathophysiology from the perspective of pathology." Journal of Obstetrics and Gynaecology Research43.4 (2017): 627-632.
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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.