General. Pharmacology

General

Maintaining important signs. The preliminary purpose is the speedy correction of maternal hemodynamic instability, which incorporates a correction of hypoxia and hypotension, for stopping the extra hypoxia and next end-organ failure.

Oxygenation and Control of the airway with tracheal intubation and management of one 100% O2 with fantastic stress air flow must be accomplished as quickly as possible.

Fluid resuscitation is vital to counteract hypotension and hemodynamic instability. Treatment of hypotension consists of optimization of preload, with rapid volume infusion of isotonic crystalloid and colloids solutions. Although each can repair blood extent in ongoing hemorrhage, transfusion of packed crimson blood cells is important to repair oxygen wearing capacity.

Transthoracic or transesophageal echocardiography can also additionally manual fluid remedy with assessment of left ventricular filling. An arterial line and pulmonary catheter might also assist to manual remedy. For refractory hypotension, vasopressor remedy is indicated.

Correcting coagulopathy — Blood and blood products, consisting of sparkling frozen plasma (FFP), platelets and cryoprecipitate, need to be to be had and administered early withinside the resuscitation segment of AFE. If platelets are < 20, 000/μ L, or if bleeding takes place and platelets are 20, 000-50, 000/μ L, transfuse platelets at 1-3 U/10 kg/day.

Administer FFP to normalize the PT.

If fibrinogen degree is < 100mg/dL, administer cryoprecipitate. Each unit of cryoprecipitate increases the fibrinogen degree 10 mg/dL.

Arterial catheterization ought to additionally be taken into consideration for correct arterial blood strain tracking and common blood sampling.

Pharmacology

Vasopressors and inotropic support are generally needed to varying degrees in AFE. Central venous access should be established for vasopressor infusion and monitoring. Choice of vasopressor drug depends on the clinical scenario.

· Epinephrine may be the first-line agent of choice as it is used in other anaphylactoid reactions, in addition to the α -adrenergic vasoconstrictor effects.

· Phenylephrine, a pure α -1 agonist, is often an excellent choice early in the treatment of AFE because at that time point systemic vasodilation is the most prominent circulatory abnormality.

· Inotropic support like dopamine or noradrenaline may be ideal agents because of the additional β -adrenergic effects, which improve cardiac function.

· Vasopressin may be used as primary therapy or as an adjunct to other inotropic therapies and has the benefit of sparing the pulmonary vasculature from vasoconstriction, especially at low doses. In the face of right heart failure, milrinone or other phosphodiesterase inhibitors should be considered. [1]

· Digoxin: acts directly on the cardiac muscle and conduction system. Digoxin causes an increase in force and velocity of systolic contraction, a slowing of the heart rate, and decreased conduction velocity through the AV node.

· Hydrocortisone: Because AFE is more similar to an anaphylactic reaction, steroids that mediate the immune responses are recommended.

· Oxytocin: Most commonly used uterotonic. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

· Methylergonovine (Methergine): Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding.

· Carboprost tromethamine: Prostaglandin similar to F2-alpha (dinoprost), but has longer duration and produces myometrial contractions that induce hemostasis at placentation site, which reduces postpartum bleeding

· The successful use of recombinant factor VIIa (rfVIIa) has been reported. [32] although it has also been associated with massive intravascular thrombosis.

· Aprotinin has also been effective in reducing hemorrhage with AFE.

· Other antifibrinolytic drugs, such as aminocaproic acid and tranexamic acid, have been described in the management of obstetric hemorrhage and menorrhagia and might also be considered during AFE. [1]

Obstetrical management must include the rapid evacuation of the fetus, usually by cesarean section. The Society for Maternal-Fetal Medicine recommends this for all fetuses over 23 weeks gestational age. Ongoing resuscitation of the mother in the obstetrical operating room with an anesthesiologist or critical care physician running the cardiovascular resuscitation must go on during the extraction of the infant. It is recommended to shift the gravid uterus to the left, therefore, relieving aortocaval compression. This multidisciplinary team must be able to initiate neonatal resuscitation and should include a neonatologist because the majority of these infants are born with low Apgar’s. The infant will likely need rapid suctioning, intubation, and vascular access. The obstetrician may elect several different procedures to alleviate the ongoing uterine hemorrhage. Uterine artery ligation or embolization has been documented with some success. Circumferential B-Lynch, Hayman, or Pereira compression sutures have been utilized to compress the atonic uterus and staunch bleeding. However, in the setting of massive hemorrhage and an atonic uterus, the best course is emergency hysterectomy. [33][34]

CONCLUSION

Survival after AFE has stepped forward extensively with early reputation of this syndrome and set off and early resuscitative measures. Previously, it became documented that 50% of sufferers die in the first hour and approximately two-1/3 inside five h of the occasion with excessive occurrence of extreme and everlasting neurological harm amongst survivors. Although mortality costs have declined, morbidity stays excessive with excessive sequelae. Beside neurologic impairment, acute oliguric or nonoliguric renal failure, cardiac failure with left ventricular impairment, cardiogenic pulmonary edema, arrhythmias, myocardial ischemia or infarction were stated. Respiratory failure with noncardiogenic pulmonary edema and refractory bronchospasm are different stated sequelae

Despite our lack of expertise of the pathophysiologic tactics of AFE, it's far very clean that early and competitive management (together with instant cesarean section) of sufferers with clinically suspected AFE complements each fetal and maternal resuscitation and improves survival. It is crucial to continually do not forget AFE withinside the differential analysis of unexpected maternal cardiopulmonary instability and take into account that the shortage of improvement of DIC and hemorrhage does now no longer exclude the prognosis of AFE. More studies on serum diagnostic tests, inclusive of zinc coproporphyrin, STN antigen, and C3 and C4 supplement is needed. Selective pulmonary vasodilators, consisting of NO for the remedy of extreme pulmonary high blood pressure in the course of the extreme segment of AFE, and rfVIIa for handling intense DIC resistant to standard remedies are promising.

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