Amniotic fluid embolism death

By Lynn Razzano, RN, MSN, ONCC

The Boston Herald recently reported that 32-year old Colleen Celia on January 15, 2014, shortly after giving birth to her fourth child. The young mother died from amniotic fluid embolism, where amniotic fluid enters the mother’s bloodstream.

CBS Boston reports – Two young fathers are searching for answers and grasping with the reality of raising children alone after both their wives died in childbirth at South Shore Hospital in the span of a month – http://bit.ly/1IrQJEG

After reading about yet another who dies after childbirth, I felt the clinical need to write this article. I honestly had not heard of this before and consider myself an expert on VTE and the prevention of the occurrence. Having done some considerable work with the release of the new OB VTE Safety Recommendations with the OB team of experts, I think this condition is worthy of researching and gaining knowledge. There is really very little written on the subject and I wanted to find out the incidence as well as any alert criteria and prevention modalities that would save a future mother from succumbing from such an rare condition.

I hope I do justice to explaining what Amniotic Fluid Embolism is and increase awareness of this condition with OB clinicians across the country. Another goal I have is to empower and engage pregnant women by educating them on this diagnosis so they may speak up with their respective OB clinicians and be a safety vehicle for their own welfare.

An amniotic fluid embolism is a rare but serious condition that occurs when amniotic fluid — the fluid that surrounds a baby in the uterus during pregnancy — or fetal material, such as hair, enters the maternal bloodstream. There is some information, in addition, that points to the possibility of meconium being released into the mother’s system.

An amniotic fluid embolism is most likely to occur during childbirth or immediately afterward, which is the immediate post partum period. This identifies to possible alerts as to the time frame of intense observations or monitoring that should occur with the OB patient.

Not surprising, an amniotic fluid embolism is difficult to diagnose which leads to clinical challenges while critical time may be wasted. In terms of patient education, OB clinicians should be teaching them. If your doctor suspects you might have an amniotic fluid embolism, you’ll need immediate treatment to prevent potentially life-threatening complications.

What are the symptoms the patient would display or exhibit if a pending amniotic fluid embolism is suspected. The urgent nature and important fact is – amniotic fluid embolism develops suddenly and rapidly.

Signs and symptoms of an amniotic fluid embolism might include:

  • Sudden shortness of breath
  • Excess fluid in the lungs (pulmonary edema)
  • Sudden low blood pressure
  • Sudden circulatory failure (cardiovascular collapse)
  • Life-threatening problems with blood clotting (disseminated intravascular coagulopathy)
  • Altered mental status, such as anxiety
  • Nausea or vomiting
  • Chills
  • Rapid heart rate or disturbances in the rhythm of the heart rate
  • Fetal distress, such as a slow heart rate
  • Seizures
  • Coma

Preparation for monitoring these above symptoms could be developed into a safety checklist that clinicians could have on the patient board or reduce and carry a pocket size version easily accessible to them. All emergency equipment should be on hand and easily available so as to manage, abort symptoms,, before any undue harm to the OB patient.

What Causes Amniotic Fluid Embolism to present itself and what is the significance clinically? :

It is not a comforting fact that amniotic fluid embolism occurs as this isn’t well understood and due to its supposed rareness is not well researched.

An amniotic fluid embolism occurs when amniotic fluid or fetal material enters the maternal bloodstream, possibly by passing through tears in the fetal membranes. It’s likely that amniotic fluid contains components that cause an inflammatory reaction and activate clotting in the mother’s lungs and blood vessels. This should be a red alert to the clinician and activate a proactive treatment and prevention plan.

However, amniotic fluid embolisms are rare — and it’s likely that some amniotic fluid commonly enters the maternal bloodstream during delivery without causing problems. It’s not clear why in some cases this leads to an amniotic fluid embolism.

Further research on what causes amniotic fluid embolisms is needed.

Due to the rarity of Amniotic fluid embolisms, it is difficult to identify risk factors. It’s estimated that there are between 1 and 12 cases of amniotic fluid embolism for every 100,000 deliveries.

Frequency

United States

Incidence of AFE is estimated at 1 case per 8,000-30,000 pregnancies. The true incidence is unknown because of inaccurate diagnoses and inconsistent reporting of nonfatal cases.

International

Incidence is similar to that of the United States.

Mortality/Morbidity

  • Maternal mortality approaches 80%.
  • Mortality was 61% in the US national registry, which listed 46 cases.
  • AFE is the cause of 5-10% of maternal mortality in the United States.
  • Of patients with AFE, 50% die within the first hour of onset of symptoms. Of survivors of the initial cardiorespiratory phase, 50% develop a coagulopathy.

Research suggests that several factors might be linked to an increased risk of an amniotic fluid embolism, however, including:

  • Advanced maternal age. If you’re 35 or older at the time of your child’s birth, you might be at increased risk of an amniotic fluid embolism.
  • Placenta problems. If there are abnormalities in your placenta you might be at increased risk of an amniotic fluid embolism. Abnormalities might include the placenta partially or totally covering the cervix (placenta previa) or the placenta peeling away from the inner wall of the uterus before delivery (placental abruption). There may be disruption in the physical barriers between mother and baby.
  • Preeclampsia. If you have preeclampsia including high blood pressure and excess protein in the urine after 20 weeks of pregnancy there might be an increased risk of developing an amniotic fluid embolism.
  • Medically induced labor. Limited research suggests that certain labor induction methods are associated with an increased risk of amniotic fluid embolism. Research on this link, however, is conflicting with no firm clinical consensus.
  • Operative delivery. Having a C-section, a forceps delivery or a vacuum extraction might increase your risk of an amniotic fluid embolism. It’s not clear, however, whether operative deliveries are true risk factors for amniotic fluid embolisms or are used after the condition develops to ensure a rapid delivery.
  • Genetics. Some experts believe that genetics might play a role in determining a woman’s risk of amniotic fluid embolism.

Complications

An amniotic fluid embolism can cause serious complications for mother and baby.

If you have an amniotic fluid embolism, you’re at increased risk of:

  • Brain injury. Low blood oxygen can cause permanent, severe neurological damage or brain death.
  • Lengthy hospital stay. Women who survive an amniotic fluid embolism often require treatment in the intensive care unit and depending on the extent of their complications may necessitate weeks or months in the hospital.
    • This increases cost expenditures in terms of transfer to a higher level of acuity and a longer length of stay.

It’s estimated that amniotic fluid embolisms cause up to 10 percent of maternal deaths in developed countries. Death can occur within an hour of the start of symptoms.

An amniotic embolism, places the unborn baby at increased risk of a brain injury due to a lack of oxygen, which may prove fatal.

Clinical considerations for managing amniotic fluid embolism suspicion might include:

  • Standards: Use of the new OB VTE Safety Recommendations would provide the assessment process and earlier recognition to manage the patient and provide the required intervention. The most significant course of clinical action that is critical is for “early on” detection of an possible amniotic fluid embolism is consistent and complete baseline assessment of OB VTE risk factors on all patients. In particular the VTE risk factors that have been identified above and common to the OB patient.
  • Clinician Education: Due to the rare nature of the condition, there needs to be vigilant education with clinicians and patients. Accountability and responsibility is still a clinical expectation even when a condition is termed rare- this does not prevent the jurisprudence that is still a clinical expectation for maximum OB patient safety.
  • Recommendations: Develop patient safety recommendations using the symptoms detailed above to serve as a clinical guide in assessing patients for suspicion or alert to potential amniotic fluid embolism. See the new OB VTE Safety Recommendations as an example of recommendations.
  • Monitoring: Ensure increased patient monitoring is provided to a patient that may have one or more of the high risk factors for developing amniotic fluid embolism.
  • Training: Ensure there is adequate cross trained skills and competencies from both OB nurses to Critical care nurses who need the specific nuances and clinical algorithms to care for the critical OB patient.
  • Patient Awareness: Consistently educate and engage the pregnant woman in the condition and provide opportunities to have the patient be their own safety advocate. This will go far in preventing mortality or complications.

For additional knowledge and clinical guidance on this rare condition, amniotic fluid embolism, please read the paper, by Katherine J. Perozzi, RN, MSN and Nadine C. Englert, RN, MSN., “Amniotic Fluid Embolism An Obstetric Emergency” in Critical Care Nurse,

For a discussion about the heightened risk of blood clots in pregnant women, please listen to this clinical education podcast with Colleen Lee MS, RN (Maternal/Perinatal Patient Safety Officer, Montefiore Medical Center) on the PPAHS YouTube Channel.

On May 30, 2013, as doctors rolled me into the operating room for my emergency C-section, I knew beyond a doubt that I was going to die — and I was right. I died on the operating table. But I didn’t know I would live to tell about it, or that I would remember all the details.

What Happened

It all started at our 20-week ultrasound that January. After seven rounds of IVF, I was expecting our second child and had had an easy pregnancy so far. But when the radiologist told us I had placenta previa, I turned to my husband and said, “I have no idea what that is, but I have a bad feeling.” Now, my husband Jonathan, who has a PhD in economics and was an Air Force pilot, is more logical, not one to think the worst. He just told me: “We’ll deal with a crisis in a crisis. For now, you’re being crazy.”

And maybe I was being crazy, but that February, when I was taking my daughter to a class, we walked by a dry fountain, and I reminisced about how nice it is when it’s on. Suddenly, I had a vision of the fountain flowing with blood. I dizzily clutched the stroller and knew something was wrong.

This became a daily occurrence. I would be in the grocery store and imagine how I was going to die in labor. I had detailed, specific visions: The baby would be fine, but my organs would combine, and I was going to hemorrhage, need a hysterectomy, and die. (Placenta previa affects about 1 in every 200 pregnancies. And in some worst cases, the placenta can join to the uterus and cause massive bleeding.)

In the past, I’ve had a strong sense of intuition, but I’d never have claimed to see the future. This was the first time I’d had an overwhelming sense of foreboding. And it was strong. I didn’t feel insane — but everybody else thought I was. We saw as many doctors as possible, but after many tests, my fears still weren’t confirmed.

So I told everyone I met, hoping that somebody had the same experience I had had and could tell me who to talk to. I posted on Facebook asking if anybody had my blood type. I started writing goodbye letters to my parents, my siblings, Jonathan, my stepdaughter Valentina, and daughter Adina. I even mailed some. I bought nothing for the baby or his room. I didn’t take pictures of my pregnant stomach. I was so sure I was going to pass away that I just detached and disconnected.

Because of my previa, I was scheduled to get a C-section at 37 weeks. To help ease my anxiety about the procedure, my gynecologist set me up for an anesthesia consultation. And that’s when I met Dr. Grace Lim. After she patiently walked me through the surgical plan, I decided to tell her about my premonitions, so I could ask what would happen in those situations. Unbeknownst to me, she flagged my file and noted that there should be extra blood and a crash cart in the room at the time of my delivery. Her planning is what saved my life.

One week before I was scheduled to have the C-section, my husband was in New York for a big conference. I was grounded in Chicago. When I started bleeding all over the kitchen floor, I called him to say the baby was coming now. I rushed to the hospital with our daughter, Adina, and the nanny, and he hightailed it to the airport.

While the doctors prepared me for surgery, I traded Skype messages with Jonathan, believing we might never speak again: “I just want you to know you are the most important person in my life and you’re an incredible father. Your children will always know it. Please take care of everybody and love your son. No matter what happens, you’ve made me the happiest woman in the whole world.” I begged the surgeons to hold off until his arrival, but the time was now. I had to shut down my computer before he could reply.

So I put on the bravest, happiest face I could as I hugged my 2-year-old daughter. I didn’t want her last memory of her mother to be crying. I smiled and said, “You’re going to meet your brother Jacob soon and I love you.”

When they wheeled me out into the operating room, I wept because I knew I wouldn’t see her again. Then I told the doctor what I had been saying for months: “There’s something wrong and I’m not going to make it through this surgery.” The last thing I remember is them putting soap on my belly to get ready for the C-section.

Jacob was delivered, and within seconds, I went into a seizure and flat-lined. I was dead for 37 seconds.

Later, they told me it was an amniotic fluid embolism (AFE), which happens in about 1 in 40,000 pregnancies. When amniotic cells get into a mother’s bloodstream and you are allergic, you go into anaphylactic shock. First, you go into cardiac arrest. If you’re lucky enough to be one of the 40% to survive that phase of an AFE, the second phase starts. That’s called DIC — disseminated intravascular coagulation. I started to hemorrhage and was given 60 units of blood. (Typically a C-section only has 6 units but Dr. Lim had ordered extra.)

According to my hospital, I am the first of the 20 cases they’ve ever had to survive without any neurological damage. The hospital will tell you it’s because they were prepared. But I prepared them.

What I Remember About “Dying”

After six days, I woke from a medically induced coma in the ICU. They had put me under because of all the damage to my organs: My lungs and bladder had collapsed, my heart went into cardiac arrest, and the blood was not staying in. Even hours after I got there, I was still hemorrhaging — so they performed a hysterectomy. My final prediction had come true. When they performed the pathology, they found what I had feared would happen: My uterus and the placenta had bonded after all, but in a microscopic connection that never would have showed on an MRI. That is how the amniotic cells got into my blood stream.

As I woke, I remember looking down at my body, swollen from fluid after the kidney failure. I looked more pregnant than I did when I walked into the hospital. Crass as it sounds, I looked at my husband and first thing I said was, “Am I still f***ing pregnant?” When he told me I gave birth six days before, it blew my mind.

The first time I saw my son, he was almost a week old. It took me awhile to not look at Jacob like he caused this or to want to hold him, even if I could have. I had ports in my chest and my neck and I was swollen and could barely put two words together. In that moment, I couldn’t be his mother. I believe children can tell if you’re afraid or nervous. I did not want him to reject me because I had this inherent fear of him. I wanted to get over that before I held him or changed his diaper. Fortunately, Jonathan would take off his shirt and put Jacob on his skin, making sure he knew that he was loved. Looking back, it’s heartbreaking.

Courtesy of Stephanie Arnold

My road to recovery was long: a month in the hospital, weeks of dialysis, cleaning my massive sutures, pain from broken ribs and scars, and endless tests and medications. At home, I had a nurse come to stay at my house each night to monitor my vitals. Nights were the worst because I was constantly thought, What if I have a surprise heart attack? What if my organs fail again?

It was a hard adjustment. Finally, I went to several therapists to help with my stress. But when I’d ask how was it I predicted everything before it happened, no one had an answer for me. So eight months later, I tried regression therapy, which uses hypnosis to take you back to the moments of trauma. It’s done a lot with victims of sexual abuse or catastrophes. I’d never been hypnotized. I videotaped my regression therapy sessions because I wanted to make sure no one made me do anything I didn’t want to do. Also, if I learned something while I was hypnotized, I wanted to make sure I remembered it.

The therapist managed to get me to a state of semi-consciousness, similar to meditation. But every time I went close to the operating room during a session, I started hyperventilating and she had to bring me out. After trauma, she explained, memories are stored like a movie strip. The cells in the body remember pain. Good anesthesia will compartmentalize it, but that doesn’t mean it doesn’t exist somewhere.

The therapist eventually suggested that I try to go back to the operating room as an observer. And that’s when, finally, I saw everything that had happened to me. It was like I was floating above my body. When I went back to those moments in therapy, you can see me on the video convulsing, going through seizure, flat lining, screaming. I recount exactly where the doctors were standing, who hit the button for the code. There are details like how many times CPR was done and that the first crash cart didn’t work, that a resident, not my own doctor, delivered the baby. Just one thing after another that there was no way I could have learned — plus, none of that would have been in the medical records.

I took the tapes to my anesthesiologist and to my gynecologist and asked for their thoughts. My doctors were baffled. There’s no way I could know those details — which were all correct — in the condition I was in. My eyes were taped. They wondered if maybe I could hear something while my brain was shutting down. But there was still no way to know were people were standing or who was doing CPR because I was dead.

Now What?

I believe everybody has this gift, I was just given quiet time to actually see it. There’s enough documentation on my case to show that not everything is explained by black and white science. I firmly believe that there is another dimension of life out there. By no means am I saying I’m a medium. But since then I’ve had messages for people from my husband’s deceased father, my best friend’s brother, even people I didn’t know.

And my premonitions haven’t stopped. This summer, I had a vision we’d lose Jacob at the county fair. I didn’t speak up, and then when he disappeared and was found later by police, I was mad at myself because I could have just asked my husband to keep an eye out.

If you sense something, say something. Call it mother’s instinct, intuition, your body trying to tip you off or a spiritual force — it’s coming from somewhere, and you should not doubt it. I spoke up two years ago and it saved my life. I could have been wrong or accepted what everyone said, and I wouldn’t be here.

Stephanie and Jonathan Arnold with their children. Courtesy of Stephanie Arnold

Stephanie Arnold is the author of 37 Seconds (available now) about her journey, and she sits on the Amniotic Fluid Embolism Foundation board and serves as an AFE lecturer and advocate.

Asher Fogle Writer When she’s not hunting for compelling personal stories or justifying her love for dessert, Asher can likely be found watching early-2000s TV on Netflix with her husband.

Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is a rare but serious complication that can happen during delivery or shortly after birth. AFE only affects an estimated 1 in 40,000 deliveries but is still a leading cause of maternal death during labor. This condition occurs when the baby’s amniotic fluid (the fluid that surrounds the baby in the placenta), fetal cells, or hair makes its way into the mother’s bloodstream. AFE can rapidly develop into a life-threatening situation that puts both the baby and mother’s life at risk. Emergency medical intervention is needed to stabilize the mother and deliver the baby as quickly as possible to avoid permanent complications. In most cases, an immediate emergency C-section is the safest option for the baby.

What are the Causes of Amniotic Fluid Embolism?

AFE is more common in vaginal delivery but can occur during a C-section as well. It can also happen shortly after birth while the placenta is still inside the mother’s body. AFE occurs when the amniotic fluid or fetal material passes the placental barrier, enters the mother’s bloodstream and starts moving throughout the circulatory system. The underlying cause for this is not fully understood, but doctors believe it can stem from a breakdown in the placental barrier. This break of the placental barrier can be triggered by trauma during labor.

When the fetal material enters the mother’s bloodstream, her immune system recognizes is as a foreign substance in the body and which triggers an acute inflammatory response. This immune response activates abnormal clotting in the mother’s lungs and blood vessels, which can lead to a serious blood-clotting condition called disseminated intravascular coagulation. While this condition is rare, amniotic fluid entering the bloodstream is not uncommon. Many mothers during labor will absorb small amounts of amniotic fluid without any complications. It’s not clear why some mothers have such an extreme immune response.

What are the Risk Factors for Amniotic Fluid Embolism?

The causes and specific risk factors for AFE are not well understood, partly because the condition is so rare. With the small amount of research that we already have, several factors have been associated with an increased risk of amniotic fluid embolism. These factors include:

  • Advanced maternal age: Mothers who are 35 years and older are at a much higher risk of pregnancy and labor complications, including AFE.
  • Placenta abnormalities: Abnormalities in the placenta can possibly lead to AFE. Placental abruption and placenta previa can break the natural barrier between your baby and your body.
  • Preeclampsia: High blood pressure during pregnancy and labor has been linked to an increased risk of AFE.
  • Medically induced labor: Some research has suggested that there are certain labor induction methods that could contribute to the development of AFE.
  • Excessive force during delivery: C-sections, using forceps, or using vacuum extraction to deliver the baby can all cause damage to the physical barriers separating the baby from the woman’s body. However, it has not been firmly established that this is can be a direct cause of AFE since these procedures are implemented after the condition has already been presented.
  • Polyhydramnios: Excessive amniotic fluid might increase the risk of AFE as well.
  • Intense contractions during labor
  • Tears in the uterus or cervix

What are the Possible Complications from Amniotic Fluid Embolism?

The effects of AFE can be devastating. The maternal mortality rate for this condition can be as high as 80%, with 50% of mothers dying within the first hour of symptom onset. For patients that do survive the embolism, the majority of them will experience long-term neurological deficits. The survival rate for infants, however, is much more promising, with 70% of infants being successfully delivered.

Still, there are several complications that can occur from AFE:

  • Brain injury to mother: The blood clots in the lungs from the embolism can reduce the amount of oxygen traveling to the mother’s brain, which can result in permanent brain damage.
  • Fetal distress: AFE can prolong the labor process, which can cause the fetus to become distressed. Fetal distress can greatly increase the risk of several complications, including hypoxia, which can also result in permanent brain damage and conditions like cerebral palsy.
  • Infant death: If the baby is deprived of oxygen for too long or is not delivered quickly enough, the baby can die during delivery.
  • Sudden cardiac arrest: The effects of AFE can develop so rapidly that the blood clots in the lungs send the mother into cardiac arrest.
  • Multiple organ failure: As the condition progresses, it can start to cause the organs to fail from lack of adequate oxygen in the blood.
  • Maternal death

Long-term effects for the mother from AFE include:

  • memory loss
  • organ failure
  • heart damage that can be temporary or permanent
  • nervous system problems
  • a partial or complete hysterectomy
  • damage to the pituitary gland
  • emotional problems if the baby does not survive

What are the Symptoms of Amniotic Fluid Embolism?

The symptoms of AFE can be obvious once fetal material enters the bloodstream because of how sudden the immune response is. The mother will have difficulty breathing or will start to lose consciousness. Other possible symptoms include:

  • fetal distress
  • vomiting
  • nausea
  • seizures
  • severe anxiety, agitation
  • skin discoloration

If the mother survives AFE, she can experience a second stage of the condition known as the hemorrhagic phase. This is when there is excessive bleeding from where the placenta was attached or the location of the cesarean incision.

What is the Treatment of Amniotic Fluid Embolism?

Treatment mainly focuses on stabilizing the mother and preventing the condition from progressing and causing severe complications. Doctors can administer oxygen therapy or a ventilator to assist with breathing. A pulmonary artery catheter may be inserted so doctors can monitor the mother’s heart. There are also some medications that can help control blood pressure. If the mother survives the condition, she will most likely need blood, platelets, and plasma transfusions to replace the amount of blood loss from hemorrhaging.

For the baby, the doctors will continuously monitor for any signs of distress. It’s critical that doctors deliver the baby as soon as possible. A delayed C-section increases the risk of birth injury. After they are delivered, they will be sent to the intensive care unit (ICU) for evaluation and close observation.

Outlook

Amniotic fluid embolism cannot be prevented and is hard to predict. The condition has the potential to be fatal for both the mother and the baby, so immediate medical intervention is necessary to ensure they survive. If you’ve previously experienced AFE, it’s important to talk to your doctor before you decide to get pregnant again so you can put measures in place to protect your health. This condition is very rare, but mothers should be aware of the possible risks involved.

Sources and Additional Literature

Nawaz, N., & Buksh, A. R. (2018). Amniotic Fluid Embolism. Journal Of The College Of Physicians And Surgeons, 28(6), S107-S109.

Tuffnell, D. J., & Slemeck, E. (2017). Amniotic fluid embolism. Obstetrics, Gynaecology & Reproductive Medicine, 27(3), 86-90.

How Dying for 37 Seconds Changed Her Life and Will Inspire You in Yours: With Stephanie Arnold

By Yitzi Weiner and Casmin Wisner

“We are all born with intuition. I just didn’t know mine would not only save my life, it would change the course of my career, exponentially.”

I had the pleasure of interviewing Stephanie Arnold, the author of 37 Seconds. Stephanie was a TV producer who spent 27 years creating and directing TV shows, music videos, and documentaries. She left the business in 2008 after meeting the love of her life. It was during the birth of her second child that Stephanie suffered a rare—and often fatal—condition called an amniotic fluid embolism (or AFE) and died on the operating table for 37 seconds. Everything she does now is a direct result of her survival.

Thank you for doing this with us. What is your backstory?

I produced television for more than 27 years. From the Puerto Rican Day Parade and the New York Magazine Awards Show to show-running syndicated shows and network shows like Deal or No Deal in spanish for Telemundo. I worked in development for a company who created Surreal Life and Flavor of Love, directed and produced music videos for a few well-known artists, and pitched and sold my own programming. I was even nominated for a couple of New York Emmys. My intuition led me to great career decisions and to work with some of the best people in the industry.
I moved to Chicago in 2008 when I married my husband Jonathan. As a result, my career stalled. I was ok with it because it forced me to shift gears and focus on what became a priority for me. Creating a family. We already had one daughter, Valentina, who my husband brought with him into our
marriage (not a step-daughter to me at all, more like my own flesh and blood), and we gave birth to our first daughter, Adina, two years after we got married.

Pregnant with our second child, I started having premonitions that I would die giving birth. My intuition was at an all-time high. This wasn’t my first time at the rodeo. This pregnancy was different. Somehow, I knew I was going to need a hysterectomy. I felt that I was going to bleed out, that the baby would
be fine, that my organs were going to attach to each other, and many more detailed visions into the not so distant future. I told everyone. My husband, (a science-minded, PhD Economist from University of Chicago and former Air Force pilot), along with everyone else to whom I voiced my fears, told me the data didn’t support what I was seeing and told me to relax. Everyone, including all the doctors, nurses, friends, strangers, and people on Facebook simply thought I was a hormonal and a histrionic pregnant woman.

That is, until the day I gave birth to our son Jacob and moments later, I died.

I had an amniotic fluid embolism, a rare and often fatal condition (1 in 40,000) where amniotic cells get into the mother’s bloodstream, and if you happen to be allergic to it, your body goes into a type of anaphylaxis and in most cases, you don’t survive. The only reason I did survive, is because I spoke up and ONE DOCTOR listened to her own intuition, flagged my file incorporating extra blood and a crash cart in the OR. And that is 100 percent what saved my life. Or as one MD said to me recently, “I want to correct you, YOU saved your own life.” Technically, we were both right.
Since the experience, my life and my world in television have never been the same.

Who is someone you greatly admire?

Sara Blakely of SPANX. She is brilliant, found a need, and turned it into a multi-billion-dollar company. However, her drive to create so she can give is what inspires me most about her. Pledging half of her wealth to charity and focusing on building up women, (instead of tearing them down) is awe-inspiring.

How do you bring goodness to the world?

People tell me it took courage to survive, but the real courage for me (outside of speaking up when no one was listening), was reliving every painful detail in my book, 37 Seconds.

My way of dealing with pain is to express it, write it, film it, and share it, but my husband’s way is much different. Suppress and repress is his M.O. and he is comfortable with it. Asking Jonathan to relive his most vulnerable side took a lot of courage from him and I will admit, the process of writing took a lot of literal blood, sweat, and tears to get through it.

If it never got published, this would likely be the end of our story, I would continue being a wife and mom, maybe dabble some more in TV, and Jonathan would be annoyed I cracked him open for an exercise in “sharing our emotions.” Not bad at all, just not what was in the cards for me. And even though I saw what would happen to me before I flat-lined, I could never have predicted what would happen in my not so distant future.

When HarperCollins bought the rights, they were certain it would compete with Heaven is for Real and Proof of Heaven. It did not. I’m not saying people didn’t embrace the book, but they wanted more. The overall reaction was “I wanted to know more about what she saw in heaven,” and I only address everything that was verifiable. Proving beyond a reasonable doubt, some other energy force is working beyond what we can see.

I could have gone into more detail, but I stuck to my intuition and felt there was a stronger message here to validate other’s visions, foresight, and the ability to feel things around us which many consider illogical. And we were pleasantly surprised by who was being affected by our story—the medical community, the agnostics, the skeptics, and complete strangers from all over the world.

Both clinicians and scientists started reaching out telling their own “sixth
sense” and intuitive stories. Every day people would explain how they had nagging feelings about a moment in their lives which they ignored, resulting in horrific outcomes and wishing they had the courage to speak up. They told how my story is now helping others speak up and saving lives.

I respect what happened to me immensely, for without it, I would never have been able to connect to these individuals on such a vulnerable and profound level. It made me realize how important this topic is, how it needs to be shared, and how science and intuitive medicine are both important for patients and doctors alike. And it showed me how it needs to be taken more seriously.

I have become a patient advocate and speaker for many medical institutions, legislative conferences, blood donation services, and universities. Educating doctors and patients alike on using their own intuition when listening or speaking to each other is one of my missions, and finding strength within yourself and your own spirit to overcome even the most catastrophic of situations is another.
I have told many stories in my career, I just never thought the biggest story I
would tell, would be the most personal one.

What are your “5 things you wish you’d known before your experience,” and why?

  1. Listen to your gut. I know we hear this, almost as a cliché, but REALLY—
    listen to your gut. My story takes it to extremes, in the fact that it can save your life, but a career, a job, a relationship, anything you decide which goes against your gut, will ultimately make you unhappy and cause you to wish that you hadn’t chose that path. How many times have we told ourselves, “I should have listened to my gut!” Take it seriously. It could result in the best decision of your life, or it can save someone’s life—maybe even your own.
  2. When an obstacle is put in front of you, go around it and don’t take it personally. Just plow through it. However, if many obstacles are preventing you from reaching that specific goal, it might not be your time to reach that goal. The universe has something else in mind for you at this time. You know the saying “go with the flow”? That flow is energy. The obstacles are blockages of that flow. Sometimes you go around it and sometimes there is another path which gets highlighted. Taking the other path leads to a flow where you feel “Hey, I am in a zone.” Ultimately, you will end up at your goal. It just might not be the one with which you started.
  3. It can be done. “It cannot be done,” is something almost everyone in my career has told me. “It isn’t done this way,” “You cannot do that.” Well, if I listened to each and every person who told me that, not only would I have never succeeded in my career, but I would not be alive. Trust yourself. Have faith in yourself. Worst case scenario: you fail, you dust yourself off, and you learn from the experience. Best case: you proved it could be done against their “so-called” odds, but most importantly, it got done because you stuck to your instincts and did it!
  4. If you sense something, say something. This is something which spoke
    loud and clear to me during my pregnancy. But I realize now, I had been sensing discomfort in many parts of my career and relationships along the way. Had I just spoken up, dealt with my frustration or misunderstandings, things would not have escalated, because it would have been handled early on. Miscommunications happen all the time. Speaking up would have helped me navigate things better and be more efficient with my time, even if I got fired. Why? Because I would have learned valuable lessons on what not to settle for in the next job and my interview process would have been clearer, leading me to a better start the next go-round.
  5. Embrace change. People, places, goals, businesses, and you, change. Change is a great thing. When I didn’t get a job or lost a job to someone else, I used to ask myself, “What is wrong with me?” I wish I would have learned back then what I know now. Many people stay in a job they dislike, complacent and living each day out like it’s Groundhog’s day. The benefit of hindsight and having a near death experience is that I understand how fleeting life can be. And when you come so close to death, you start evaluating what you want in your life.
    My decision to shift gears was thrust upon me, because I had no choice. I tried to go back to producing. I had created a new show I was out pitching, yet everyone wanted to hear our story. I couldn’t get away from it. They kept saying “you should write a book.” I didn’t want to and I continued to pitch and I continued to get rejected. When I finally embraced what everyone else saw for me, the energy stopped working against me and this beautiful path lit up showing me exactly where I needed to be. At many points in one’s life, there are paths to take a chance and make a change. One of those decisions could change the trajectory of your life for the better. Embrace the change.

What are some things you’re working on or excited about?

The book, 37 Seconds is selling in different languages, in 12 countries and growing. I continue to speak, and I went back to TV, but in a different capacity. I signed my life rights to a production company to create a scripted series based on what happened and what continues to happen. Yes, I still have premonitions and yes, I see much more. The journey continues into the next book.
I am also currently writing a movie with a well-known scribe which you will hear about in the upcoming year.

Is there a person in the world whom you would love to have a breakfast or lunch with, and why?

Sheryl Sandberg. I love my husband the way she loves (present tense is on purpose) hers. I had such a visceral reaction when I learned of her husband’s passing that I reached out to her immediately. I had zero expectations I would hear from her, I just wanted to give her support energetically. I never got a response, but I felt compelled to talk to her about that soulful connection and how he will again show up for her. I was moved by her open letter on Facebook and her incredible book, Option B. The resilience and strength it takes to try as best you can to compartmentalize the pain, keep going for the sake of others—especially your children—and move forward. She is
someone I would love to break bread with and just give her and her children a hug.

37 Seconds

“Stephanie Arnold’s journalistic instincts made this remarkable happening a compelling reading experience.” – Dennis Swanson, President of Station Operations at Fox Television “Engaging, riveting, terrifying, inspiring, enlightening…this book isn’t just for the believer, this book is for the curious and the cynical…No matter who you are, the story of what happened to this woman when she died for ‘37 seconds’ will make you rethink how we all should live.” – Maureen Maher, CBS News correspondent/48 Hours “Arnold’s amazing, enthralling, and revealing story of how her clairvoyant visions anticipated and ultimately brought her back from the clutches of death could redefine the way clergy, physicians, and scientists think about dying…Nay Sayers and believers alike must take note of what really happens during those 37 seconds of death.” – Dr. Rachael Ross, co-host of The Doctors “I found myself wanting to read page after page without a break. There are so many thoughts I had and have – thoughts about western medicine, thoughts about life, thoughts about afterlife, thoughts about speaking out, thoughts about intuition.” – Debra Wong Yang, Former Judge and US Attorney “A remarkable story of strength and love, Arnold’s simple, direct prose reaches deep into your heart. This is a beautiful story of spirit about how life is to be cherished and how love is to be honored. I’m looking forward to the movie!” – Diane Alexander, Producer, The Second City “A vivid account of Arnold’s clinical death–a death she foresaw–following the birth of her son. If you’re skeptical of such things, Arnold’s reporting on her own story will make you a believer. You won’t want to put it down. – Bethany McLean, Vanity Fair contributing editor and New York Times bestselling author “Not everyone with a great story to tell is also a great writer. Fortunately for us Arnold is the whole package; a truly gifted writer who gives us the gift of her heartfelt and life-changing story. Life and death, love and caring come together in this must-read remembrance.” – James Rickards, author of The Death of Money “A phenomenal read. This novel is for anyone who needs to be reminded that your own intuition is a perfectly good explanation for any of your thoughts, perceptions, or beliefs. It’s your inner wisdom designed to guide you through life and protect you.” – Briana Williams, MamaGlow.com “Wow! Riveting. Stephanie Arnold takes all her readers–even the hyper-logical–on her journey along the most fascinating paths of the human spirit.” – Matthew Rhodes-Kropf, Associate Professor, Harvard Business School “A rapid, tense drama… a medical phenomenon coupled with her unusual ability to follow through on the forewarnings she received. Arnold’s explanations are non-melodramatic, illuminating, edifying, and leave the door wide open for new discussions about souls and where the life force goes when the body dies.” – Shelf Awareness “I loved 37 Seconds. Loved. It. This book is emotional and moving and contains such an important message of God’s love.” – Tracy A. Fischer for Readers’ Favorite Book Review “Stephanie Arnold’s ability to create a well-constructed out of body and near-death experience enables readers to ponder such things for themselves…a must-read. It encourages us all to believe that there is so much more beyond our understanding of our physical lives. A thought-provoking and inspiring read.” – Hilary Hawkes for Readers’ Favorite Book Review

California Woman Who Survived the ‘Most Feared Complication of Childbirth’ Now Advocates for Other Mothers

Know a hero? Send suggestions to [email protected] For more inspiring stories, read the latest issue of PEOPLE magazine

When Miranda Klassen’s trouble-free first pregnancy ended in an almost fatal delivery, she woke up from a medically induced coma with a newborn son and very few answers.

Now, the San Diego, California woman has dedicated her life to supporting families that have been affected by the rare birth complication that almost killed her – and unraveling the medical mystery that surrounds it.

“My husband and I went to the hospital thinking this was going to be one of the greatest moments of our lives, and it turned out to be nearly fatal and completely life-changing for both of us,” Klassen tells PEOPLE of that fateful day in 2008.

While in labor, the San Diego, California, woman suffered an amniotic fluid embolism, which is an unpreventable and often-fatal complication of pregnancy that occurs when amniotic fluid enters a mother’s blood stream and triggers an allergic-like reaction.

“The first phase is cardiorespiratory collapse, where your heart and your lungs stop,” Klassen, 39, explains. “If you live through that, the next phase is massive hemorrhaging – your blood cannot coagulate and you bleed from every orifice.”

While AFEs are extremely rare – occurring in approximately one out of every 40,000 births in North America – they are among the leading causes of maternal death in the United States. Estimated fatality rates vary widely – from 80 to 40 percent among mothers and 65 percent among infants still in the womb during an AFE.

Image zoom Miranda Klassen on the beach with her son, Van Melissa Au, Dandelion Dreams Photography

Those that do survive often face permanent neurological damage. “The majority of women who suffer an AFE die, while those that survive are often left in a persistent vegetative state,” Klassen says.

After waking up from two days in a medically induced coma, Klassen learned that she had survived because two people on her medical team at Scripps Memorial Hospital Encinitas recognized her symptoms early on. She also learned that many women with AFE are not so lucky.

Just months after leaving the hospital, Klassen started the Amniotic Fluid Embolism Foundation – a non-profit patient advocacy organization that supports mothers and families affected by AFEs.

Image zoom Bryce, Miranda and Van Klassen Melissa Au, Dandelion Dreams Photography

To date, the AFE Foundation has helped more than 25 survivors go on to safely have another child. The foundation has also established the world’s largest registry of AFE cases to advance medical research.

“My husband and I were fortunate in that we were able to get pregnant really easily,” Klassen says. “Everything about the pregnancy was uncomplicated. We found out we were having a boy, and I had always had visions of three little boys running around my house.”

In April 2008, Klassen went into labor. After several hours, nurses noticed that the baby’s heart rate was decreasing and an emergency C-section was ordered.

“Before they got the gurney out of the door, I started to have a seizure,” Klassen says. “I was convulsing and my eyes were rolling into the back of my head and my heart stopped.”

Klassen’s husband, Bryce, was ordered to leave the room. A nurse told him soon after that his son had been delivered and resuscitated while doctors continued to work on his wife.

“Forty-five minutes later, my OBGYN came out covered in blood and completely shaken and told my husband that the he believed I was suffering from a very rare complication that was fatal,” she shares.

After her heart and lungs failed, Klassen began hemorrhaging. She was then placed in a medically induced coma so that she could breathe with the aid of a machine.

“There was a team of about 20 different doctors and clinicians working on me, and they drained the hospital’s entire blood bank,” she explains. “The doctors told my family they could not guarantee that I would survive the night and added that if I did, they were fairly certain I would not be the same person I was when I checked into the hospital.”

While Klassen remained in a coma for two days, her family had no idea if she would ever meet her newborn son. When she woke up, she had no recollection of what had occurred – the last thing she remembered was checking into the hospital days earlier.

Image zoom Miranda Klassen in the hospital with her son Van Courtesy Miranda Klassen

“ first reaction when I woke up from the coma was trying to wrap my head around what had happened,” Klassen tells PEOPLE. “And the second was being shocked that this was all part of the norm.”

Klassen was released from the hospital eight days later with her son and a host of medical complications.

“I had longterm heart and kidney damage,” she says. “I had several procedures done to stop the bleeding, and I won’t be able to have anymore children. I had very little short-term memory, and I asked questions over and over again.”

Still, the new mother found the energy to search for more information about the rare complication that had almost taken her life – and was shocked when she found very little research.

“I told my husband, ‘Honey, this is crazy. There’s no research, there’s no organization, I’m going to start one,’ ” Klassen recalls.

Five months later, she returned to her full-time job in corporate finance and spent her nights developing her foundation. Her husband also found a new calling – going back to work to become an intensive care unit nurse so that he could work alongside the team that saved his wife’s life.

“Our son went to daycare and after I would put him to bed, I would get on the computer and work until midnight,” she says. “I found researchers and experts and emailed them saying, ‘How do we stop this? How do we prevent this? This is horrific, women are dying and no one has heard of it.’ ”

One of those experts, Dr. Gary Dildy, a Houston-based obstetrician-gynecologist, now serves as the medical advisory board chair for the AFE Foundation and works closely with Klassen on advocacy and research.

“Miranda was very passionate about trying to do something to support people and their families who have had to contend with this rare and poorly understood condition,” Dildy tells PEOPLE. “So we started collecting medical records and interviews and getting together as much information as possible.”

This research led to the creation of the AFE Registry at Baylor College of Medicine – now the world’s largest research registry for AFE. Dr. Dildy tells PEOPLE this research “stands to be the best hope for unraveling the mystery of AFE, the most feared complication of childbirth.”

While Klassen collaborated with researchers in the hopes of one day being able to prevent women from dying of AFE, she also dedicated herself to helping the families of those who had gone through the horrifying experience.

Image zoom A corkboard in Miranda Klassen’s office shows families that have been affected by AFEs Courtesy Miranda Klassen

“We work with the husbands who now have motherless children, having lost the loves of their lives on the very day that their first-born was brought into the world,” Klassen says. “It’s the hardest part of what I do, but it’s also the part that means the most to me.”

In January 2015, Klassen quit her job in finance to run the foundation full time, “making minimum wage and loving every minute of it,” she adds.

The foundation now offers support groups for grieving fathers and families, as well as parents grieving the loss of an infant. It also offers guides on managing medical expenses, finding psychological support and connecting with other survivors and families.

“It’s very isolating when you wake up from a coma and are told, ‘Oh you’re very lucky you’re alive, it’s such a miracle,’ ” Klassen says. “To be able to pair up a mother who lost her daughter in childbirth with another mother who s walking the same path is so important and so vital to their healing.”

Thanks to the network Klassen created, many AFE survivors have gained the support they need to have another child.

After surviving an AFE in the 2008 delivery of her 28-week-old son, Amy De Simone of Atlanta, Georgia, dreamed of having more children, but she was terrified to try.

Image zoom Amy De Simone holds her son Aiden, born at 28 weeks, in the hospital after surviving an AFE Courtesy Amy De Simone

“I went around and interviewed different OBGYNs and tried to get collective feedback on whether or not it would be something we could pursue,” De Simone, 39, tells PEOPLE. “One man said he would be scared to be my doctor.”

However, she found the hope she so desperately needed in an AFE Foundation support group dedicated to women who have gone on to have successful deliveries.

“If I had not connected with Miranda and I had not found this group, I’m not sure we could ve ever gotten through that mental road block of how scary it was,” she reflects.

Now, the mother of sons Aiden, 7, and Liam, 3, serves as board chair for the AFE Foundation and oversees many of the foundation’s outreach, education and support programs.

Image zoom Amy De Simone holds her son Aiden and newborn son Liam Courtesy Amy De Simone

“My ultimate hope is that we will solve AFE because no one should have to go through it,” De Simone says. “In the meantime, we just want to be there to support these families so that no one has to be alone.”

Klassen and her staff work tirelessly to support those who have been affected by AFE, making personal connections with families across the country.

Klassen visited the family of a woman in Texas who had died during the birth of her eight child. After learning that Klassen had lived through the same complication that took his mother’s life, one of the woman’s younger sons came up and asked her, “Why did you live and my mother died?”

“I had huge tears,” Klassen says of her conversation with the young boy. “I scooped him up and I said, ‘I’m sorry. I don’t know why, but I promise you that for the rest of my life I will work to get you that answer.’ ”

I Nearly Died Giving Birth: Surviving an Amniotic Fluid Embolism

It was February 14, 2018 – Valentine’s Day – one year ago – when my husband and I went in for a scheduled induction for our first child. We celebrated with a romantic dinner before settling into our hospital room at Overland Park Regional Medical Center. We were over the moon excited, texting goofy selfies to our parents asking for guesses on the birth time. We were ready. We read the books, we had the supplies, and we took the classes. We were ready. But we were not ready for this.

Around 5 a.m., things went from a healthy, normal labor/induction to nearly fatal for both me and my unborn son. Out of nowhere, I went into cardiac arrest, the team started CPR and I was emergently taken to the operating room for a C-section and to revive my heart. It took 14 minutes before my heart started beating. During that time they also did CPR to revive my son. Afterward, I was taken to the ICU and my son to the Level III Neonatal Intensive Care Unit. Doctors quickly diagnosed me with a rare condition called Amniotic Fluid Embolism (AFE) which occurs in 1 in 40,000 births but is the leading cause of maternal mortality around the world, second in the United States.

The first three days were critical. Resuscitating me was just the first step in a long process of organ failure, blood loss and trauma to my body. I developed a bleeding disorder called DIC (disseminated intravascular coagulation) which caused me to bleed uncontrollably for nearly seven hours, and I required 109 units of blood. I had five surgeries to stop the bleeding and repair damage. I also had to be put on dialysis because of the damage to my kidneys caused by the cardiac arrest and massive blood loss. The blood and fluids caused me to gain 70 pounds in about 12 hours causing massive nerve damage to my abdomen, hands and feet.

My son, Sullivan, had to receive whole body cooling and required one unit of blood and was declared brain dead for the first few days of his life. He did not handle the cooling well and the choice was to take him off the table and risk permanent damage to his brain or keep him on the treatment and risk his life. Doctors decided to take him off the cooling treatment and things started to improve. Against all odds, he’s progressing normally and shows no signs of deficits, physically or mentally.

Read More from KC Mom’s Blog

Manging amniotic fluid embolism

KEY POINTS

  • Amniotic fluid embolism is a leading cause of maternal mortality in developed countries.
  • It presents with maternal collapse or seizures, or occasionally fetal distress.
  • Resuscitation must be prompt and multidisciplinary, including delivery if necessary.
  • There is no specific therapy except intensive support with transfusion.
  • Mortality may not be as high as previously thought, since milder cases do occur.

A mniotic fluid embolism (AFE) is a dramatic and perplexing condition. Within moments of the appearance of symptoms, a gravida’s life is at stake, and both maternal and fetal deterioration are rapid. Further, because the diagnosis isn’t always clear, the hospital team must rule out other possible etiologies while trying to prevent respiratory arrest and hemorrhage. The relative rarity of AFE adds to the difficulty of deciphering its pathophysiology. That rarity, coupled with the complexity of management, may explain why AFE remains a leading cause of maternal death. In the United Kingdom over the past 15 years, AFE has been responsible for 8.4% of maternal deaths. In the United States and Australia, it has been associated with 7.5% to 10% of these deaths.1-3

Fortunately, a gloomy prognosis may no longer be inevitable. Over the past 20 years or so, mortality rates for AFE appear to have dropped. Still, when this condition presents, immediate action is vital if there’s any hope of saving mother and fetus. Here, I present clinical features that may signal an AFE and describe various management strategies outlined in the literature.

Declining mortality rates

A 1979 review suggested a mortality rate of 86% for women suffering an AFE. But in a retrospective look at the 1995 US National Amniotic Fluid Embolus Registry, researchers noted a mortality rate of 61%4,5 (though only 7% to 15% of all the women survived neurologically intact5). Other recent surveys report even lower mortality rates: under 30% (TABLE).3-6

The changing mortality rate is probably a result of 2 factors: better intensive care and a recognition that “milder” cases do occur. For example, as Benson notes, “the mere fact of survival” was generally considered “proof that a given individual did not have an amniotic fluid embolism.”7 Benson proposes a new clinical definition of AFE that would apply “to patients who survive as well as to those who die.”7 Milder cases tend to present with less dramatic collapse and often only transient hemodynamic change, whereas severe cases are characterized by collapse with cardiac arrest.

TABLE

Amniotic fluid embolism-related mortality and morbidity: selected series

SERIES SITE YEAR NUMBER OF CASES MORTALITY OTHER MORBIDITY INFANTS*
US registry (Clark)5 United States Published 1995 (1988-1993) 46 61% Only 15% neurologically intact 22/28 survived, 11 (50%) neurologically intact
Burrows and Khoo3 Brisbane, Australia Published 1995 (1984-1993) 9 22% 2/9 had hysterectomy; 1 long-term disability 8/11 survived (2 sets of twins)
Gilbert and Danielsen6 California Published 1999 (1994-1995) 57 28% 5/39 survivors needed “extra arrangements” on discharge† 95% survived; 72% normal discharge
UK registry (D.J.T., unpublished data) United Kingdom 1997-2000 25 16% 4/21 survivors and 1 of 4 women who died had hysterectomy; 1 surviving woman had internal iliac ligation and liver hematoma; 2 women had renal failure and recovered; 1 woman had subglottic stenosis 3 perinatal deaths; 5/15 survivors severely acidotic
*From cases occurring before or at delivery only.
† The authors did not specify what these “extra arrangements” were.

Clinical features

The pathophysiology of AFE is poorly understood. Amniotic fluid and fetal cells enter the maternal circulation, leading to sudden maternal or fetal deterioration—the hallmark clinical features of AFE.

In the United States, Clark established clinical criteria for AFE for the national registry; these criteria have been followed in the UK since 1997 in an effort to develop a registry of cases there.5,8 The criteria are:

  • acute hypotension or cardiac arrest
  • acute hypoxia (dyspnea, cyanosis, or respiratory arrest)
  • coagulopathy (laboratory evidence of intravascular coagulation or severe hemorrhage)
  • onset of all of the above during labor or within 30 minutes of delivery
  • no other clinical conditions or potential explanations for the symptoms and signs

Typically, AFE presents with a cluster of features. This becomes clear when a larger series of cases is considered. In early series reporting a high mortality rate, such as the Morgan series, almost all women presented with cardiorespiratory collapse.4 Other signs and symptoms were breathlessness, hypotension, collapse (e.g., hypovolemic), and seizures. Fetal signs and symptoms did not figure in the Morgan series, but in 17% of the US series the abnormal fetal-heart-rate (FHR) pattern was bradycardia.5 In the UK series, 9 cases (36%) presented with abnormal FHR patterns, though not all had bradycardia (D.J.T., unpublished data). Coagulopathy and bleeding were uncommon presenting features in all 3 series, occurring at a rate of 12% in Morgan’s series, 0% in the US series, and 4% in the UK series. Coagulopathy and massive hemorrhage seem to be features that develop later. Often the coagulopathy is present shortly after presentation—and can be detected if looked for—but becomes clinically apparent only with time.

Amniotic fluid embolism

Overview

Amniotic fluid embolism is a rare but serious condition that occurs when amniotic fluid — the fluid that surrounds a baby in the uterus during pregnancy — or fetal material, such as fetal cells, enters the mother’s bloodstream. Amniotic fluid embolism is most likely to occur during delivery or in the immediate postpartum period.

Amniotic fluid embolism is difficult to diagnose. If your doctor suspects you might have one, you’ll need immediate treatment to prevent potentially life-threatening complications.

Symptoms

Amniotic fluid embolism might develop suddenly and rapidly. Signs and symptoms might include:

  • Sudden shortness of breath
  • Excess fluid in the lungs (pulmonary edema)
  • Sudden low blood pressure
  • Sudden failure of the heart to effectively pump blood (cardiovascular collapse)
  • Life-threatening problems with blood clotting (disseminated intravascular coagulopathy)
  • Bleeding from the uterus, cesarean incision or intravenous (IV) sites
  • Altered mental status, such as anxiety or a sense of doom
  • Chills
  • Rapid heart rate or disturbances in the rhythm of the heart rate
  • Fetal distress, such as a slow heart rate, or other fetal heart rate abnormalities
  • Seizures
  • Loss of consciousness

Causes

Amniotic fluid embolism occurs when amniotic fluid or fetal material enters the mother’s bloodstream. A likely cause is a breakdown in the placental barrier, such as from trauma.

When this breakdown happens, the immune system responds by releasing products that cause an inflammatory reaction, which activates abnormal clotting in the mother’s lungs and blood vessels. This can result in a serious blood-clotting disorder known as disseminated intravascular coagulation.

However, amniotic fluid embolisms are rare — and it’s likely that some amniotic fluid commonly enters the mother’s bloodstream during delivery without causing problems. It’s not clear why in some mothers this leads to amniotic fluid embolism.

Risk factors

It’s estimated that there are between one and 12 cases of amniotic fluid embolism for every 100,000 deliveries. Because amniotic fluid embolisms are rare, it’s difficult to identify risk factors.

Research suggests that several factors might be linked to an increased risk of amniotic fluid embolism, however, including:

  • Advanced maternal age. If you’re 35 or older at the time of your child’s birth, you might be at increased risk of amniotic fluid embolism.
  • Placenta problems. Abnormalities in the placenta — the structure that develops in your uterus during pregnancy — might increase your risk of amniotic fluid embolism. Abnormalities might include the placenta partially or totally covering the cervix (placenta previa) or the placenta peeling away from the inner wall of the uterus before delivery (placental abruption). These conditions can disrupt the physical barriers between you and your baby.
  • Preeclampsia. Having high blood pressure and excess protein in your urine after 20 weeks of pregnancy (preeclampsia) can increase your risk.
  • Medically induced labor. Limited research suggests that certain labor induction methods are associated with an increased risk of amniotic fluid embolism. Research on this link, however, is conflicting.
  • Operative delivery. Having a C-section, a forceps delivery or a vacuum extraction might increase your risk of amniotic fluid embolism. These procedures can disrupt the physical barriers between you and your baby. It’s not clear, however, whether operative deliveries are true risk factors for amniotic fluid embolism because they’re used after the condition develops to ensure a rapid delivery.
  • Polyhydramnios. Having too much amniotic fluid around your baby may put you at risk of amniotic fluid embolism.

Complications

Amniotic fluid embolism can cause serious complications for you and your baby, including:

  • Brain injury. Low blood oxygen can cause permanent, severe neurological damage or brain death.
  • Lengthy hospital stay. Women who survive an amniotic fluid embolism often require treatment in the intensive care unit and — depending on the extent of their complications — might spend weeks or months in the hospital.
  • Maternal death. The number of women who die of amniotic fluid embolism (mortality rate) is very high. The numbers vary, but as many as 20 percent of maternal deaths in developed countries may be due to amniotic fluid embolisms.
  • Infant death. Your baby is at risk of brain injury or death. Prompt evaluation and delivery of your baby improves survival.

Diagnosis

A diagnosis of amniotic fluid embolism is typically made after other conditions have been ruled out.

Your health care provider might order the following lab tests during your evaluation:

  • Blood tests, including those that evaluate clotting, heart enzymes, electrolytes and blood type, as well as a complete blood count (CBC)
  • Electrocardiogram (ECG or EKG) to evaluate your heart’s rhythm
  • Pulse oximetry to check the amount of oxygen in your blood
  • Chest X-ray to look for fluid around your heart
  • Echocardiography to evaluate your heart’s function

Treatment

Amniotic fluid embolism requires rapid treatment to address low blood oxygen and low blood pressure.

Emergency treatments might include:

  • Catheter placement. A thin, hollow tube placed into one of your arteries (arterial catheter) might be used to monitor your blood pressure. You might also have another tube placed into a vein in your chest (central venous catheter), which can be used to give fluids, medications or transfusions, as well as draw blood.
  • Oxygen. You might need to have a breathing tube inserted into your airway to help you breathe.
  • Medications. Your doctor might give you medications to improve and support your heart function. Other medications might be used to decrease the pressure caused by fluid going into your heart and lungs.
  • Transfusions. If you have uncontrollable bleeding, you’ll need transfusions of blood, blood products and replacement fluids.

If you have amniotic fluid embolism before delivering your baby, your doctor will treat you with the goal of safely delivering your baby as soon as possible. An emergency C-section might be needed.

Coping and support

Experiencing a life-threatening pregnancy condition can be frightening and stressful for you and your family. Afterward, you might relive the experience and have nightmares and flashbacks.

During this challenging time, lean on loved ones for support. Consider joining a survivors’ network. Also, work with your health care provider to determine how you can safely manage your recovery and your role as the mother of a newborn.

Connecticut State Department of Public Health

Amniotic Fluid Embolism (AFE)

About

Amniotic fluid embolism (AFE) is a rare and unexpected birth complication that may occur when a mother suffers an allergic-like response to amniotic fluid that may enter her bloodstream during labor or shortly after delivery. The response can be life threatening to both mother and to her baby(ies) if she develops this before delivery. It can cause maternal respiratory and cardiac complications as well as blood clotting problems that can lead to uncontrolled bleeding. AFE is estimated to affect 1 in every 40,000 deliveries.

Although rare, clinicians should be prepared for this obstetric emergency and be aware of the clinical presentation and proficient in their understanding of the pathophysiology, treatment, and diagnosis of amniotic fluid embolism.

Amniotic Fluid Embolism is difficult to diagnose. If the doctor suspects AFE, immediate action and treatment must be taken to address the potentially life threatening complications.

Signs and Symptoms

Amniotic fluid embolism might develop suddenly and rapidly. Early signs and symptoms might include:

  • Increased anxiety
  • Agitation
  • Impending sense of doom
  • Confusion
  • Nausea or vomiting
  • Chills
  • Skin discoloration
  • Shortness of breath
  • Fetal distress
  • Abnormal vital signs

Which can lead to more serious and acute symptoms:

  • Loss of consciousness
  • Seizure and/or cardiopulmonary arrest
  • Bleeding from the uterus, cesarean incision or intravenous (IV) sites (disseminated intravascular coagulopathy)

Resources

AFE Clinical Fact Sheet (October 2019)

Resources for Parents and Families

Amniotic Fluid Embolism Foundation provides Crisis Resources, family support, support groups

Resources for Clinicians

Articles

Amniotic fluid embolism. Clark SL. Obstet Gynecol. 2014;123:337-348: https://www.ncbi.nlm.nih.gov/pubmed/24402585.

For more information on AFE including research, crisis resources, and support groups, visit the Amniotic Fluid Embolism Foundation website.

Personal Story

Read Diana’s story as well as other AFE stories.