Amniotic Fluid Embolism in an Elective Caesarean Section: A Multidisciplinary Survival Case Report
Babatunde Osokoya (ST5 Anaesthetics Trainee), Fiona Yau (Consultant Anaesthetist),

Cherry Wang  (Consultant Anaesthetist)
Broomfield Hospital, Chelmsford, Mid and South Essex NHS Foundation Trust , UK

 

Introduction

Amniotic Fluid Embolism (AFE) is a rare and catastrophic obstetric emergency classically presenting with sudden maternal collapse, hypotension, hypoxaemia and coagulopathy. Diagnosis is one of exclusion.^1,2

We discuss a case in which early recognition and prompt response resulted in a positive outcome.

 

Case History

28/08/2025

41 year old female

G6P1 (4 miscarriages) at 38-week gestation

Planned for Category 4 LSCS + sterilisation

BMI 27 (1.62m, 71.8kg)

Previous  open myomectomy and emergency caesarean section, both uneventful

Allergy-none

Hb-108 g/L, Platelets 194

 

Regional anaesthesia

Baseline-135/85mmHg, PR-90 b/m, Sats 97%

Spinal – uncomplicated, first pass

2.6ml of 0.5% heavy bupivacaine + 300mcg diamorphine

Block level before surgery: T4 bilaterally to touch, T2 to col

Phenylephrine infusion started

Antibiotics: Co-moxiclav 1.2g stat

 

Intraoperative  Events

At point of delivery (19 mins into surgery)

Mother calling out in and in brief discomfort

Then reported unable to breath

Able to move hands

 

Immediate resuscitation

Became unresponsive

Cardiac arrest call made, AFE suspected

Low heart rate, low BP, SpO2 not recording

Glycopyrrolate + atropine given

Suxamethonium 100 mg, intubated, Sevoflurane on

Normal airway pressure (19 cmH20) &  ETCO2 (3.9 kPa)

Intermittent brief CPR

Four aliquots of 100 mcg adrenaline

ROSC in 3 minutes

Blood loss – 0.9 L(but under control)

Oxygen via facemask given to mother

Male baby delivered, resuscitated from code blue to no issues

 

Post Partum Haemorrhage

Haematuria noticed 45 mins post operation

Clots per vaginam, EBL -1.8L, Hb 104 g/L

Bakre balloon inserted and  2nd PRBC transfused

 

Immediate Post Operative Investigations

Chest Xray: Normal

12 lead ECG: Left axis deviation

Bedside echo:  LVH ?long standing HTN, No RV strain

CT head, pulmonary angiography, abdomen & pelvis:  No abnormalities detected.

 

Intensive Care

Transferred to ICU on low dose noradrenaline

8 cryoprecipitate given

Labetalol and magnesium infusion

Bakri balloon removed

Hb 69 g/L, platelet 55, 3rd PRBC given

Extubated on day 2, stepped down  on day 3 with no neurological deficit

 

Discharge

Discharged on day 7

Follow up clinics

Treated for hypertension

Allergy testing 09/12/2025: Negative

 

Differentials	Positives	Negatives
Anaphylaxis	Co-amoxiclav, adrenaline effective	Low  airway pressure, No rash/ angioedema
High block	Dyspnoea, hypotension	Acute, moved hands
Stroke	Collapse	Negative CT
Myocardial infarction	Dyspnoea	Negative ECG & Echo
Eclampsia	Collapse	Hypotension
Pulmonary embolism	Dyspnoea, hypotension	Negative CT

 

Discussion

AFE is rare and  causes significant morbidity and mortality. It  is thought to occur  due to maternal circulation exposed to amniotic fluid or foetal antigens2.

The MBRRACE reported in UK a rate of 0.45 per 100,000 maternities (nine deaths between 2021-2023).3 Uterine atony occurs in about 23 % of AFE cases1 and in our case caused PPH, further reducing chances of survival.

It is known to be associated with hypotension (100%), foetal distress (100%), pulmonary oedema (93%), cardiac arrest (87%), coagulopathy (83%), dyspnoea (49%)2, most which occurred in our patient.

High index of suspicion, multidisciplinary care, early use of point of care testing and aggressive supportive care all played vital roles in our outcome. Although not universally available in many maternities, the early use of TEG in this case was pivotal in aiding both diagnostic confidence and giving targeted treatment.

Key Learning Points

Clinical diagnosis- act early

Immediate CPR saves lives

Treat coagulopathy early

Use TEG/ROTEM

Multidisciplinary teamwork