An elderly multiparous woman with intrauterine foetal death was admitted with strong labor pains.The patient suddenly goes in shock with cyanosis respiratory disturbances and pulmonary oedema.The most likely clinical diagnosis is:

Ans. is c, i.e. Amniotic fluid embolismRef. COGDT 10/e, p 991, 992; Sheila Balakrishnan p 490, 491, Dutta Obs. 7/e, p 324, 325In the question, the female is:MultiparousAdvanced maternal ageFetus is deadThe patient is having strong uterine contractions and suddenly goes in shock with cyanosis, respiratory disturbance and pulmonary edema. All these favour the diagnosis of amniotic fluid embolism.Amniotic fluid embolism: It is characterized by an abrupt onset of respiratory distress and coagulopathy.Amniotic fluid enters the circulation and sets up a disseminated intravascular coagulation, leading to consumptive coagulopathy.Classically a woman in late labor or immediate postpartum gasps for air, has bronchospasm, becomes cyanotic and undergoes immediate collapse and cardiorespiratory arrest, usually accompanied by hemorrhage. Sudden death is usual.It is diagnosed clinically.Risk factors:Advanced maternal ageMultiparityTetanic uterine contractionUse of uterine stimulantsUterine ruptureCesarean sectionPremature separation of placentaIntra uterine fetal death.Remember: Amniotic fluidenters maternal circulation as a result of breech in the physiological barrier that normally exists between maternal and fetal compartments-so any cause leading to this mixing like cesarean section, premature separation of placenta, rupture uterus etc. Predisposes to amniotic fluid embolism.Most common timing for:Amniotic fluid embolismi. After ARMii. At cesarean sectioniii. In labor with strong uterine contractions.iv. Immediate postpartum.Management: Aimed at minimizing hypoxemia with supplemental oxygen, maintaining blood pressure and managing associated coagulopathy.