title: Amniotic fluid embolism: an Australian-New Zealand population-based study.
abstract: BACKGROUND
  Amniotic fluid embolism (AFE) is a major cause of direct maternal mortality in Australia and New Zealand. There has been no national population study of AFE in either country. The aim of this study was to estimate the incidence of amniotic fluid embolism in Australia and New Zealand and to describe risk factors, management, and perinatal outcomes.
  
  
  METHODS
  A population-based descriptive study using the Australasian Maternity Outcomes Surveillance System (AMOSS) carried out in 263 eligible sites (>50 births per year) covering an estimated 96% of women giving birth in Australia and all 24 New Zealand maternity units (100% of women giving birth in hospitals) between January 1 2010-December 31 2011. A case of AFE was defined either as a clinical diagnosis (acute hypotension or cardiac arrest, acute hypoxia and coagulopathy in the absence of any other potential explanation for the symptoms and signs observed) or as a post mortem diagnosis (presence of fetal squames/debris in the pulmonary circulation).
  
  
  RESULTS
  Thirty-three cases of AFE were reported from an estimated cohort of 613,731women giving birth, with an estimated incidence of 5.4 cases per 100,000 women giving birth (95% CI 3.5 to 7.2 per 100,000). Two (6%) events occurred at home whilst 46% (n = 15) occurred in the birth suite and 46% (n = 15) in the operating theatre (location not reported in one case). Fourteen women (42%) underwent either an induction or augmentation of labour and 22 (67%) underwent a caesarean section. Eight women (24%) conceived using assisted reproduction technology. Thirteen (42%) women required cardiopulmonary resuscitation, 18% (n = 6) had a hysterectomy and 85% (n = 28) received a transfusion of blood or blood products. Twenty (61%) were admitted to an Intensive Care Unit (ICU), eight (24%) were admitted to a High Dependency Unit (HDU) and seven (21%) were transferred to another hospital for further management. Five woman died (case fatality rate 15%) giving an estimated maternal mortality rate due to AFE of 0.8 per 100,000 women giving birth (95% CI 0.1% to 1.5%). There were two deaths among 36 infants.
  
  
  CONCLUSIONS
  A coordinated emergency response requiring resource intense multi-disciplinary input is required in the management of women with AFE. Although the case fatality rate is lower than in previously published studies, high rates of hysterectomy, resuscitation, and admission to higher care settings reflect the significant morbidity associated with AFE. Active, ongoing surveillance to document the risk factors and short and long-term outcomes of women and their babies following AFE may be helpful to guide best practice, management, counselling and service planning. A potential link between AFE and assisted reproductive technology warrants further investigation.
authors.affiliation: School of Women's and Infants' Health and School of Medicine and Pharmacology, University of Western Australia, Perth, Australia. Nolan.mcdonnell@health.wa.gov.au.|Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital, 374 Bagot Road, Subiaco, WA, 6008, Australia. Nolan.mcdonnell@health.wa.gov.au.|Department of Anaesthesia, St John of God Hospital (Subiaco), Perth, Australia. Nolan.mcdonnell@health.wa.gov.au.
authors.forename: Nolan
authors.initials: N
authors.lastname: McDonnell
authors.affiliation: National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK. marian.knight@npeu.ox.ac.uk.
authors.forename: Marian
authors.initials: M
authors.lastname: Knight
authors.affiliation: Sydney Medical School Nepean, The University of Sydney, Sydney, Australia. michael.peek@sydney.edu.au.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Peek
authors.affiliation: School of Medicine, Gold Coast Campus, Griffith University, Gold Coast, Australia. d.ellwood@griffith.edu.au.|Gold Coast University Hospital, Gold Coast, Australia. d.ellwood@griffith.edu.au.
authors.forename: David
authors.initials: D
authors.lastname: Ellwood
authors.affiliation: University of Technology Sydney, Faculty of Health, Sydney, Australia. Caroline.Homer@uts.edu.au.
authors.forename: Caroline S E
authors.initials: CS
authors.lastname: Homer
authors.affiliation: National Women's Health, Auckland City Hospital, Auckland, New Zealand. claire.mclintock@adhb.govt.nz.
authors.forename: Claire
authors.initials: C
authors.lastname: McLintock
authors.affiliation: University of Technology Sydney, Faculty of Health, Sydney, Australia. Geraldine.Vaughan@uts.edu.au.
authors.forename: Geraldine
authors.initials: G
authors.lastname: Vaughan
authors.affiliation: Judith Lumley Research Centre, La Trobe University, Melbourne, Australia. W.Pollock@latrobe.edu.au.|Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia. W.Pollock@latrobe.edu.au.
authors.forename: Wendy
authors.initials: W
authors.lastname: Pollock
authors.affiliation: University of Technology Sydney, Faculty of Health, Sydney, Australia. Zhuoyang.Li@uts.edu.au.
authors.forename: Zhuoyang
authors.initials: Z
authors.lastname: Li
authors.affiliation: University of Technology Sydney, Faculty of Health, Sydney, Australia. Nasrin.Javid@uts.edu.au.
authors.forename: Nasrin
authors.initials: N
authors.lastname: Javid
authors.affiliation: University of Technology Sydney, Faculty of Health, Sydney, Australia. elizabeth.sullivan@uts.edu.au.|School of Women's and Children's Health, The University of New South Wales, Sydney, Australia. elizabeth.sullivan@uts.edu.au.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Sullivan
mesh_terms: D000293:Adolescent; D000328:Adult; D001315:Australia / Q000453:epidemiology; D002585:Cesarean Section / Q000009:adverse effects*; D004619:Embolism, Amniotic Fluid / Q000175:diagnosis* / Q000453:epidemiology*; D005260:Female; D006801:Humans; D015994:Incidence; D007743:Labor, Obstetric; D008428:Maternal Mortality; D009520:New Zealand / Q000453:epidemiology; D011159:Population Surveillance; D011247:Pregnancy; D012307:Risk Factors; D055815:Young Adult