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  • Title: Fatal amniotic fluid embolism during legally induced abortion, United States, 1972 to 1978.
    Author: Guidotti RJ, Grimes DA, Cates W.
    Journal: Am J Obstet Gynecol; 1981 Oct 01; 141(3):257-61. PubMed ID: 7282806.
    Abstract:
    Amniotic fluid embolism (AFE) has emerged as an important cause of death from legally induced abortion. In the period 1972-1978, 12 probably and three autopsy-confirmed cases of fatal AFE during legally induced abortion were identified in the United States (12% of all deaths from legal abortion). Fourteen deaths from AFE were associated with labor-inducing techniques, and one with hysterotomy. The risk of death appears to be related to gestational age: the death-to-case rate for AFE increases progressively from nil at less than or equal to 12 weeks' gestation to 7.2 deaths per 100,000 abortions at greater than or equal to 21 weeks' gestation. Because treatment is frequently ineffective, prevention of AFE is critical. Performing abortions early in pregnancy and using curettage techniques whenever feasible should reduce the risk of death from this obstetric accident during legally induced abortion. Amniotic fluid embolism (AFE) has increased in importance as a cause of maternal death. During 1968-75 454 women died of AFE in the U.S., or 9% of all maternal deaths. AFE has recently been found to be an important cause of abortion-related deaths; since 1972 AFE has accounted for 12% of all deaths related to legally induced abortion; the overall estimated death-to-case rate for AFE is 0.2/100.000 legal abortions. 15 cases of fatal AFE associated with legally induced abortion were reported in 1978-79, according to the Center for Disease Controls; 3 of these cases were confirmed by autopsy. Age ranged from 16 to 35 years; 7 patients were white, 6 blacks, and 2 were Asian. Gestational age went from 14 to 35 weeks. 5 women had preexisting conditions; 14 women underwent instillation of hypertonic solution, hyperosmolar urea, or PGF2alpha; 1 woman underwent hysterotomy. All women were in labor when manifestations of AFE became evident; death usually occurred soon after the appearance of signs. Risk of death from AFE seems to increase progressively with advancing gestational age; risk at 21 weeks gestation is about 24 times higher than from abortion at 13-15 weeks' gestation. During the same period of time no deaths were associated with curettage abortions. Estimated death-to-case rate for instillation was not significantly different than for hysterotomy; the estimated death-to-case rate for black women and minority women was 2 times higher than for white women. Age did not make a difference in relationship to death. AFE is caused by the forcing of amniotic fluid into the maternal vascular system during the period of intense uterine contractions. The amount of amniotic fluid is much larger during the second and third trimester of pregnancy; this probably explains the increased risk of death from AFE afer 12 weeks' gestation. Prevention rather than treatment of AFE is of paramount importance. 2 measures may reduce the risk of abortion-related AFE: 1) abortion before the 12-15 week, and 2) curettage at about 13 weeks' gestation. Curettage, presumably by avoiding labor contractions, lowers the risk of AFE.
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