Amniotic Fluid Embolism: Clinical Guidelines

List of Abbreviations

aPTT activated partial thromboplastin time

DIC disseminated intravascular coagulation

CPR cardiopulmonary resuscitation

AFE amniotic fluid embolism

ARDS acute respiratory distress syndrome in adults

CO cardiac output

SV stroke volume

MAP mean arterial pressure

INR international normalized ratio

FDP fibrin degradation products

VC vital capacity

BV circulating blood volume

ECG electrocardiogram

SpO₂ blood oxygen saturation

ABG/ASTR acid-base balance

CK creatine phosphokinase

CVC central venous catheter

ScvO₂ central venous oxygen saturation

pCO₂ partial pressure of carbon dioxide

V-apCO₂ veno-arterial partial pressure of carbon dioxide difference

CBC complete blood count

HES hydroxyethyl starch

TEG thromboelastography

ROTEM rotelem/rotational thromboelastometry

PTI prothrombin index

CTG cardiotocography

ECMO extracorporeal membrane oxygenation.

Terms and Definitions

Embolism – embolia (Greek *embole* – insertion, incursion) is a pathological process caused by the transport via the bloodstream of various substrates (emboli) not normally present, capable of causing acute vessel occlusion with impaired blood supply to a tissue or organ.

Arterial hypotension is defined as systolic blood pressure <90 mm Hg, or mean arterial pressure (MAP) <65 mm Hg, or a decrease of ≥40 mm Hg from baseline [1].

Circulatory shock is defined as a life-threatening, generalized form of acute circulatory failure associated with the inability of the circulatory system to deliver oxygen in accordance with tissue demands [1].

DIC (disseminated intravascular coagulation, consumption coagulopathy, thrombohemorrhagic syndrome) is a clinico-pathological syndrome complicating a number of diseases. It is characterized by systemic activation of pathways that trigger and regulate coagulation, capable of causing the formation of fibrin thrombi. This leads to organ failure associated with the consumption of platelets and clotting factors, which in turn leads to bleeding [2].

DIC is an acquired, secondary acute disorder of hemostasis [3,4].

− Accompanies only critical conditions.

− Belongs to consumption coagulopathies (coagulopathy consumptive), in which components of the coagulation system and—most importantly for the patient's outcome—the anticoagulant system of the blood are consumed.

− Clinically, DIC may be accompanied by both bleeding and thrombosis in the microcirculation zone with the development of multiple organ dysfunction syndrome.

Massive blood loss is an acute loss of ≥1500 ml of blood (25-30% of circulating blood volume) or ≥2500 ml of blood (50% of circulating blood volume) within 3 hours.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Amniotic fluid embolism is the acute onset of arterial hypotension, shock, respiratory failure, hypoxia, and coagulopathy (DIC) with massive hemorrhage associated with the entry of amniotic fluid and its components into the maternal pulmonary circulation during pregnancy, childbirth, and within 12 hours postpartum in the absence of other causes¹ [5,6].

¹ Amniotic fluid embolism: intensive care and obstetric management. Clinical guidelines (treatment protocols) of the Russian Ministry of Health No. 15-4/10/2-7317 dated Oct 20, 2017 - 34 p.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Currently, AFE is considered an anaphylaxis to biologically active substances present in amniotic fluid and is also defined as "anaphylactoid syndrome of pregnancy." There are no proven risk factors. However, the following factors appear to be associated with a higher risk of developing AFE² [5–13]

• Polyhydramnios.

• Intense uterine contractions during labor.

• Abdominal trauma.

• Cesarean section.

• Labor induction/pre-induction.

• Uterine inertia / dyscoordinated labor.

• Placenta previa.

• Eclampsia.

• Multiple pregnancy.

• Uterine or cervical rupture.

• Placental abruption.

• Diabetes mellitus.

• Fetal macrosomia.

• Fetal distress.

• Antenatal fetal death.

• Male infant gender.

Among the listed risk factors, the leading ones are: maternal age over 35, multiple pregnancy, cesarean section, and placenta previa [14–26]. Pharmacological agents used for labor induction/pre-induction are also among the leading proven risk factors [25–27].

² Amniotic fluid embolism: intensive care and obstetric management. Clinical guidelines (treatment protocols) of the Russian Ministry of Health No. 15-4/10/2-7317 dated Oct 20, 2017 - 34 p.

1.3 Epidemiology of the Disease or Condition

The incidence of amniotic fluid embolism varies across different countries, but the generally accepted rate is approximately 1 case per 20,000 deliveries [6,8,28]. Differences in AFE incidence estimates are related to multiple factors, such as research methodology (single reported cases vs. population-based morbidity data), non-specific diagnostic criteria, lack of reliable diagnostic tests and methods, and the absence of a unified disease registry [25,29–31]. AFE accounts for a significant proportion of global maternal mortality: 7.6% in the USA, 8% in Australia, 16% in the UK, and 8.3% in Russia (2024). The majority of AFE cases (70%) occur during labor, 19% during cesarean section, and 11% after vaginal delivery [32–36].

The pathogenesis of AFE is not yet fully understood. Recent evidence indicates that the occurrence of AFE is not the result of "simple" mechanical obstruction of pulmonary artery branches, but rather a humoral response causing anaphylaxis or complement activation [37]. This theory is supported by the fact that amniotic fluid contains vasoactive and procoagulant products, including platelet-activating factor, cytokines, bradykinin, thromboxane, leukotrienes, and arachidonic acid, which trigger intravascular blood coagulation [21,38]. It is also believed that when amniotic fluid enters the maternal systemic vasculature, the plasma concentration of endothelin increases, acting as a bronchoconstrictor as well as a pulmonary and coronary vasoconstrictor, which may contribute to respiratory and cardiovascular collapse [39,40]. Mortality from amniotic fluid embolism significantly correlates with spontaneous vaginal delivery and cardiac arrest. The outcome of AFE plays a crucial role in perinatal prognosis for the newborn. Fatal amniotic embolism causes intrauterine fetal demise and intrapartum fetal death [135].

1.4 Features of Coding the Disease or Condition

Class XV: Pregnancy, childbirth and the puerperium;

O75.1 Maternal shock during or after labor and delivery. Obstetric shock.

O88.1 Amniotic fluid embolism. Anaphylactoid syndrome of pregnancy.

O88.8 Other obstetric embolisms. Obstetric fat embolism.

1.5 Classification of the disease or condition

Depending on the leading clinical symptom complex in amniotic fluid embolism, the following pathological types are distinguished (see Appendix A3.1. Classification of amniotic fluid embolism based on the leading clinical symptom complex) [11,33,41,42]:

• Cardiopulmonary collapse type (classic type)

• DIC type

1.6 Clinical presentation of the disease or condition

Sudden onset of the disease: either against the background of complete health or preceded by nonspecific prodromal symptoms such as anxiety, agitation, numbness, feeling cold, dizziness, chest pain, sense of air hunger, transient hypoxia, and dyspnea, which may precede cardiovascular collapse.

Overall, there is high variability in the clinical manifestations of AFE, ranging from classic cardiopulmonary collapse with coagulopathy to minor and subclinical symptoms.

The main clinical symptoms are^3,4 [5,6,43,44]:

Neurological status: Seizures, altered consciousness, or coma occur in 15–50% of patients, headaches (7%).

Respiratory system: acute shortness of breath, dyspnea (50 to 80%). Cyanosis – of the nasolabial triangle, periphery, and mucous membranes (83%). Pulmonary edema or ARDS (93%), cough (7%).

Cardiovascular system: sudden hypotension (56 to 100%), transient hypertension (11%), cardiac arrest (30 to 87%), chest pain (2%).

Postpartum complications: uterine atony (hypotonic postpartum hemorrhage) 23%.

Fetal manifestations: acute fetal hypoxia (100%).

Differential diagnosis of amniotic fluid embolism with other diseases and conditions.

In laboring and postpartum women presenting with clinical signs of sudden cardiovascular collapse or cardiac arrest, seizures, severe respiratory distress, or hypoxia, particularly when combined with coagulopathy, a differential diagnosis must be performed for the following conditions (see Appendix A3.2) [8]:

• eclampsia;

• embolism (air, fat, thromromass);

• uterine rupture;

• placental abruption;

• massive postpartum hemorrhage, hypovolemic shock;

• acute heart failure (acute coronary syndrome, cardiomyopathy);

• anaphylactic shock;

• sepsis, septic shock;

• toxic effect of local anesthetic;

• high spinal anesthesia;

• transfusion reaction;

• aspiration of gastric contents;

• dissecting aortic aneurysm.

A typical presentation of amniotic fluid embolism involves a triad of sudden hypoxia and hypotension, followed in many cases by coagulopathy, all occurring during and after delivery within an interval of up to 12 hours. The diagnosis of amniotic fluid embolism is clinical, based on the presence of these elements and the exclusion of other probable causes. Amniotic fluid embolism should be considered in the differential diagnosis of any pregnant or immediate postpartum woman who suffers from sudden cardiovascular collapse or cardiac arrest, seizures, severe respiratory distress or hypoxia, especially if such events are followed by coagulopathy that cannot be otherwise explained [135].

³ Amniotic fluid embolism: intensive care and obstetric management. Clinical guidelines (treatment protocols) of the Russian Ministry of Health No. 15-4/10/2-7317 dated October 20, 2017 - 34 p.

⁴ RCOG. Maternal Collapse in Pregnancy and the Puerperium: Green-top Guideline No. 56.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis of AFE

The diagnosis of AFE is clinical and is a diagnosis of exclusion [8]. There are no laboratory tests with high specificity and reliability for diagnosing this nosology.

Amniotic fluid embolism (AFE) should be suspected in situations when, during pregnancy, labor, cesarean section, or in the immediate postpartum period (up to 12 hours) without other established causes, the following combination (more than one) of major signs develops⁵ [5,11,45–47]:

1. Acute arterial hypotension (systolic blood pressure <90 mm Hg) or cardiac arrest.

2. Acute maternal hypoxia (dyspnea, cyanosis, or peripheral capillary oxygen saturation SpO₂ (SpO₂) <90%) and/or fetal hypoxia.

3. Coagulopathy, disseminated intravascular coagulation (DIC) syndrome, and massive hemorrhage in the absence of other causes.

In the event of the patient's death, the diagnosis is verified postmortem [36]. However, there are no reliable histological signs of AFE, and autopsy findings must be evaluated in conjunction with the clinical picture [36,48,49].

⁵ Amniotic fluid embolism: intensive care and obstetric management. Clinical guidelines (treatment protocols) of the Russian Ministry of Health No. 15-4/10/2-7317 dated 20.10.2017 - 34 p.

2.1 Complaints and Anamnesis

• If available, all patients with suspected AFE are recommended to undergo a detailed taking of obstetric and gynecological history and complaints, as well as a clinical and laboratory examination to assess risk factors for amniotic fluid embolism [8].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comment: AFE is characterized by the absence of specific complaints, an acute onset of the disease, and a progressive course. The main complaints with preserved consciousness are [8]:

• Fatigue

• Dizziness

• Difficulty breathing, sensation of air hunger

• Cough

• Headache

• Chest pain

2.2 Physical Examination

• All patients with signs of AFE are recommended to undergo a general physical examination: assess the state of the skin, neurological status, and level of consciousness using the Glasgow Coma Scale (see Appendix G3), and measure the respiratory rate [8].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• All patients with signs of AFE are recommended to undergo pulmonary auscultation [8].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• If AFE is suspected, it is recommended to have an obstetrician-gynecologist perform an examination to assess the presence and nature of vaginal discharge, and the condition of the uterus (fundal height, tone (hypotonia/atony), tenderness) [5,8,50,51].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments: This examination should be performed in all patients with suspected AFE to determine obstetric management, decide on the method of delivery, initiate and determine the scope of intensive care, and identify indications for mechanical ventilation [5,8,50,51].

⁶ Clinical guidelines "Singleton delivery, delivery by cesarean section", 2020.

2.3 Laboratory Diagnostics

• All patients with signs of AFE are recommended to undergo a coagulogram (fibrinogen level, prothrombin time, APTT, INR) and, if available, viscoelastic tests (thromboelastography (TEG) or rotational thromboelastometry (ROTEM)) for early diagnosis of coagulopathies and selection of transfusion therapy before coagulogram results are obtained [36,52–55]. The frequency is determined by the patient's condition.

GCR BLOE 3Grade of Recommendation B (Level of Evidence 3).

Comments: Coagulopathy and DIC syndrome with massive bleeding are a characteristic feature of AFE. The onset of hemostatic disorders may develop within 10–30 minutes from the onset of AFE symptoms or may occur with a delay (up to 12 hours). Early detection of coagulopathy and DIC syndrome is necessary for the timely initiation of targeted replacement therapy. Critical changes: fibrinogen concentration less than 2 g/l, INR increase more than, 1.5 times the upper limit of normal, APTT increase more than 1.5–2 times the upper limit of normal, hypocoagulation on TEG. The fibrinogen level can be used as a predictor of the severity of obstetric hemorrhage; low fibrinogen levels are characteristic of AFE. Rapid assessment of the blood coagulation system using TEG and ROTEM makes it possible to assess hemostatic disorders before obtaining coagulogram results, and is used for the early diagnosis of coagulopathies, selection of transfusion therapy, and evaluation of the adequacy of ongoing therapy [3,4,10,36,50,56]. (See Appendix G4. Diagnostic criteria for DIC syndrome)

• All patients are recommended to undergo a complete blood count (total hemoglobin, erythrocytes, platelets, and hematocrit) when AFE is suspected and its clinical presentation develops [36,50,55,56]. The frequency is determined by the patient's condition.

GCR BLEL 3Recommendation Grade B (Level of Evidence — 3).

Comments: Determining hemoglobin and platelet levels is necessary to detect and treat anemia and thrombocytopenia and to determine indications for blood component transfusion, which helps reduce the risk of adverse perinatal outcomes. Performed in all patients. Critical changes: hemoglobin less than 70 g/l, platelet count less than 50,000/μl [3,4,50,56].

• All patients with suspected AFE are recommended to undergo serial testing of acid-base balance and blood gases [17]. The frequency is determined by the patient's condition.

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: Acid-base balance (ABB) is characterized by a decrease in PO₂ values and an increase in PCO₂ indicators with the development of respiratory and metabolic acidosis, and lactic acidosis. Serial assessment of ABB parameters is necessary to evaluate the adequacy of ongoing respiratory and infusion-transfusion therapy. Target ranges: pH 7.35–7.45, PCO₂ 35–45 mm Hg, PO₂ 80–95 mm Hg [17,57–59]

• All patients with suspected AFE are recommended to undergo a general routine biochemical blood test, including the determination of troponin I and T levels (rapid testing if available), natriuretic peptide, creatine kinase isoenzyme (CK-MB) levels/activity, and lactic acid (lactate) levels in arterial blood [45,50,60]. The frequency is determined by the patient's condition.

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: These parameters are nonspecific; an increase in cardiac-specific enzymes (CK-MB, troponin T or I, natriuretic peptide) is possible, indirectly confirming myocardial dysfunction. Blood lactate levels must be measured in all cases of unstable hemodynamics. Elevated lactate levels are directly proportional to the impairment of peripheral circulation. Critical changes: above 2 mEq/L or mmol/L. With the development of AFES, an elevated serum tryptase level is noted; however, there is no convincing evidence regarding the diagnostic value of the test due to insufficient specificity. An elevated tryptase level is also associated with anaphylaxis and must be differentiated from AFES [8,60–62].

Comments: This test is performed in all women with a previously placed central venous catheter presenting with signs of AFES requiring mechanical ventilation and intensive care. Target values: SCVO₂ above 70% [1,63].

2.4 Instrumental Diagnostics

• All patients with suspected AFES are recommended to undergo monitoring of basic vital parameters to the following extent: blood pressure, heart rate, in order to assess the function of the cardiovascular system and the adequacy of ongoing intensive care or CPR [8].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments: Target values: systolic blood pressure above 90 mmHg, mean arterial pressure above 65 mmHg. Routine use of invasive hemodynamic monitoring is not indicated due to the high risk of bleeding, unless an arterial catheter (line) has been previously placed [5,8,17].

• All patients with suspected AFES are recommended to undergo pulse oximetry with plethysmography in order to diagnose the degree of respiratory impairment, assess ongoing respiratory therapy, and evaluate the effectiveness of cardiopulmonary resuscitation [8].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: Target values SрO₂ at least 94% [1,8].

• All patients with suspected AFES are recommended to undergo transthoracic echocardiography to determine the level of pulmonary hypertension, diagnose acute right ventricular failure, and assess myocardial contractility impairment. When evaluating, attention should be paid to TAPSE (Tricuspid Annular Plane Systolic Excursion (normal >1.7 cm)), right ventricular ejection fraction (normal >35%) [5,64].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

Comments: The method is not highly specific, but it allows for a quantitative and qualitative assessment of right ventricular overload or dysfunction, as well as evaluation of CPR effectiveness. The procedure should not delay the initiation of intensive care and CPR. Transesophageal echocardiography requires more time for preparation and performance, availability of equipment, and practical skills of the personnel. In this context, transthoracic echocardiography has the advantage [5,50].

• All patients with suspected AFES are recommended to undergo electrocardiography to detect signs of right heart overload and rule out other cardiac pathology [5,65].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: ECG changes are nonspecific; ECG signs of right heart overload are most frequently observed (right axis deviation, increased P wave amplitude in leads II, III, and aVF, ST-segment depression, and T-wave inversion in right chest leads) [5,8].

• All patients with suspected amniotic fluid embolism are recommended to undergo chest X-ray for differential diagnosis, detection of concomitant pathology, and dynamic monitoring [5,66].

GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)

Comments: X-ray changes are nonspecific and characterized by enlargement of the right heart chambers, a pattern of interstitial confluent edema, with "butterfly"-shaped pattern consolidation in the perihilar region and peripheral translucency [5,50].

Comments: This test is performed in all women with signs of amniotic fluid embolism. Fetal bradycardia develops in response to maternal hypoxia. A critical decrease in fetal heart rate below 110 bpm, or below 60 bpm for 3–5 minutes, indicates a terminal condition of the fetus [45,50].

2.5 Other Procedures

Assessment of circulating blood volume deficit (see Clinical Guidelines "Postpartum Hemorrhage", 2025)

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

• All patients with suspected amniotic fluid embolism are recommended to ensure adequate venous access by inserting at least two peripheral intravenous catheters smaller than 16 G, unless established previously [50].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: In cases of difficult intravenous catheter insertion, ultrasound navigation should be used. If a central venous catheter was not placed previously, routine emergency central venous catheterization is undesirable: it requires practical skills from the staff, additional time, and increases the risk of complications. Recommended (safest and ensuring effective pharmacokinetics of drugs) routes of drug administration during cardiopulmonary resuscitation are intravenous or intraosseous. After drug administration into a peripheral vein, it should be flushed with at least 20 ml of crystalloid solution (B05BB: Solutions affecting the water-electrolyte balance) and elevated for 10–20 seconds to accelerate drug delivery to the central circulation. Intraosseous access is used if intravenous access fails after three attempts, provided intraosseous devices and practical skills are available. With intraosseous drug administration, adequate plasma concentrations are achieved at approximately the same rate as with intravenous administration [5,50,67].

• All patients with suspected amniotic fluid embolism are recommended to undergo urinary bladder catheterization with a urethral catheter for diuresis monitoring in all women with signs of amniotic fluid embolism, unless placed previously [5].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: Target diuresis values are at least 0.5 ml/kg/h [5,8,17,67].

• All patients with suspected amniotic fluid embolism are recommended to receive comprehensive intensive therapy depending on the predominant clinical manifestations: correction of arterial hypotension, immediate initiation of CPR in case of cardiac arrest, respiratory therapy with mechanical ventilation, and correction of massive blood loss and coagulopathic bleeding [26,59].

GPP BLE 2Grade of Recommendations B (Level of Evidence 2).

Comments: Timely initiation of comprehensive intensive therapy involving a multidisciplinary team (anesthesiologist-resuscitator, obstetriciangynecologist, neonatologist, transfusionist) increases the chances of a favorable maternal and fetal outcome. After the diagnosis of amniotic fluid embolism, an anesthesiologist-resuscitator is called within 10 minutes, venous access is secured (2 veins), a complete blood count is performed (total hemoglobin, erythrocytes, platelets, and hematocrit assessment), along with coagulation profile parameters (fibrinogen, prothrombin index, APTT, INR), lactic acid level, acid-base status and blood gas analysis, non-invasive vital signs monitoring (BP, HR, RR, ECG, SpO₂, body temperature), and diuresis assessment. In case of sudden cardiac arrest in a pregnant woman, diagnosed based on the following signs: absence of unconsciousness and spontaneous breathing, perform basic life support taking into account the specific features in pregnant women [68]. (see Clinical Guidelines "Singleton childbirth, delivery by cesarean section", 2021) [6,10,11,43,47,58,67,69–73].^7,8,9

• In the presence of progressive respiratory failure in patients with signs of amniotic fluid embolism, recommended is respiratory support ranging from low-flow oxygenation to invasive mechanical ventilation in accordance with the general clinical status and arterial blood gas analysis data [74,75].

GCR BLEL 3Recommendation Grade B (Level of Evidence — 3).

Comments: For endotracheal intubation, use 7.0–8.5 endotracheal tubes. If necessary, use the obstetric difficult airway protocol. Indications for emergency mechanical ventilation include: cardiac arrest; apnea or bradypnea (<8 breaths/min); hypoxic depression of consciousness; excessive work of breathing; exhaustion (fatigue) of the primary and accessory respiratory muscles; progressive cyanosis and clammy skin; progressive tachycardia of hypoxic origin; pulmonary edema; progressive hypoxemia refractory to oxygen therapy; PaO₂ less than 60 mm Hg (less than 65 mm Hg at an oxygen flow rate >5 L/min), SaO₂ less than 90%, PaCO₂ greater than 55 mm Hg, VC less than 15 mL/kg. Mechanical ventilation modes and parameters are selected individually, based on lung-protective ventilation and acceptable gas exchange and ventilation targets. During mechanical ventilation, end-tidal CO₂ levels should be monitored (capnometry). There is no need for oxygen supplementation or respiratory therapy with SpO₂ values of 94–98% while breathing ambient air [51, 75–77].

Comments: Do not delay the initiation of defibrillation. Use adhesive pads; do not perform fetal monitoring during resuscitation efforts. Continue CPR and drug administration before, during, and after delivery of the fetus. Hypoxia, acidosis, and hypercapnia should be avoided as they increase pulmonary vascular resistance and lead to further heart failure [67, 78–83]. When performing basic and/or advanced life support in a pregnant woman, consider the possible or verified cause of cardiac arrest (blood loss, pulmonary embolism, anaphylaxis, etc.) and assess the possibility of its elimination to increase the effectiveness of resuscitation efforts [78, 84–86]. In the event of sudden cardiac arrest in a pregnant woman at a gestational age of more than 20 weeks, eliminate the aortocaval compression mechanism by displacing the pregnant uterus as far to the left as possible while the patient is in the supine position to ensure adequate venous return to the heart and increase cardiac output, and initiate basic life support with left uterine displacement; if CPR is ineffective within 4 minutes at a gestational age of more than 20 weeks, perform delivery [75–77, 81–83, 87]. The gravid uterus impairs venous return due to aortocaval compression and thus reduces the functional state of the heart by approximately 60%. Delivery reduces oxygen consumption, improves venous return and cardiac function, facilitates closed chest compressions, and improves ventilation. It also allows for internal closed chest compressions via the diaphragm [74, 78]. It is recommended that basic life support in sudden cardiac arrest in all pregnant women be performed in the following sequence: ensure personal safety, call for help, and initiate CPR with the patient in the supine position: chest compressions at a rate of 100–120/min, to a depth of 5–6 cm, with a chest compression-to-ventilation ratio of 30:2 [78, 88–93]¹⁰. Basic and advanced life support in a pregnant woman are performed in accordance with the recommendations of the National Resuscitation Council and international guidelines [78, 94, 95]¹¹.

• Following delivery in the event of sudden cardiac arrest, advanced life support is recommended for all patients for 30 minutes [74, 78]^{12, 13}. (See clinical guidelines "Single-term deliveries, delivery by caesarean section", 2020.)

GLE BLOD 3Level of evidence B (reliability level of evidence - 3).

Comments: Resuscitation measures are performed in accordance with the recommendations of the Russian National Resuscitation Council and the European Resuscitation Council (ERC) [78, 94, 95]¹⁴. During advanced life support for sudden cardiac arrest in a pregnant woman, the same defibrillation settings are used as in non-pregnant individuals [96, 97]¹⁵. During advanced life support for sudden cardiac arrest in a pregnant woman, the same medications and venous access routes are used as in non-pregnant individuals [78, 94, 95, 98]¹⁶.

Comments: During infusion-transfusion therapy, avoid excessive fluid administration, as this will exacerbate right ventricular failure and pulmonary edema [67].

Comment: If hemodynamic stabilization (systolic blood pressure >90 mm Hg, mean arterial pressure >65 mm Hg) is not achieved after administering 30 mL/kg of warmed plasma substitutes (B05AA – Blood plasma and plasma protein fractions) at maximum speed in cases of decompensated hemorrhagic shock, low cardiac index, and the need for emergency surgery under general anesthesia and mechanical ventilation, the administration of vasopressors (C01CA: Adrenergic and dopaminergic agents) and inotropic drugs (C01CX: Other cardiac stimulants) must be initiated [1, 86, 102–105]. Target hemodynamic parameters: systolic blood pressure >90 mm Hg, mean arterial pressure >65 mm Hg, cardiac index >2.0 L/min·m². (Dosages of vasoactive drugs (C01CA: Adrenergic and dopaminergic agents, C01CX: Other cardiac stimulants) according to the instructions for use) [8].

Comment: See Clinical Guidelines "Pulmonary Hypertension, Including Chronic Thromboembolic Pulmonary Hypertension", 2024.

• All patients with hemorrhagic shock and clinical manifestations of amniotic fluid embolism are recommended to undergo early initiation of active warming [109, 110].

GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)

Comment: Warming devices used include: forced-air warmers, blankets, and administration exclusively of warmed infusion solutions and blood components [45, 58].

Comment: Drugs should be used when indicated and based on coagulation test results. Doses of antifibrinolytics (tranexamic acid**) according to the package insert: intravenously 15 mg/kg (average 1000 mg) over 10 minutes, with a possible dose increase up to 4000 mg if bleeding continues. Re-administration is possible after 8 hours [111–116]. For the treatment of coagulopathy, see Clinical Guidelines "Postpartum Hemorrhage", 2025 (Appendix A3.3).

⁷ Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of the Criteria for Assessing the Quality of Medical Care" (Registered with the Russian Ministry of Justice on May 17, 2017, No. 46740)

⁸ European Resuscitation Council Guidelines for Resuscitation 2015 // Resuscitation. 2015. Vol. 95. P. 148–201.

⁹ RCOG. Maternal Collapse in Pregnancy and the Puerperium: Green-top Guideline No. 56.

¹⁰ European Resuscitation Council (ERC) Guidelines 2021

¹¹ European Resuscitation Council (ERC) Guidelines 2021

¹² European Resuscitation Council (ERC) Guidelines 2021

¹³ Decree of the Government of the Russian Federation No. 950 dated September 20, 2012, "On Approval of the Rules for Determining the Moment of Human Death, Including Criteria and Procedures for Establishing Human Death, the Rules for Termination of Resuscitation Measures, and the Form of the Protocol for Establishing Human Death"

¹⁴ European Resuscitation Council (ERC) Guidelines 2021

¹⁵ RCOG. Maternal Collapse in Pregnancy and the Puerperium: Green-top Guideline No. 56.

¹⁶ European Resuscitation Council (ERC) Guidelines 2021

¹⁷ National Clinical Guideline Centre (UK). Intravenous Fluid Therapy: Intravenous Fluid Therapy in Adults in Hospital. London: Royal College of Physicians

3.2 Surgical Treatment

The main goal is to stop bleeding using surgical and conservative methods. In cases of stable hemodynamics and no coagulopathy (DIC), the principle of staged surgical hemostasis may be applied – moving from conservative to surgical methods, bearing in mind that the ineffectiveness of any bleeding-cessation measure is an indication to proceed to the next stage.

Comments: Surgical intervention should be performed no later than 20 minutes from the moment of diagnosis in cases of massive blood loss exceeding 30% of circulating blood volume (if conservative treatment is ineffective)¹⁸. In case of blood loss with signs of coagulopathy (DIC) and shock symptoms, laparotomy is indicated as quickly as possible for surgical hemostasis [117,118]. Hysterectomy should not be considered as the sole and primary element of surgical hemostasis. Staged surgical hemostasis should be performed based on the clinical presentation of the disease, the degree of blood loss, the medical facility's resources, and the staff's experience and skills [67]. (See Clinical Guidelines "Postpartum Hemorrhage", 2021)

Comments: In cases of maternal hemodynamic instability, obstetric management will depend on the gestational age, presence of fetal distress, maternal condition, and availability of anesthetic support [8]. Delivery and left uterine displacement reduce aortocaval compression and optimize CPR (See clinical guidelines "Single-term deliveries, delivery via caesarean section", 2021). If there is no technical capability to perform delivery on site, the patient is transported to the operating room (a location equipped for surgery) as quickly as possible without interrupting resuscitation measures [119–122].

• In all women with suspected AFE or a developed clinical presentation of AFE following operative or vaginal delivery, prevention and treatment of uterine atony should be performed using uterotonic agents (G02A: Uterotonics) [116,121–128].

GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5).

Comments: prevention and treatment of uterine atony with uterotonic agents are carried out in accordance with clinical guidelines ("Postpartum Hemorrhages", 2021). The dosage of uterotonic agents is administered according to the drug instructions [118,123–130].

¹⁸ Order of the Russian Ministry of Health No. 1170n "On approval of the rules for the provision of medical care to the population in the profile 'transfusiology'" dated October 28, 2020

¹⁹ Clinical Guidelines "Single-term deliveries, delivery via caesarean section", 2020.

3.3 Anesthetic management in AFE

• In female patients with AFE presenting with massive blood loss and hemorrhagic shock who require anesthetic management, it is recommended to perform general anesthesia with mechanical ventilation [72].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comment: When performing general anesthesia, use ketamine**, fentanyl** in dosages according to the drug instructions. Indications for prolonged mechanical ventilation after surgery: unstable hemodynamics with a tendency towards arterial hypotension (systolic BP less than 90 mm Hg, need for vasopressors – C01CA: Adrenergic and dopaminergic agents) due to inadequate blood volume replacement, ongoing bleeding, hemoglobin level less than 70 g/L and the need for continued blood transfusion, mixed venous oxygen saturation less than 70%, persistent coagulopathy (INR and aPTT more than 1.5 times the upper limit of normal, fibrinogen less than 1.0 g/L, platelet count less than 50,000/μL), and the need for replacement therapy. The duration of mechanical ventilation depends on the rate at which criteria for positive effects are achieved in massive blood loss and hemorrhagic shock [6,70,72]²⁰.

²⁰ Anesthesia, Intensive Care, and Resuscitation in Obstetrics and Gynecology. Clinical Guidelines. Treatment Protocols edited by A.V. Kulikov, E.M. Shifman, 2019.

3.4 Other treatment

Comment: Treatment of hemorrhagic shock and coagulopathic bleeding in patients with AFE is carried out in accordance with clinical guidelines (treatment protocol) [3,6,8,131,132]^21,22. (See clinical guidelines "Postpartum Hemorrhage", 2025.)

• If the medical organization has the capability for veno-arterial ECMO, it is recommended to consider its use in patients with AFE who have prolonged CPR or refractory right ventricular failure [51].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: The ECMO procedure, especially during resuscitation efforts, is associated with the risk of vascular injury and requires careful determination of indications and contraindications, availability of specialists, and the need for continuous presence; therefore, the decision to use this technique is made on an individual basis in each case, taking into account all factors and risks, provided it is the only measure to ensure adequate gas exchange and circulatory support and the medical facility's capabilities allow it [8,50,51,67].

²¹ Order of the Ministry of Health of the Russian Federation No. 1170n dated October 28, 2020, "On approval of the rules for the provision of medical care to the population in the profile 'transfusiology'"

²² Order of the Ministry of Health of the Russian Federation No. 1134n dated October 20, 2020, "On approval of the rules for medical examination of a recipient, performing individual compatibility tests, including a biological test, during the transfusion of donor blood and/or its components"

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not applicable.

5. Prevention and Dispensary Observation

Not applicable.

6. Organization of Medical Care

If AFE is suspected, medical care must be provided in the intensive care unit of the hospital where the complication occurred. The Obstetric Remote Consultation Center (ORCC) and the Federal Perinatal Center must be notified of this complication. Subsequently, in the absence of contraindications for transport, the patient should be transferred to a Level 3 obstetric hospital or a multidisciplinary hospital.

7. Additional Information

Given the variety of clinical manifestations and severity levels of AFE, the mortality rate also varies significantly.

Despite significant progress in intensive care, the rate of long-term complications of AFE among female survivors remains consistently high. Persistent neurological disorders were noted in 61% of women. However, brain tissue lesions were observed in only 6% of cases, and the incidence of cerebrovascular disorders was 20%. Hysterectomy was performed in 25% of surviving women, and more than 50% received a blood transfusion. During intensive care in patients with AFE, multi-organ failure, septic and neurological complications must be prevented by complying with the requirements of relevant protocols and algorithms.

Several clinical cases of pregnancies in patients after AFE have been published, with no recurrence of AFE in subsequent pregnancies. Despite the small sample size, all observations noted that the risk of recurrent AFE is extremely low, as this complication develops as a result of exposure to antigens during a specific pregnancy, whereas the next one may occur in the absence of these agents [8,33,45,67].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Natalia V. Artymuk – MD, Professor, Head of the Department of Obstetrics and Gynecology named after Prof. G.A. Ushakova, Kemerovo State Medical University of the Russian Ministry of Health, President of the Kemerovo Regional Public Organization "Association of Obstetricians and Gynecologists", Chief Freelance Specialist of the Ministry of Health of the Russian Federation in Obstetrics and Gynecology in the Siberian Federal District, Member of the Presidium of the Association of Obstetric Anesthesiologists-Resuscitators (Kemerovo). No conflict of interest.

2. Sergey V. Barinov – MD, Professor, Head of the Department of Obstetrics and Gynecology No. 2, Omsk State Medical University of the Russian Ministry of Health, freelance expert of the territorial management of Roszdravnadzor in Omsk Oblast (Omsk). No conflict of interest.

3. Nadezhda V. Bashmakova – MD, Professor, Chief Researcher, Ural Research Institute of Maternity and Infancy Care of the Russian Ministry of Health, Chief Freelance Specialist of the Russian Ministry of Health in Obstetrics and Gynecology in the Ural Federal District (Yekaterinburg). No conflict of interest.

4. Alexander V. Belov – PhD, Associate Professor at the Department of Anesthesiology and Intensive Care, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, anesthesiologist-resuscitator at the Department of Anesthesiology and Intensive Care, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

5. Tatyana E. Belokrinitskaya – MD, PhD, Professor, Honored Doctor of the Russian Federation, Head of the Department of Obstetrics and Gynecology of the Faculty of Advanced Training and Professional Retraining of Specialists, Chita State Medical Academy of the Ministry of Health of the Russian Federation, Chief Freelance Specialist of the Ministry of Health of the Russian Federation in Obstetrics and Gynecology in the Far Eastern Federal District, Member of the Board of the Russian Society of Obstetricians and Gynecologists, Member of the Presidium of the Association of Obstetric Anesthesiologists-Resuscitators, Deputy of the Legislative Assembly of the Zabaykalsky Krai, President of the Trans-Baikal Society of Obstetricians and Gynecologists (Chita). There is no conflict of interest.

6. Vadim S. Gorokhovsky – PhD, Associate Professor, Head of the Department of Anesthesiology, Intensive Care, Transfusiology and Emergency Medicine, Far Eastern State Medical University of the Russian Ministry of Health, Member of the Presidium of the Association of Obstetric Anesthesiologists-Resuscitators, Chairman of the Public Organization of Anesthesiologists-Resuscitators of Khabarovsk Krai (Khabarovsk). No conflict of interest.

7. Elena L. Dolgopolova – Postgraduate Student, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

8. Drobinskaya Alla Nikolaevna – Candidate of Medical Sciences, Associate Professor of the V.L. Zelman Mirror Department of Anesthesiology and Intensive Care at the Institute of Medicine and Psychology of the Novosibirsk National Research State University of the Russian Ministry of Health, Chief freelance obstetric anesthesiologist-resuscitator of the Ministry of Health of the Novosibirsk Region, Honored Doctor of the Russian Federation, Presidium Member of the Association of Obstetric Anesthesiologists-Resuscitators (Novosibirsk). There is no conflict of interest.

9. Ketskalo Mikhail Valeryevich – Candidate of Medical Sciences, Deputy Director – Director of the National Medical Research Center for Anesthesiology and Resuscitation (for pregnant women), Deputy Director of the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation, Presidium Member of the Association of Anesthesiologists-Resuscitators of Russia, President of ROSECMO LLC. There is no conflict of interest.

10. Vladimir A. Klimov – PhD, Chief Freelance Specialist in Obstetrics of the Russian Ministry of Health, Head of the Medical Care Organization Service, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health. No conflict of interest.

11. Alexander V. Kulikov – MD, Professor, Professor at the Department of Obstetrics, Gynecology and Transfusiology, Ural State Medical University of the Russian Ministry of Health, Vice-President of the Association of Obstetric Anesthesiologists-Resuscitators, Board Member of the Federation of Anesthesiologists and Reanimatologists (FAR), Chairman of the FAR Committee on Anesthesia and Intensive Care in Obstetrics and Gynecology (Yekaterinburg). No conflict of interest.

12. Dmitry V. Marshalov – MD, Associate Professor, Leading Researcher at the National Medical Research Center for Anesthesiology and Intensive Care (for pregnant women), National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health; Associate Professor at the Department of Emergency Anesthesiology, Intensive Care and Simulation Technologies in Medicine, Saratov State Medical University named after V.I. Razumovsky of the Russian Ministry of Health; Member of the FAR Committee on Anesthesiology and Intensive Care in Obstetrics, Member of the FAR Committee on Clinical Transfusiology and Hemostasiology (Moscow). No conflict of interest.

13. Denis N. Protsenko – MD, Associate Professor, Head of the Department of Anesthesiology and Intensive Care, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Chief Physician of City Clinical Hospital No. 40 of the Moscow Healthcare Department, Chief Freelance Anesthesiologist-Resuscitator of the Moscow Healthcare Department, Member of the Presidium of the Association of Obstetric Anesthesiologists-Resuscitators (Moscow). No conflict of interest.

14. Natalia Yu. Pylaeva – MD, Anesthesiologist-Resuscitator, Associate Professor at the Department of General Surgery, Anesthesiology, Intensive Care and Emergency Medicine, Faculty of Training of Highly Qualified Medical Personnel and Additional Professional Education, V.I. Vernadsky Crimean Federal University (structural unit), Member of the Association of Obstetric Anesthesiologists-Resuscitators (Simferopol). No conflict of interest.

15. Yury S. Raspopin – Head of the Department of Anesthesiology and Intensive Care, Krasnoyarsk Regional Clinical Center for Maternal and Child Health; Assistant Professor at the Department of Anesthesiology and Intensive Care, Institute of Postgraduate Education, Krasnoyarsk State Medical University named after Professor V.F. Voino-Yasenetsky of the Russian Ministry of Health; Anesthesiologist-Resuscitator of the highest qualification category, Member of the Association of Obstetric Anesthesiologists-Resuscitators (Krasnoyarsk). No conflict of interest.

16. Oleg V. Rogachevsky – MD, Head of the Department of Extracorporeal Treatment Methods and Detoxification, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

17. Borislav V. Silaev – PhD, Head of the Department of Anesthesiology and Intensive Care, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

18. Tatyana A. Fedorova – MD, Head of the Department of Transfusiology and Hemocorrection, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

19. Oleg S. Filippov – MD, Professor, Deputy Director of the Department of Medical Care for Children and Obstetrics Services of the Russian Ministry of Health, Honored Doctor of the Russian Federation, Professor at the Department of Obstetrics and Gynecology, Faculty of Advanced Training for Physicians, A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Russian Ministry of Health (Moscow). No conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Anesthesiologists-resuscitators.

2. Obstetrician-gynecologists.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

• Procedure for the provision of medical care to the adult population in the profile "anesthesiology and intensive care", approved by Order of the Ministry of Health of the Russian Federation No. 919n dated November 15, 2012.

• Order of the Ministry of Health of the Russian Federation No. 1170n dated October 28, 2020 "On approval of the procedure for providing medical care to the population in the profile 'transfusiology'"

• Order of the Ministry of Health of the Russian Federation No. 1134n dated October 20, 2020 "On approval of the procedure for medical examination of a recipient, performing tests for individual compatibility, including a biological test, during the transfusion of donor blood and (or) its components"

• Order of the Ministry of Health of the Russian Federation No. 598n dated November 7, 2012 "On approval of the standard of specialized medical care for bleeding in the placental and postpartum periods".

• Order of the Ministry of Health of the Russian Federation dated October 20, 2020, No. 1130n "On Approval of the Procedure for Providing Medical Care in the Field of 'Obstetrics and Gynecology'."

• Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care."

• Intensive care of amniotic fluid embolism.

• Clinical Guidelines (Treatment Protocols), 2018. Approved by the decision of the Presidium of the All-Russian Public Organization of Anesthesiologists and Reanimatologists "Federation of Anesthesiologists and Reanimatologists"

Appendix A3.1. Classification of amniotic fluid embolism based on the leading clinical symptom complex

Appendix A3.2. Differential diagnosis of amniotic fluid embolism [5, 33]

Appendix A3.3. Agents for prevention and correction of coagulation disorders in bleeding (see Clinical Guidelines "Postpartum Hemorrhage", 2021

Appendix B. Physician Action Algorithms

Appendix B1. Amniotic fluid embolism. Initial intensive care checklist [51].

(This checklist is a sample only. Each facility may modify it according to its specific capabilities).

_____________________________________________________________________________________________

☐ Measures for circulatory stabilization

ABC assessment:

☐ Airway patency

☐ Breathing

☐ Circulation

Assign a leader/timekeeper to call out time at 1-minute intervals.

If pulseless, initiate CPR (according to ERC 2021)

☐ Uterine displacement to the left or tilt

☐ Place on a hard surface

Consider moving to the operating room only if it can be done in 2 minutes or less.

If pulse is absent after 4 min, INITIATE perimortem Cesarean delivery (resuscitative hysterotomy)

☐ Minimal preoperative preparation, without waiting for the prophylactic effect of antibacterial drugs (See Clinical Guidelines "Singleton Childbirth, Delivery via Cesarean Section", 2020).

☐ Goal is to increase the chances of return of spontaneous circulation.

☐ Anticipate uterine atony, DIC, hemorrhage (see Clinical Guidelines "Postpartum Hemorrhage", 2021.)

Oxytocin prophylaxis (H01BB: oxytocin and derivatives) plus other uterotonics (G02A: Uterotonic drugs) as needed

Consider intraosseous line placement if large-bore intravenous access is required.

Initiate massive transfusion protocol.

☐ Cryoprecipitate (human blood coagulation factor VIII) to correct fibrinogen levels is preferred over FFP to prevent volume overload.

Consider thromboelastometry if available.

Tranexamic acid** (1 g IV over 10 minutes) for DIC or bleeding

☐ Manage pulmonary hypertension and right ventricular failure (see Clinical Guidelines "Pulmonary hypertension, including chronic thromboembolic pulmonary hypertension")

(Anesthesiology, Intensive Care, or Cardiology)

Consider echocardiography (transthoracic or transesophageal).

Avoid fluid overload (e.g., 500 mL boluses and reassessment)

Vasopressor if needed: norepinephrine 0.05-3.3 mcg/kg/min

Inotropes if needed:

☐ Dobutamine 2.5-5.0 mcg/kg/min

Pulmonary vasodilator if right ventricular unloading is needed

☐ Inhaled nitric oxide 5-40 ppm or

☐ Inhaled iloprost 10-50 ng/kg/min or

☐ IV iloprost (central vein) 1-2 ng/kg/min or

☐ Sildenafil 20 mg PO (if awake/via tube)

Consider ECMO for prolonged CPR or refractory right ventricular failure.

No need for oxygen supplementation if O2 saturation is 94% to 98%.

☐ Debriefing (entire team)

Identify opportunities for improvement, including the need for checklist modifications

Discuss family and staff support needs

Report the case of amniotic fluid embolism

___________________________________________________________________________       

Version dated February 17, 2021

Appendix B2. Algorithm for the diagnosis of amniotic fluid embolism

Appendix B3. Algorithm for the management of coagulopathic bleeding in amniotic fluid embolism

Appendix B4. Cardiopulmonary resuscitation algorithm for amniotic fluid embolism in the delivery room / operating room

Appendix B6. Difficult airway algorithm in obstetrics23

See Clinical Guidelines "Single-term deliveries, delivery by cesarean section", 2020

Appendix B7. "Cannot ventilate - cannot intubate" algorithm24

See Clinical Guidelines "Single-term deliveries, delivery by cesarean section", 2020

²³ R. Hofmeyr. Difficult Airway Society 2015 Guidelines, p. 9-10, 2015

²⁴ R. Hofmeyr. Difficult Airway Society 2015 Guidelines, p. 9-10, 2015

Appendix C. Patient Information

Not applicable.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Assessment of the depth of impaired consciousness in adults using the Glasgow Coma Scale [133].

Interpretation:

15 points indicates clear consciousness; - 14 points on the GCS correspond to mild obtundation according to the national classification of impaired consciousness; - 12-13 points – moderate obtundation; - 9-11 points – stupor; - 6-8 points – moderate coma; - 4-5 points – deep coma; - 3 points –atonic coma.

Appendix G2. Diagnostic scale for DIC. Modified overt (with bleeding) DIC scale for obstetrics [134]25.

²⁵ International Society on Thrombosis and Hemostasis according to Clark S.L. et al.