Management of Amniotic Fluid Embolism

Date: November 4, 2026
Reason for Alert: To confirm the importance of focusing on maternal resuscitation prior to initiation of proposed or suggested treatments for suspected amniotic fluid embolism.

Potential risks of the stated issue: Amniotic fluid embolism (AFE) (also known as anaphylactoid syndrome of pregnancy), is a rare, life-threatening syndrome that occurs during labor or immediately postpartum. The pathophysiology is unclear but thought to be related to the release of trophoblasts or other material into the maternal circulation triggering a cascade of inflammatory and hemostatic reactions that may result in cardiopulmonary collapse, respiratory failure, and disseminated intravascular coagulation (Dildy et al., 2024; Shamshirsaz & Clark, 2016; Society for Maternal Fetal Medicine (SMFM) et al., 2026).

Recommendations for practice:

  • AWHONN supports SMFM (SMFM et al., 2026) and American Association of Nurse Anesthesiology (2023) management recommendations of suspected AFE that focus on maternal resuscitation including oxygenation, hemodynamic support, and correction of coagulopathy.
  • AWHONN also supports a multidisciplinary approach to the management of a patient with suspected AFE. The multidisciplinary team may include, but not limited to, obstetric providers and nurses, maternal fetal medicine, anesthesia care providers, respiratory therapy, critical care, and neonatology (SMFM et al., 2026).
  • AWHONN recognizes that the management of AFE is mainly supportive and includes cardiopulmonary resuscitation, prompt delivery of the viable fetus, early identification and hemodynamic management of right ventricular failure, control of bleeding (medical or surgical intervention), mechanical ventilation, and post resuscitation critical care (Pacheco et al., 2025)
  • Multiple treatments have been proposed or suggested in several case reports, but none have been accepted or supported by scientific evidence and should never supersede or distract from prioritizing effective resuscitative care. Amongst these treatments for the management of AFE is the use of atropine, ondansetron, ketorolac (A-OK). Administration of these medications may be considered and utilized by some providers but should be used with extreme caution (Pacheco et al., 2025). Further research and studies are needed for the use of A-OK.

Benefits of recommendations: Focusing on adequate oxygenation, supporting blood pressure, treating heart failure, and managing coagulopathy aggressively is viewed as the standard of care for AFE and can help improve patient outcomes (Pacheco et al., 2025).

References:

American Association of Nurse Anesthesiology. (2023). Analgesia and anesthesia for the obstetric patients. Practice guidelines. https://issuu.com/aanapublishing/docs/analgesia_and_anesthesia_for_the_obstetric_patient?fr=sN2ZlNTU2NDAxMjU

Dildy, G. A., Belfort, M. A., & Clark, S. L. (2024). Amniotic fluid embolism. In. L. D. Pacheco, J. P. Phelan, T. L. Halscott, L. A. Moroz, A. J. Vaught, A. F. Saad, & A. A. Shamshirsaz (Eds.). Critical care obstetrics (7th ed., pp. 736). Wiley Blackwell.

Pacheco, L. D., Clark, S. M., Fox, K., Bauer, M. E., & Clark, S. L. (2025). Use of Atropine, Ondansetron, and Ketorolac in Suspected Amniotic Fluid Embolism. Obstetrics & Gynecology, 147(6), 780–784. https://doi.org/10.1097/AOG.0000000000006095

Pacheco, L. D., Saade, G., Hankins, G. D., Clark, S. L., & Society for Maternal-Fetal Medicine (SMFM). (2016). Amniotic fluid embolism: Diagnosis and management. American Journal of Obstetrics and Gynecology, 215(2), B16-B24. https://doi.org/10.1016/j.ajog.2016.03.012

Shamshirsaz, A. A., & Clark, S. L. (2016). Amniotic Fluid Embolism. Obstetrics and gynecology clinics of North America, 43(4), 779–790. https://doi.org/10.1016/j.ogc.2016.07.001

Society for Maternal‐Fetal Medicine (SMFM), Martinez‐King, L. C., Combs, C. A., Montgomery, D. M., Toner, L. E., Dildy, G. A., & SMFM Patient Safety and Quality Committee. (2026). Society for Maternal‐Fetal Medicine Special Statement: Checklist for initial management of amniotic fluid embolism—Updated 2026. Pregnancy, 2(5), e70364. https://doi.org/10.1002/pmf2.70364

AFE Practice Alert (11/2026)