Aissi James et al.

Critical Care (2022) 26:96

https://doi.org/10.1186/s13054-022-03969-3

RESEARCH Open Access

Amniotic fluid embolism rescued

by venoarterial extracorporeal membrane
oxygenation
Sarah Aissi James1, Thomas Klein2, Guillaume Lebreton3,4, Jacky Nizard5, Juliette Chommeloux1,3,
Nicolas Bréchot1,3, Marc Pineton de Chambrun1,3, Guillaume Hékimian1,3, Charles‑Edouard Luyt1,3, Bruno Levy2,
Antoine Kimmoun2, Alain Combes1,3,6 and Matthieu Schmidt1,3,6,7*

Abstract
Background: Amniotic fluid embolism (AFE) is a rare but often catastrophic complication of pregnancy that leads to
cardiopulmonary dysfunction and severe disseminated intravascular coagulopathy (DIC). Although few case reports
have reported successful use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with AFE, concerns
can be raised about the increased bleeding risks with that device.
Methods: This study included patients with AFE rescued by VA-ECMO hospitalized in two high ECMO volume cent‑
ers between August 2008 and February 2021. Clinical characteristics, critical care management, in-intensive care unit
(ICU) complications, and hospital outcomes were collected. ICU survivors were assessed for health-related quality of
life (HRQL) in May 2021.
Results: During that 13-year study period, VA-ECMO was initiated in 54 parturient women in two high ECMO volume
centers. Among that population, 10 patients with AFE [median (range) age 33 (24–40), SAPS II at 69 (56–81)] who ful‑
filled our diagnosis criteria were treated with VA-ECMO. Pregnancy evolved for 36 (30–41) weeks. Seven patients had a
cardiac arrest before ECMO and two were cannulated under cardiopulmonary resuscitation. Pre-ECMO hemodynamic
was severely impaired with an inotrope score at 370 (55–1530) μg/kg/min, a severe left ventricular ejection fraction
measured at 14 (0–40)%, and lactate at 12 (2–30) mmol/L. 70% of these patients were alive at hospital discharge
despite an extreme pre-ECMO severity and massive blood product transfusion. However, HRQL was lower than age-
matched controls and still profoundly impaired in the role-physical, bodily pain, and general health components after
a median of 44 months follow-up.
Conclusion: In this rare per-delivery complication, our results support the use of VA-ECMO despite intense DIC and
ongoing bleeding. Future studies should focus on customized, patient-centered, rehabilitation programs that could
lead to improved HRQL in this population.
Keywords: Extracorporeal membrane oxygenation, Amniotic fluid embolism, Cardiogenic shock, Disseminated
intravascular coagulopathy, Outcomes

Amniotic fluid embolism (AFE) is a rare but often cata-

strophic complication of pregnancy, occurring in 1.9–2.5
*Correspondence: [email protected]
7
Service de Medecine Intensive Reanimation, iCAN, Institute per 100,000 maternities. With a maternal mortality rate
of Cardiometabolism and Nutrition, Hôpital de la Pitié–Salpêtrière, 47, bd ranging from 11 to 43% [1], AFE has become one of
de l’Hôpital, 75651 Paris Cedex 13, France the main direct causes of maternal death in developed
Full list of author information is available at the end of the article

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​
mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Aissi James et al. Critical Care (2022) 26:96 Page 2 of 8

countries. The pathophysiology of AFE involves disrup- Survivors gave oral consent to participate in the tel-
tion of the maternal-placental interface, allowing entry of ephone interview conducted by the same investigator
fetal and amniotic components into the maternal circula- (S.AJ).
tion, which induces a massive release of mediators lead-
ing to a proinflammatory and procoagulant reaction [2]. Data collection
Diagnosis is often performed after the exclusion of other Clinical characteristics of the parturient included gesta-
peripartum complications. Sudden onset of cardiovas- tional age, gravidity and parity status, body mass index,
cular collapse, cardiac arrest, acute respiratory failure, previous medical history, reported AFE risk factors,
and fulminant disseminated intravascular coagulopathy type of delivery, and anesthetic procedure. Besides, we
(DIC) during delivery are the main clinical signs of the described the clinical presentation of AFE, the value
most severe forms. Because the cardiopulmonary dys- of serum insulin-like growth factor binding protein-1
function associated with AFE is typically self-limited, (IGFBP-1) (if quantitative dosage available), the presence
venoarterial extracorporeal membrane oxygenation (VA- of fetal material and squamous cells in the maternal bron-
ECMO) support has been reported in severe forms [3, choalveolar lavage, and the management of peri-delivery
4]. However, the rarity of the condition, and the difficul- hemorrhage. The following variables were recorded
ties to diagnose AFE, make it particularly challenging to during the first 24 h of ECMO implantation: Simplified
study. To date, data available on this specific population Acute Physiology Score (SAPS) 2 [7] and Sepsis-Related
rescued by VA-ECMO were mainly described in single- Organ Failure Assessment (SOFA) score [8]; pre-ECMO
case reports [3, 4] and concerns can be raised about the inotrope score defined as the dose of dobutamine (μg/kg/
increased bleeding risks with ECMO in that context. min) + (dose of epinephrine [μg/kg/min] + dose of norep-
The objectives of this multicenter, retrospective study inephrine [μg/kg/min]) × 100 [9]; implantation of ECMO
were (1) to report outcomes of ECMO-treated AFE; (2) under cardiopulmonary resuscitation; use of intra-aortic
to describe their critical care management and in-ICU balloon pump; blood-gas analyses; and blood lactate.
complications; and (3) to report long-term maternal
health-related quality of life (HRQOL). Outcome variables
Main outcome variables included survival to ICU dis-
Methods charge, and long-term survival (evaluated in May 2021).
Study design and patients Other outcome variables included days under ECMO
This study included patients with AFE rescued by VA- therapy; time on mechanical ventilation after ECMO
ECMO hospitalized in two university tertiary medical implantation; and ICU length of stay. ECMO-associated
centers between August 2008 and February 2021. The complications were monitored: leg ischemia, femo-
medical ICUs from Pitie Salpetrière hospital, Paris, and ral hemorrhage due to arterial laceration, deep-vein or
the University hospital of Nancy, France are among the inferior vena cava thrombosis, cannula insertion-site
largest ECMO centers in France with more than 100 infection, ischemic or hemorrhagic stroke, cardiac tam-
ECMO cases per year. All consecutive pregnant women ponade, or other technical problems. Lastly, the num-
who received ECMO during the delivery period were ber of packs of red blood cells, fresh frozen plasma, and
screened. Patients who fulfilled the criteria proposed by platelets transfused were noted.
Clark et al. [5] for AFE diagnosis were included. Briefly,
these criteria combine (1) sudden onset of cardiorespira- Long‑term outcome variables
tory arrest or both hypotension and respiratory compro- Patients alive in May 2021 were evaluated for their
mise; (2) documentation of overt DIC; (3) clinical onset Health-related quality of life psychologic status during
during labor or within 30 min of delivery of the placenta a telephone interview. To assess HRQOL, patients were
and (4) no fever during labor [5]. DIC was diagnosed asked to complete the French version of the Short-Form
using the Modified International Society on Thrombo- 36 (SF-36; based on the Medical Outcome Study Survey)
sis and Hemostasis scoring system for overt dissemi- questionnaire during a phone call explaining the purpose
nated intravascular coagulation in pregnancy, which uses and objectives of the study. This standardized, widely
platelet count, prothrombin time, and fibrinogen level. A used questionnaire has been validated for the French
score ≥ 3 being compatible with overt DIC in pregnancy population [10]. Its 36 items are combined to evaluate
[6]. According to French research methodology MR004, eight domains (physical functioning, role-physical, bod-
this work was considered a non-interventional retrospec- ily pain, general health, vitality, social functioning, role-
tive study and therefore only needed information from emotional, and mental health). The aggregate physical
the survivors. The National Commission for Informatics and mental component summary measures were then
and Liberties (CNIL) approved this study (no.1950673). computed as recommended by the developers [10, 11].
Aissi James et al. Critical Care (2022) 26:96 Page 3 of 8

Our patients’ mean SF-36 levels were compared with Table 1 Clinical characteristics of patients with confirmed
those obtained for French age- and sex-matched controls amniotic fluid embolism rescued by VA-ECMO
with no adverse health conditions [10], those who had a N = 10
venovenous (VV) ECMO for a severe acute respiratory
distress syndrome (ARDS) [12], and survivors after a sep- Age, years 33 (24–40)
tic shock rescued by VA-ECMO [13]. Body mass index, kg/m2 27 (21–35)
Post-traumatic stress disorder (PTSD)-related symp- SAPS 2 score 69 (56–81)
toms were assessed with the Impact of Event Scale SOFA score 13 (9–17)
consisting of 15 questions divided into two subscales: Parity, n 2 (1–4)
intrusion (seven items) and avoidance (eight items) [14]. Gestation, weeks 36 (30–41)
An impact of event scale score ≥ 30 defined a patient at Amniotic embolism risks factors
risk for PTSD [14]. Lastly, other long-term outcome vari- Maternal age > 35 years 6 (60)
ables included the resumption of professional activity, Pre-eclampsia 1 (10)
new pregnancy, and child health status. Placenta insertion abnormalities or hydramnios 2 (20)
Multiple pregnancy 0 (0)
Patient management during ECMO Medically induced labor 3 (30)
The detailed management of patients under VA-ECMO C-section delivery 4 (40)
was described previously [15, 16]. Briefly, pump speed Instrumental assisted delivery 3 (30)
was adjusted to obtain a blood flow of 3–5 L/min. Intra- Gestational diabetes 3 (30)
venous unfractionated heparin was not used in case of Obstetric and anesthetic procedure
DIC, platelets count < 50,000 G/l, or in case of bleeding. Cesarean section 4 (40)
For highly unstable patients diagnosed with refractory Vaginal delivery 6 (60)
cardiogenic shock at other hospitals, our institution’s Emergency procedure 4 (40)
Mobile Circulatory Assistance Units traveled rapidly to Epidural analgesia 9 (90)
primary care hospitals with a portable ECMO system, General anesthesia 1 (10)
installed the device before refractory multiple organ fail- Clinical presentation
ure or cardiac arrest took hold, and then transported the Cardiac arrest 7 (70)
patient to our tertiary cares. The early intra-aortic bal- Cardiovascular collapse 9 (90)
loon pump-ECMO combination is currently used to pro- Acute respiratory failure 3 (30)
tect against hydrostatic pulmonary edema in peripheral Disseminated intravascular coagulation 10 (100)
VA-ECMO-assisted patients in case of lack of arterial Modified ISTH score * 3.5 (3–5)
pulsatility or aortic Velocity Time Integral < 5 cm. Altered mental status or seizures 1 (10)
Fetal distress 4 (40)
Statistical analyses Amniotic fluid embolism markers
This study followed CONSORT recommendations for Serum insulin-like growth factor binding pro‑ 5 (62)
tein-1 > 150 μg/L §
reporting cohort studies (STROBE statement) [17]. Data
Fetal material or squamous cells in the maternal BAL £ 5 (62)
are presented as n (%) or median (range).
For comparisons of patients’ mean SF-36 scores with Data are expressed as n (%) or median (range)
*Modified International Society on Thrombosis and Hemostasis scoring system
those of their age- and sex-matched control subjects, or for overt disseminated intravascular coagulation in pregnancy use platelet
with other populations rescued by ECMO, paired t-tests count, prothrombin time, and fibrinogen level. A score ≥ 3 being compatible
or Wilcoxon tests were used. p ≤ 0.05 defined statistical with overt DIC in pregnancy [5]
§
significance. Analyses were computed with StatView v5.0 Available in 8 patients
£
Available in 8 patients
(SAS Institute Inc., Cary, NC, USA) software.
BAL bronchoalveolar lavage, ICU intensive care unit, ISTH International Society
on Thrombosis and Hemostasis, SOFA Sequential Organ Failure Assessment,
Results SAPS II Simplified Acute Physiology Score, VA-ECMO venoarterial extracorporeal
membrane oxygenation
Study population
During that 13-year study period, VA-ECMO was initi-
ated in 2857 patients, whose 54 were during the peri-
partum period. Among that population, 10 patients age was 33 (24–40) with a pregnancy evolving for
with AFE, who fulfilled our diagnosis criteria [5] were 36 (30–41) weeks and a SAPS II at 69 (56–81) at ICU
treated with VA-ECMO. None of them had cardiovas- admission. Reported AFE risks factors were frequent
cular or respiratory history. Their main characteristics with maternal age > 35 years, caesarian section delivery,
are reported in Table 1. Briefly there median (range) instrumental assisted delivery, and gestational diabetes
Aissi James et al. Critical Care (2022) 26:96 Page 4 of 8

being reported in 60, 40, 30, and 30% of our cohort, Table 2 ECMO management, in ICU complications, and
respectively. outcomes of patients with amniotic fluid embolism rescued by
Refractory cardiovascular collapse and cardiac arrest, VA-ECMO
occurring during labor or just after delivery were the N = 10
most frequent clinical presentation. Besides, all patients
had DIC and peripartum hemorrhage. Ongoing severe Before ICU peri-delivery hemorrhage 10 (100)
coagulopathy and post-partum hemorrhage lead to Red blood cell transfusion, units 13 (4–32)
hemostatic procedures and surgical hysterectomy in 70 Fresh frozen plasma transfusion, units 13 (4–37)
and 50% of patients. Noticeably, one patient had altered Platelet transfusion, units 5 (0–30)
mental status whereas fetal distress was reported in 4 Fibrinogen administration, g 8 (0–18)
cases. Serum IGFBP-1, performed at different times Hemostatic procedure 7 (70)
after the first symptoms, was > 150 μg/L in 5/8 patients Surgical hysterectomy 5 (50)
whereas fetal material or squamous cells were found in Triple ligature 1 (10)
5 out of 8 bronchoalveolar samples performed in these Selective arterial embolization 1 (10)
patients. ECMO
All patients received a VA-ECMO initiated by the Pre-ECMO inotropic score, μg/kg/min 370 (55–1530)
Mobile Circulatory Assistance Units with a switch to a Pre-ECMO lactate, mmol/L 12 (2–30)
veno-arteriovenous ECMO in one patient. Seven patients Pre-ECMO left ventricular function, % 14 (0–40)
had a cardiac arrest before ECMO, whom two were ECMO duration, days 4 (1–6)
cannulated under cardiopulmonary resuscitation. Pre- Levosimendan during ECMO 1 (10)
ECMO hemodynamic was severely impaired with an ECMO-related complication 5 (50)
inotrope score at 370 (55–1530) μg/kg/min, a severe left Pericardial tamponade 1 (10)
ventricular ejection fraction measured at 14 (0–40)%, and Intracranial hemorrhage 1 (10)
lactate at 12 (2–30) mmol/L. Acute leg ischemia 2 (20)
In-ICU
Acute kidney injury ≥ KDIGO 3 8 (80)
Short‑ and long‑term outcomes
Renal replacement therapy 7 (70)
Complications during ECMO are listed in Table 2. Peri-
Acute liver failure (i.e., SOFA liver ≥ 2) 5 (50)
cardial tamponade, intracranial hemorrhage, and acute
Red blood cell transfusion, units 6 (0–19)
leg ischemia occurred in 10, 10, and 20% of patients,
Fresh frozen plasma transfusion, units 9 (0–49)
respectively. Also, 80% of patients developed acute kid-
Platelet transfusion, units 13 (0–75)
ney injury ≥ Kidney Disease: Improving Global Out-
At least one ventilator associated pneumonia 3 (30)
comes (KDIGO) 3 and 50% acute liver failure (i.e., SOFA
Outcomes
liver ≥ 2) during their ICU stay. Seven (70%) patients
ECMO duration, days 4 (1–6)
required renal replacement therapy and seven (70%)
In survivors, days 4 (3–6)
patients survived ICU discharge. In-ICU deaths were
Inotrope duration, days 5 (1–8)
attributed to brain death for two and multiple organ
Mechanical ventilation duration, days 5 (1–13)
failure for one patient. Respective median durations of
In survivors, days 6 (2–13)
ECMO and mechanical ventilation support were 4 (1–6)
ICU length of stay, days 12 (1–25)
and 5 (1–13) days. The median ICU length of stay was 12
In survivors, days 16 (5–25)
(1–25) days. All infants survived (Fig. 1).
Maternal survival at ICU discharge 7 (70)
A long-term evaluation was conducted after a median
Infant survival 10 (100)
of 44 (2–94) months after ICU discharge in seven
patients. Among these 7 patients, 4 had returned to their Data are expressed as n (%) or median (range)
previous work (60%), and 2 had a new pregnancy (but ECMO extracorporeal membrane oxygenation, ICU intensive care unit, KDIGO
Kidney Disease: Improving Global Outcomes, SOFA Sequential Organ Failure
three patients had a hysterectomy during AFE episode). Assessment
Severe motor sequellae were reported, related to femo-
ral artery stenosis on the cannulation site for one patient
domain scores were comparable with those of the gen-
and due to to acute leg ischemia leading to transfemoral
eral population, except for their social functioning com-
amputation for a second one. All infants were in healthy
ponent, which was lower (p = 0.04). Their SF-36 physical
conditions. SF-36 assessment HRQL is reported in Fig. 2.
aggregate scores were also significantly lower compared
Compared with age- and sex-matched controls, our
to age- and sex-matched controls (p < 0.01), while their
responding AFE survivors had significantly lower SF-36
mental aggregate scores were comparable. Compared to
physical domain scores (p < 0.01). Their psychological
Aissi James et al. Critical Care (2022) 26:96 Page 5 of 8

Fig. 1 Study flowchart. AFE amniotic fluid embolism, VA-ECMO venoarterial extracorporeal membrane oxygenation, ICU intensive care unit

other populations rescued by either VV or VA ECMO, components when compared to other survivors rescued
role- physical, bodily pain, and general health com- by ECMO.
ponents were lower despite similar or better physical The diagnosis of AFE is challenging as there are widely
functioning components (Fig. 2). Two patients had an varying criteria for the diagnosis of AFE [5], most of
IES score ≥ of 30 (i.e, patients at risk for PTSD) 2 and AFE definitions are nonspecific, biological markers may
64 months after ICU discharge, respectively. not be specific to AFE [18], and exhaustive searches for
alternative diagnoses are not uniformly done in a context
of critically ill patients. For these reasons, we decided to
Discussion restrict our inclusion criteria to the most recent defini-
To our knowledge, this is the largest and most detailed tion proposed by Clark et al. [5]. These uniform diag-
follow-up study of catastrophic AFE patients requiring nostic criteria help to prevent the inclusion of patients
ECMO. AFE is a rare ECMO indication but is associated with alternative diagnoses such as hypovolemic shock
with a 70% survival rate at hospital discharge despite an secondary to postpartum hemorrhage, anesthetic acci-
extreme pre-ECMO severity. In this rare per-delivery dent, pulmonary thromboembolism, septic, and ana-
complication, our results support the use of VA-ECMO phylactic shock. For instance, we excluded 3 patients
despite intense DIC and active bleeding. Besides, physi- for whom AFE diagnosis was retained in the medical
cians should be aware that these patients would need record without strictly fulfilling all of our AFE criteria.
massive blood product transfusion during the first Two of them did not have DIC and one had fever, which
ECMO days. However, long-term HRQL was lower than could have been compatible with anaphylactic shock
age-matched controls and still profoundly impaired and septic shock, respectively. Several studies suggest a
in the role-physical, bodily pain, and general health role for IGFBP-1 in the development of multiple organ
Aissi James et al. Critical Care (2022) 26:96 Page 6 of 8

Fig. 2 Comparison of mean SF-36 scores of AFE survivors treated by ECMO after a median follow-up of 40 months after intensive care unit
discharge and their age- and sex-matched French control subjects [10], and 84 venovenous ECMO treated ARDS survivors [12], and 32 severe septic
shock rescued by VA-ECMO [13]. Higher scores denote a better health-related quality of life. ARDS acute respiratory distress syndrome, VV-ECMO
venovenous extracorporeal membrane oxygenation, VA-ECMO venoarterial extracorporeal membrane oxygenation

dysfunction [19]. As detection of squamous cells into the observed in this series is similar to the case-fatality
maternal circulation or in the lungs requires procedural reported in other case series (11–43%) with patients
skill and may not be specific to AFE [20, 21], a high con- with lower severity [1, 18]. By aggressively treating
centration of serum IGFBP-1 levels has been proposed bleeding events and judiciously managing systemic
for the diagnosis of AFE [18]. However, serum markers anticoagulation, ECMO appears adequate to rescue
could be sometimes difficult to interpret since massive very severe AFE. Indeed, AFE is a self-resolving dis-
transfusion often occurred, distorting maternal serum ease affecting the pulmonary and cardiovascular sys-
dosages. Because of the lack of a systematic measure of tems with most death and complications occurring
IGFBP-1 and inconsistent quantitative measurement in during the first 24 h [1]. Our results reinforce that
all pregnant women on ECMO during the study period, high bleeding risk should not be seen as an absolute
this biomarker was not retained as an inclusion criterion. contraindication to use ECMO [23]. However, ECMO
Extracorporeal life support has been successfully management should be wisely adapted to these com-
used in pregnant and postpartum patients for a vari- plex situations with DIC, thrombocytopenia, and
ety of indications [22]. Despite an extreme severity frequent ongoing bleeding. An anticoagulation-free
at the time of ECMO initiation, the 70% survival rate ECMO strategy, which combines no heparin bolus at
Aissi James et al. Critical Care (2022) 26:96 Page 7 of 8

cannulation and no anticoagulation as long as there are Conclusion

bleeding and/or DIC appears mandatory. This strategy In conclusion, the survival of ECMO-rescued preg-
on VA-ECMO is feasible and has been reported with nant women with catastrophic AFE in our experienced
other ECMO indications such as trauma [24] or refrac- centers was 70%. Ongoing bleeding, need for massive
tory pulmonary embolism despite thrombolysis [25]. transfusion and DIC should not refrain physicians to
As reported in our results, massive transfusion of fresh early contact a Mobile Circulatory Assistance Units
frozen plasma, platelets, red blood cell packs, and to prompty initiate VA-ECMO in these severely ill
fibrinogen, as well as arterial embolization or surgical patients with cardiopulmonary dysfunction and high
hemostasis is frequently needed before or during car- bleeding risk. However, general health, vitality, and
diopulmonary support by VA-ECMO. role-physical impairment reported after long-term fol-
The favorable survival of these very severe patients low-up emphasizes the importance to integrate these
should not overshadow that the long-term HRQL young patients into customized, patient-centered, reha-
was still impaired compared with that of sex-and bilitation programs after ICU discharge.
age-matched controls, especially concerning SF-36
general health, vitality, role-physical and social func-
Abbreviations
tioning, while mental health and role-emotional were AFE: Amniotic fluid embolism; DIC: Disseminated intravascular coagulopathy;
considered satisfactory. Although differences in case ARDS: Acute respiratory distress syndrome; ICU: Intensive care unit; IGFBP-1:
mixes make comparisons between series difficult we Insulin-like growth factor binding protein-1; HRQOL: Health-related quality of
life; PTSD: Post-traumatic stress disorder; SAPS II: Simplified acute physiology
observed that our patient’s SF-36 scores were worse score II; SOFA: Sequential organ-failure assessment; VA-ECMO: Venoarterial
than those reported by ARDS or septic shock survivors extracorporeal membrane oxygenation.
rescued by VV or VA-ECMO, respectively [12, 13].
Acknowledgements
Muscle weakness, chronic fatigue, and pain still signif- None.
icantly impact work or daily activities after a median of
44 months after ICU discharge. Previous studies also Author contributions
SAJ conceived of the study, participated in its design, data collection, coordi‑
highlighted that women who give birth with severe nation, performed the statistics and draft the manuscript; TK participated in
obstetrical adverse events are at higher risk of long- its design, data collection and revised the manuscript; GL participated in its
term physical and mental health sequels compared design, data collection and revised the manuscript; JN participated in data col‑
lection and revised the manuscript; JC participated in its design, data collec‑
to uncomplicated obstetrical populations [26]. In our tion and revised the manuscript; NB participated in its design, data collection
population, only 60% of these young women returned and revised the manuscript; MPC participated in its design, data collection
to their previous work. These results highlight the and revised the manuscript; GH participated in its design, data collection
and revised the manuscript; CEL participated in its design, data collection
urgent need for studies focusing on the establishment and revised the manuscript; BL participated in its design, data collection and
of customized, patient-centered, rehabilitation pro- revised the manuscript; AC participated in its design, data collection, coordi‑
grams that could help improve long-term postpartum nation, and draft the manuscript; and MS conceived of the study, participated
in its design, data collection, coordination, performed the statistics and draft
health-related quality of life [27–29]. the manuscript. All authors read and approved the final manuscript.
We are aware that our study has limitations. First,
AFE is a relatively rare disease that has limited our Funding
None.
sample size. Second, our patients were treated in
high-volume, experienced ECMO centers. Because Availability of data and materials
better post-ECMO outcomes have been reported in Not applicable.
such centers [30], caution is required when extrapo-
lating these results to less-experienced ECMO cent- Declarations
ers. Third, the sole strict clinical-biological definition Ethics approval and consent to participate
of AFE may have led to underreporting some cases. All patients were informed by phone that their data were included in this
Therefore, we cannot rule out that more AFE cases cohort.
could have been included with other AFE defini- Consent for publication
tions or based on serum biomarkers. Lastly, the self- Not applicable.
assessed, persistently impaired physical health and
Competing interests
vitality might not be specific to ECMO itself but may Pr Combes reports grants from Getinge, personal fees from Getinge, Baxter
represent sequelae of any severe disease requiring high and Xenios outside the submitted work. Pr Schmidt reports receiving personal
doses of vasopressors, transfusion, and prolonged ICU fees from Getinge, Drager, and Xenios, outside the submitted work. Pr Kim‑
moun reports receiving personal feels from Aguettant outside the submitted
stays as well as psychological and somatic sequelae work. No other disclosures were reported.
after a highly complicated delivery.
Aissi James et al. Critical Care (2022) 26:96 Page 8 of 8

Author details fulminant myocarditis patients rescued by mechanical circulatory sup‑

1
Service de Médecine Intensive‑Réanimation, Institut de Cardiologie, APHP port. Crit Care Med. 2011;39:1029–35.
Sorbonne Université Hôpital Pitié–Salpêtrière, 75013 Paris, France. 2 Université 16. Aissaoui N, Luyt C-E, Leprince P, Trouillet J-L, Léger P, Pavie A, et al. Predic‑
de Lorraine, CHRU de Nancy, Institut Lorrain du Cœur Et Des Vaisseaux, Service tors of successful extracorporeal membrane oxygenation (ECMO) wean‑
de Médecine Intensive-Réanimation, U1116, FCRIN-INICRCT​, Nancy, France. ing after assistance for refractory cardiogenic shock. Intensive Care Med.
3
Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, 2011;37:1738–45.
UMRS_1166-ICAN, 75013 Paris, France. 4 Service de Chirurgie Cardiaque, 17. STROBE Statement: Home [Internet]. [cited 2020 Aug 21]. https://​www.​
Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié–Salpêtrière, strobe-​state​ment.​org/​index.​php?​id=​strobe-​home.
75013 Paris, France. 5 Department of Gynaecology and Obstetrics, Groupe 18. Legrand M, Rossignol M, Dreux S, Luton D, Ventré C, Barranger E, et al.
Hospitalier Pitié‑Salpêtrière, CNRS UMR 7222, INSERM U1150, Sorbonne Diagnostic accuracy of insulin-like growth factor binding protein-1 for
Universités, Paris, France. 6 Sorbonne Université, GRC 30, RESPIRE, Assistance amniotic fluid embolism*. Crit Care Med. 2012;40:2059–63.
Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France. 7 Ser‑ 19. de Groof F, Joosten KFM, Janssen JAMJL, de Kleijn ED, Hazelzet JA, Hop
vice de Medecine Intensive Reanimation, iCAN, Institute of Cardiometabolism WCJ, et al. Acute stress response in children with meningococcal sepsis:
and Nutrition, Hôpital de la Pitié–Salpêtrière, 47, bd de l’Hôpital, 75651 Paris important differences in the growth hormone/insulin-like growth factor
Cedex 13, France. I axis between nonsurvivors and survivors. J Clin Endocrinol Metab.
2002;87:3118–24.
Received: 14 December 2021 Accepted: 23 March 2022 20. Clark SL, Pavlova Z, Greenspoon J, Horenstein J, Phelan JP. Squamous
cells in the maternal pulmonary circulation. Am J Obstet Gynecol.
1986;154:104–6.
21. Clark SL. New concepts of amniotic fluid embolism: a review. Obstet
Gynecol Surv. 1990;45:360–8.
References 22. Olson TL, O’Neil ER, Ramanathan K, Lorusso R, MacLaren G, Anders MM.
1. Knight M, Berg C, Brocklehurst P, Kramer M, Lewis G, Oats J, et al. Amniotic Extracorporeal membrane oxygenation in peripartum cardiomyopathy: a
fluid embolism incidence, risk factors and outcomes: a review and rec‑ review of the ELSO Registry. Int J Cardiol. 2020;311:71–6.
ommendations. BMC Pregnancy Childbirth. 2012;12:7. 23. Lorusso R, Shekar K, MacLaren G, Schmidt M, Pellegrino V, Meyns B, et al.
2. Pacheco LD, Saade G, Hankins GDV, Clark SL. Amniotic fluid embolism: ELSO interim guidelines for venoarterial extracorporeal membrane
diagnosis and management. Am J Obstet Gynecol. 2016;215:B16-24. oxygenation in adult cardiac patients. ASAIO J. 2021;67:827–44.
3. Adachi M, Adachi T, Fujita T, Hyuga S, Onishi Y, Okutomi T. Venoarterial 24. Della Torre V, Robba C, Pelosi P, Bilotta F. Extra corporeal membrane
extracorporeal membrane oxygenation as an early treatment for amni‑ oxygenation in the critical trauma patient. Curr Opin Anaesthesiol.
otic fluid embolism with cardiac arrest: a case report. J Obstet Gynaecol 2019;32:234–41.
Res. 2021;47:3374–8. 25. Corsi F, Lebreton G, Bréchot N, Hekimian G, Nieszkowska A, Trouillet J-L,
4. Creel-Bulos C, Hassani B, Stentz MJ, Budhrani G, Daneshmand MA, Jabaley et al. Life-threatening massive pulmonary embolism rescued by venoar‑
CS, et al. Extracorporeal membrane oxygenation for amniotic fluid terial-extracorporeal membrane oxygenation. Crit Care. 2017;21:76.
embolism-induced cardiac arrest in the first trimester of pregnancy: a 26. Filippi V, Ganaba R, Baggaley RF, Marshall T, Storeng KT, Sombié I, et al.
case report. Crit Care Explor. 2020;2:e0162. Health of women after severe obstetric complications in Burkina Faso: a
5. Clark SL, Romero R, Dildy GA, Callaghan WM, Smiley RM, Bracey AW, et al. longitudinal study. Lancet. 2007;370:1329–37.
Proposed diagnostic criteria for the case definition of amniotic fluid 27. Prick BW, Bijlenga D, Jansen AJG, Boers KE, Scherjon SA, Koopmans CM,
embolism in research studies. Am J Obstet Gynecol. 2016;215:408–12. et al. Determinants of health-related quality of life in the postpartum
6. Clark SL, Christmas JT, Frye DR, Meyers JA, Perlin JB. Maternal mortality period after obstetric complications. Eur J Obstet Gynecol Reprod Biol.
in the United States: predictability and the impact of protocols on fatal 2015;185:88–95.
postcesarean pulmonary embolism and hypertension-related intracranial 28. Skinner EM, Barnett B, Dietz HP. Psychological consequences of pelvic
hemorrhage. Am J Obstet Gynecol. 2014;211(32):e1-9. floor trauma following vaginal birth: a qualitative study from two Austral‑
7. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology ian tertiary maternity units. Arch Womens Ment Health. 2018;21:341–51.
Score (SAPS II) based on a European/North American multicenter study. 29. Elden H, Olsen MF, Hussein NF, Axelsson LW, Sengpiel V, Ullman M.
JAMA. 1993;270:2957–63. Postpartum septic symphysitis, a rare condition with possible long-term
8. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining consequences: a cohort study with long-term follow-up. BMC Pregnancy
H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to Childbirth. 2021;21:776.
describe organ dysfunction/failure. On behalf of the Working Group 30. Barbaro RP, Odetola FO, Kidwell KM, Paden ML, Bartlett RH, Davis MM,
on Sepsis-Related Problems of the European Society of Intensive Care et al. Association of hospital-level volume of extracorporeal membrane
Medicine. Intensive Care Med. 1996;22:707–10. oxygenation cases and mortality. Analysis of the extracorporeal life sup‑
9. MacLaren G, Butt W, Best D, Donath S. Central extracorporeal membrane port organization registry. Am J Respir Crit Care Med. 2015;191:894–901.
oxygenation for refractory pediatric septic shock. Pediatr Crit Care Med.
2011;12:133–6.
10. Leplège A, Ecosse E, Verdier A, Perneger TV. The French SF-36 Health
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub‑
Survey: translation, cultural adaptation and preliminary psychometric
lished maps and institutional affiliations.
evaluation. J Clin Epidemiol. 1998;51:1013–23.
11. Ware JE, Sherbourne CD. The MOS 36-item short-form health sur‑
vey (SF-36). I. Conceptual framework and item selection. Med Care.
1992;30:473–83.
12. Schmidt M, Zogheib E, Roze H, Repesse X, Lebreton G, Luyt CE, et al.
The PRESERVE mortality risk score and analysis of long-term outcomes
after extracorporeal membrane oxygenation for severe acute respiratory
distress syndrome. Intensive Care Med. 2013;39:1704–13.
13. Bréchot N, Hajage D, Kimmoun A, Demiselle J, Agerstrand C, Montero
S, et al. Venoarterial extracorporeal membrane oxygenation to rescue
sepsis-induced cardiogenic shock: a retrospective, multicentre, interna‑
tional cohort study. Lancet. 2020;396:545–52.
14. Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: a measure of
subjective stress. Psychosom Med. 1979;41:209–18.
15. Mirabel M, Luyt C-E, Leprince P, Trouillet J-L, Léger P, Pavie A, et al.
Outcomes, long-term quality of life, and psychologic assessment of