Use of Atropine, Ondansetron, and Ketorolac in Suspected Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is a rare, life-threatening obstetric event associated with extremely high maternal and perinatal morbidity and mortality with no known definitive pathophysiologic pathway. Current recommended management strategies are mainly supportive and include high-quality cardiopulmonary resuscitation and prompt delivery of the potentially viable fetus to improve neonatal survival and maternal resuscitation. More recently, case reports have described success in the resuscitation of patients with presumed AFE with a protocol that includes intravenous administration of atropine (1 mg), ondansetron (8 mg), and ketorolac (30 mg). The currently available evidence for the use of atropine, ondansetron, and ketorolac to treat AFE is limited, consisting of only case reports. As a result, the potential harms, including worsening of bleeding or coagulopathy, worsening kidney function, maternal tachycardia, cardiac arrhythmias, and myocardial injury, with the use of atropine, ondansetron, and ketorolac in cases of suspected AFE must be considered. We caution against the widespread use of this protocol for suspected cases of AFE and remind clinicians of the many disappointing histories of medical interventions later discredited. We recommend that adequately oxygenating, supporting blood pressure, treating heart failure, and aggressively managing coagulopathy remain the mainstays of therapy and should be recognized as the standard of care.