Amniotic Fluid Embolism Quiz
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Questions and Answers

What condition may result from the entry of amniotic fluid into the maternal circulation?

  • Amniotic fluid embolism (AFE) (correct)
  • Gestational hypertension
  • Chorioamnionitis
  • Placentitis

    • What is a common consequence of amniotic fluid embolism on maternal physiology?

  • Acute pulmonary arterial obstruction (correct)
  • Elevation of estrogen levels
  • Increased uterine contractions
  • Decreased cardiac output

    • Which of the following components is found in amniotic fluid?

  • Oxygenated fetal blood
  • Fetal hair (correct)
  • Maternal blood
  • Mature placenta tissue

    • Which site is proposed as a probable entry point for amniotic fluid into the maternal circulation during labor?

    <p>Tears in the lower uterine segment (C)</p> Signup and view all the answers

    What causes the body's reaction leading to amniotic fluid embolism?

    <p>Immune response to chemical mediators (B)</p> Signup and view all the answers

    Which measurement is NOT part of the initial hemodynamic assessment?

    <p>Complete blood count (C)</p> Signup and view all the answers

    What echocardiographic finding is highly indicative of a significant condition associated with AFE?

    <p>Bowing of the interventricular septum (A)</p> Signup and view all the answers

    Which coagulation test is included in a coagulation screen for diagnosis?

    <p>Prothrombin time (A)</p> Signup and view all the answers

    What is a common metabolic condition associated with AFE?

    <p>Metabolic acidosis (A)</p> Signup and view all the answers

    What does a bowing septum in the echocardiogram resemble?

    <p>Letter ‘D’ (C)</p> Signup and view all the answers

    Which of the following is NOT a route where the barrier may break down leading to AFE?

    <p>Internal uterine cavity (A)</p> Signup and view all the answers

    Which scoring system helps determine the presence of DIC in pregnancy?

    <p>International Society on Thrombosis and Haemostasis scoring system (B)</p> Signup and view all the answers

    What is a common symptom associated with the cardiac effects of AFE?

    <p>Increased heart rate (C)</p> Signup and view all the answers

    What is typically observed in electrocardiography for postpartum cardiomyopathy?

    <p>Significant ST-T wave changes (A)</p> Signup and view all the answers

    Which echocardiographic findings are indicative of amniotic fluid embolism (AFE)?

    <p>Right ventricular dilatation and septal bowing (C)</p> Signup and view all the answers

    What clinical manifestations are associated with venous air embolism?

    <p>Wheezing, gasping, and chest pain (C)</p> Signup and view all the answers

    Which condition would be suggested by hypertension, headache, and seizures?

    <p>Eclampsia (B)</p> Signup and view all the answers

    What is the expected presentation of septic shock?

    <p>Symptoms of systemic inflammatory response syndrome (SIRS) (D)</p> Signup and view all the answers

    What is the reported mortality rate for the maternal outcome of amniotic fluid embolism (AFE)?

    <p>40-60% (A)</p> Signup and view all the answers

    What percentage of women who survive amniotic fluid embolism (AFE) are likely to have neurologic impairments?

    <p>7% (D)</p> Signup and view all the answers

    What are the controversies surrounding subsequent pregnancies after AFE?

    <p>Recommendations for elective caesarean delivery (B)</p> Signup and view all the answers

    What is one of the criteria for diagnosing acute amniotic fluid embolism (AFE)?

    <p>Sudden cardiopulmonary collapse (C)</p> Signup and view all the answers

    Which of the following symptoms occur during the management of AFE?

    <p>Hypoxia with SpO2 less than 90% (C)</p> Signup and view all the answers

    What should be prioritized in the management of hypoxia during AFE?

    <p>Maintenance of oxygenation (B)</p> Signup and view all the answers

    What is the primary effect of the intraventricular septum bowing into the left ventricle?

    <p>Causes obstruction and systolic dysfunction (C)</p> Signup and view all the answers

    Which factors contribute to the procoagulant state during pregnancy?

    <p>Increased levels of clotting factors and inflammatory mediators (A)</p> Signup and view all the answers

    Which method is used to measure pulmonary artery pressures in AFE management?

    <p>Pulmonary wedge catheter (Swan Ganz) (A)</p> Signup and view all the answers

    What initiates the pathologic activation of the coagulation pathway in amniotic fluid embolism (AFE)?

    <p>Amniotic fluid entering maternal circulation (A)</p> Signup and view all the answers

    In the context of AFE, how should fluid administration be approached?

    <p>Fluids should be limited if coagulopathy develops (C)</p> Signup and view all the answers

    What is the target mean arterial pressure (MAP) to maintain during AFE management?

    <p>65 mmHg or more (B)</p> Signup and view all the answers

    What percentage of patients with AFE experience disseminated intravascular coagulation (DIC)?

    <p>80% (D)</p> Signup and view all the answers

    Which symptom is commonly associated with the onset of amniotic fluid embolism in women during late labor?

    <p>Acute shortness of breath and hypotension (D)</p> Signup and view all the answers

    Which agent may be added to support cardiac output if norepinephrine is insufficient?

    <p>Vasopressin (B)</p> Signup and view all the answers

    What is the ideal urine output to aim for during the management of AFE?

    <p>40-50 ml/hr (C)</p> Signup and view all the answers

    What is a potential consequence of severe DIC in cases of AFE?

    <p>Severe, unrelenting bleeding (A)</p> Signup and view all the answers

    Which inflammatory mediators are involved in the response to amniotic fluid in maternal circulation?

    <p>Platelet-activating factor and TNF-alpha (C)</p> Signup and view all the answers

    What is a characteristic sign that may precede seizures in women with AFE?

    <p>Feeling of impending doom (A)</p> Signup and view all the answers

    What is the primary indication for using ECMO in obstetric management?

    <p>Refractory cardiogenic shock secondary to amniotic fluid embolus (A)</p> Signup and view all the answers

    What is the purpose of administering tranexamic acid during obstetric emergencies?

    <p>To reduce fibrinolysis (A)</p> Signup and view all the answers

    Which procedure is NOT typically used to treat atonic uterus and massive hemorrhage?

    <p>Cardiac catheterization (D)</p> Signup and view all the answers

    Which condition is NOT included in the differential diagnosis for cardiovascular collapse during delivery?

    <p>Cholecystitis (B)</p> Signup and view all the answers

    What critical step should be taken to relieve aortocaval compression during an emergency birth?

    <p>Turn the gravid uterus to the left (D)</p> Signup and view all the answers

    How is a myocardial infarction differentiated from a pulmonary embolism during an emergency?

    <p>Myocardial infarction presents with specific ST-T wave changes (A)</p> Signup and view all the answers

    What is a common neonatal resuscitation procedure performed by the multidisciplinary team?

    <p>Rapid suctioning (B)</p> Signup and view all the answers

    Which of the following is NOT one of the concentrated clotting factors found in cryoprecipitate?

    <p>Platelets (A)</p> Signup and view all the answers

    Flashcards

    Amniotic Fluid Embolism (AFE) Incidence

    AFE occurs at a rate of 1 case per 8,000 to 30,000 pregnancies. Exact rates are unknown due to diagnostic inaccuracies and unreported nonfatal cases.

    AFE Pathophysiology

    Entry of amniotic fluid and fetal material into the maternal bloodstream, likely via small tears in the uterine or endocervical veins during labor.

    AFE Trigger

    Maternal immune response to chemicals in amniotic fluid, not the fluid itself, is believed to trigger the condition.

    AFE Hemodynamic Effect

    AFE causes pulmonary arterial blockage, right ventricle and atrium enlargement, and significant tricuspid valve regurgitation.

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    Amniotic Fluid Composition

    Amniotic fluid includes fetal urine, hair, vernix, prostaglandins, and leukotrienes.

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    Disseminated Intravascular Coagulation (DIC)

    A syndrome where inflammatory mediators trigger blood clotting and the breakdown of clots.

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    AFE Leading Cause of Maternal Death

    In some countries, like Germany, amniotic fluid embolism is the leading cause of maternal death during childbirth.

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    Placenta-Amniotic Interface Disruption

    Disruption of the connection between the placenta and amniotic sac due to placental damage leads to amniotic fluid entering the maternal circulation.

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    AFE

    Amniotic fluid embolism, a life-threatening condition during pregnancy characterized by sudden respiratory distress and cardiovascular collapse.

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    Cardiovascular collapse

    Sudden failure of the cardiovascular system, leading to a dangerously low blood pressure.

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    Placental complications

    Problems related to the placenta, such as placenta accreta, abruption, or previa, can trigger AFE.

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    Preeclampsia

    A pregnancy complication involving high blood pressure and protein in the urine.

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    Pulmonary vasoconstriction

    Narrowing of blood vessels in the lungs.

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    Symptoms of AFE

    Rapid onset of shortness of breath, low blood pressure, and potentially seizures before cardiac arrest.

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    Coagulation Cascade

    The series of events leading to blood clotting.

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    AFE diagnosis

    AFE (Amniotic Fluid Embolism) diagnosis is challenging, as there isn't a single definitive test. Different international standards offer various criteria.

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    AFE risk factors (transmission)

    AFE happens when the barrier between the mother and amniotic fluid breaks down. This breach can occur through endocervical veins, uterine trauma sites, or the placental attachment site.

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    Initial hemodynamic assessment

    Start with measuring pulmonary wedge pressure, cardiac output, central venous pressure, pulse oximetry, arterial waveform, electrocardiography, and chest radiography.

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    Echocardiography in AFE

    TTE or TEE (transthoracic or transesophageal echocardiography) is vital. Look for right ventricle dilatation, hypokinesis, tricuspid regurgitation, and right atrial enlargement, and early cardiac thrombi.

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    Coagulation screen

    Essential tests include platelets, prothrombin time, partial thromboplastin time, bleeding time, fibrinogen, d-dimer, and fibrin degradation products (FDPs).

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    Metabolic/respiratory assessment

    AFE is often associated with metabolic and respiratory acidosis, which should be evaluated by arterial blood gas (ABG) and end-tidal CO2 (etCO2).

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    DIC (Disseminated Intravascular Coagulation) in pregnancy

    The ISTH (International Society on Thrombosis and Haemostasis) scoring system helps determine DIC presence based on platelet count, INR, and fibrinogen.

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    Intraventricular septum bowing

    A significant AFE finding is the bowing of the intraventricular septum, causing left ventricle obstruction and systolic dysfunction. Its appearance resembles the letter ‘D’ in echocardiograms.

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    AFE Criteria: Sudden Cardiopulmonary Collapse

    AFE (Acute Fetal/Maternal Emergency) requires sudden drop in blood pressure (systolic < 90 mmHg) and/or significant oxygen deprivation (SpO2 < 90%).

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    AFE Criteria: Disseminated Intravascular Coagulation (DIC)

    AFE diagnosis requires evidence of a widespread clotting disorder.

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    AFE Criteria: Timing

    Symptoms of AFE must appear during labor, placental delivery, or within 30 minutes of.

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    AFE Management: Cardiopulmonary Resuscitation

    Immediate, effective CPR is critical in AFE management.

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    AFE Management: Fetus Evacuation

    Removal of the fetus is necessary to address the emergency.

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    AFE Management: Oxygenation Maintenance

    Prioritizing oxygen supply is essential for supporting maternal health.

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    AFE Management: Coagulopathy Correction

    Correcting the clotting disorder, critical in AFE management.

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    AFE Management: Fluid Administration Cautiousness

    Fluid management must be carefully monitored when coagulopathy is present, as excessive fluids can impair clotting further.

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    ECMO (Extracorporeal Membrane Oxygenation)

    A life-support treatment that uses a machine to oxygenate blood outside of the body, often used for severe shock.

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    Cardiogenic shock

    A condition of circulatory failure caused by the inability of the heart to pump blood effectively.

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    Amniotic fluid embolism (AFE)

    A serious complication of pregnancy where amniotic fluid enters the mother's bloodstream.

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    Peripartum cardiomyopathy

    A condition where the heart muscle weakens during or after pregnancy.

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    Emergency hysterectomy

    Surgical removal of the uterus in an emergency situation, typically due to excessive bleeding.

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    Pulmonary embolism (PE)

    A blood clot that travels to the lungs and blocks blood flow.

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    Differential diagnosis

    The process of distinguishing possible medical conditions that could cause similar symptoms.

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    Myocardial infarction (MI)

    Heart attack; death of heart tissue due to a blocked artery.

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    AFE Incidence

    AFE is a rare event, occurring in 1 out of every 8,000 to 30,000 pregnancies.

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    AFE Mortality Rate

    The mortality rate for AFE is high, ranging from 40% to 60%.

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    AFE Survival Prognosis

    Maternal survival is uncommon, but prognosis improves with early recognition and prompt resuscitation.

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    AFE Long-term Effects

    Survivors often experience serious neurologic, pulmonary, or cardiovascular deficits.

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    AFE Recurrence Risk

    The risk of AFE recurrence is unknown.

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    AFE Infant Mortality Rate

    The mortality rate for infants is slightly lower than for mothers, around 30%.

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    AFE Subsequent Pregnancies

    Elective Cesarean delivery during future pregnancies may be recommended to avoid labor, but this practice is controversial.

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    AFE Diagnostic Challenge

    Exact incidence is difficult to determine due to diagnostic inaccuracies and unreported nonfatal cases.

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    Study Notes

    Amniotic Fluid Embolism (AFE)

    • AFE ranks as the 9th leading cause of direct maternal death in recent years.
    • AFE is a difficult condition to define, describe, and understand, yet it remains a significant contributor to maternal deaths.
    • AFE is not a simple condition, where a breach in the barrier allows amniotic fluid into the maternal circulation and triggers inflammatory response, coagulation activation, and eventually disseminated intravascular coagulation (DIC).

    Aim & Learning Outcomes

    • Students will learn to analyze AFE by examining incidence, pathophysiology, morbidity/mortality, signs/symptoms, progression, risk factors, and management.
    • A key aspect of learning is understanding the midwife's role in AFE management.

    Introduction

    • AFE ranks as the 9th leading cause of direct maternal deaths in recent years.
    • The condition—amniotic fluid embolism (AFE)—remains challenging to describe accurately, yet it remains a significant contributor to maternal mortality.

    Epidemiology

    • The incidence of AFE is estimated to range from 1 in 8,000 to 30,000 pregnancies.
    • Exact prevalence is unclear due to difficulties in accurate diagnosis and under-reporting of non-fatal cases.
    • In Germany, AFE was the leading cause of death during childbirth in 2011.
    • In Australia, AFE is identified as a leading direct cause of maternal mortality in deliveries ranging from 1 in 8000 to 1 in 80,000.
    • In the UK, the estimated incidence is 1.9 per 10,000 to 7.7 per 10,000 births.
    • In the USA, AFE occurs in 2 to 8 per 100,000 deliveries and is linked to maternal mortality between 7.5% and 10%.

    Etiology

    • AFE is an unpredictable condition where the exact cause is unknown.
    • Risk factors include advanced maternal age and multiple pregnancies, inducing labor, history of cerebrovascular disorders, and cardiac diseases, and association with certain obstetric procedures, conditions such as cesarean delivery, placenta previa, eclampsia, placental abruption, polyhydramnios, dilation and curettage, and renal disease.
    • Fetal, maternal conditions can trigger an inflammatory reaction that activates the coagulation cascade in the mother, causing disseminated intravascular coagulation (DIC) potentially resulting in maternal death.

    Pathophysiology

    • Amniotic fluid comprises fetal urine, cellular components, hair, vernix, and various prostaglandins and leukotrienes, which can enter maternal circulation.
    • The initial breach might not be the amniotic fluid itself, but rather the maternal immune response to these components.
    • Possible entry sites include placental attachment sites, cervical veins, and uterine surgical incisions during labor and birth.
    • Entry of the amniotic fluid into the maternal circulation can lead to severe pulmonary vasoconstriction and bronchoconstriction, activated coagulation cascade, ultimately triggering DIC.
    • Acute obstruction of pulmonary arteries, cardiac output decrease, right ventricular enlargement, and tricuspid regurgitation are observed.
    • The setting for AFE involves disruption of the placenta-amniotic interface, leading to the entry of amniotic fluid and related components into the maternal circulation, triggering inflammatory mediators, activating coagulation and fibrinolytic systems

    History and Examination

    • A medical history that potentially reveals risk factors for AFE.
    • Women experiencing AFE in the later stages of labor often present with acute shortness of breath, hypotension, and agitation.
    • Symptoms may sometimes include seizures preceding cardiac arrest.
    • A Massive DIC-associated haemorrhage often follows, and death occurs mainly within an hour of symptom onset.

    Assessment

    • Definitive diagnostic tests for AFE are unavailable. The diagnosis relies on a combination of clinical presentation and exclusion of other conditions.
    • The assessment should focus on hemodynamic instability. Hematologic evaluation is needed for assessing DIC.
    • Essential components of the evaluation include oxygenation, circulatory support, and correction of coagulation disorders

    Management

    • Prompt, effective cardiopulmonary resuscitation of the mother, and rapid evacuation of the fetus are fundamental in managing AFE.
    • Supportive care plays a prominent role in managing AFE, with a focus on maintaining oxygenation, circulatory support, and correction of any coagulopathy.
    • The treatment involves administration of fluids intravenously, pulmonary artery catheter monitoring, and vasopressors to maintain blood pressure.
    • If the condition persists, patients may require procedures like ECMO (extracorporeal membrane oxygenation) or other support at an intensive care unit (ICU) level.

    Obstetric Management

    • Delivery of the fetus should be prioritized, often via cesarean section if the pregnancy is beyond 23 weeks.
    • Ongoing maternal resuscitation is crucial along with anaesthetist and cardiac arrest team involvement.
    • Measures to prevent aortocaval compression, such as turning the gravid uterus to the left, support neonatal resuscitation efforts.
    • Procedures like uterine artery ligation or embolization may help control uterine hemorrhage.
    • Emergency hysterectomy is considered in cases of uncontrolled, massive hemorrhage or a failing uterus.

    Differential Diagnosis

    • A range of conditions can mimic AFE, including pulmonary embolism, peripartum cardiomyopathy, septic shock, myocardial infarction, venous air embolism, eclampsia, anaphylaxis, and cephalad spread of spinal anesthesia.

    Prognosis

    • Maternal survival is infrequent, with mortality rates ranging from 40% to 60%.
    • Prognosis improvement is observed with early diagnosis and prompt intervention.
    • Neurological damage, pulmonary problems, and cardiovascular issues often affect women who survive the initial event.
    • Long-term survival and subsequent pregnancy success after recovery may vary considerably from individuals to individuals.

    Complications

    • Severe maternal complications likely include renal failure, prolonged respiratory failure (adult respiratory distress syndrome), myocardial infarctions, cardiomyopathy, congestive heart failure, left ventricular systolic dysfunction, prolonged coagulopathy, liver failure, seizures, brain damage (anoxic encephalopathy), and other cognitive impairments.

    Conclusion

    • AFE is a rare but catastrophic syndrome, characterized by acute hypoxia, cardiovascular collapse, and coagulopathy.
    • Early detection and prompt management are crucial to enhancing maternal survival.
    • The pathophysiology of AFE still faces some controversy, and the exact mechanism triggering the response varies considerably among individuals.

    Patient Education

    • To help patients understand and avoid the most common triggers, patient education is crucial, especially in avoiding possible trauma and prevention during procedures like insertion of pressure catheters or membrane rupture, and incision of the placenta.

    Enhancing Healthcare Team Outcomes

    • A well-coordinated multidisciplinary team—including obstetricians, maternal-fetal specialists, anesthesiologists, midwives, neonatologists, hematologists, respiratory therapists, and neonatal intensive care nurses—is essential for effective AFE management.
    • Prompt and synchronized treatment pathways are crucial for successful maternal outcomes and infant survival.

    Role of the Midwife in AFE

    • The midwife plays a vital role in correctly identifying and managing AFE.
    • The midwife should be able to recognize AFE as an emergency, follow established protocols, address the woman and her partner's psychological needs, evaluate and address the patient's personalized needs, and provide post-event debriefing.

    Summary of Key Signs and Symptoms

    • AFE is characterized by fetal compromise due to uterine hypoxic causing uterine hypertonia, in addition, placental hemorrhage and maternal collapse.
    • Key respiratory signs include cyanosis, dyspnea, and respiratory arrest.
    • Cardiovascular symptoms include tachycardia, hypotension, pale, clammy skin, and potential cardiac arrest.
    • Coagulation disorders, hemorrhage, and DIC are prevalent signs
    • Neurological symptoms might include restlessness, panic, and seizures.

    Research Questions

    • The current incidence of AFE in the UK.
    • Risk factors for AFE in the UK.
    • How AFE is managed in the UK.
    • Outcomes for mothers and infants affected by AFE in the UK.

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