羊水栓塞處理方案

1、AFE（1）Risk factors for amniotic fluid embolismFetal factorsMaternal factorsObstetrical factorsMale genderAdvanced maternal age >35Cesarean sectionPlacenta previaMultiparityCervical lacerationPlacenta accretaDiabetesInduction of laborPlacental abruptionInstrumental delivery: forceps andvacuum-assi

2、sted vaginal deliveriesFetal distressUterine rupturePolyhydramniosEclampsiaFetal macrosomiaOxytocin usePremature rupture of membranesIntrauterine death（2）Pathophysiology of amniotic fluid embolism（3）Classification of AFE. Amniotic fluid embolism can be classified as (1) the mechanical obstruction su

3、btype, (2) the anaphylactic subtype, and (3) the DIC subtype. This subclassificationmay be beneficial in the diagnosis and the personalized treatment of AFE.(4)Proposed clinical phases of amniotic fluid embolism（5）Clinical manifestations of amniotic fluid embolism（6）diagnostic criteria（UK obstetric

4、surveillance system）Either - In the absence of any other clear causeAcute maternal collapse with one or more of the followingAcute fetal compromiseCardiac arrestCardiac arrhythmiasHypotensionMaternal hemorrhageCoagulopathyPremonitory symptomsSeizureShortness of breathExcluding women with maternal he

5、morrhage as the first presentingfeature in whom there was no evidence of early coagulopathy orcardio-respiratory compromiseOrWomen in whom the diagnosis was made at postmortem examination with fetal squames or hair in the lungs（7）Adjuvant laboratory tests in amniotic fluid embolismComplete blood cou

6、ntsPeripheral smearCoagulation profile - PT, aPTT, D-dimer, fibrin degradation products,fibrinogenThromboelastography/thromboelastometrySerum electrolytesABGECGCardiac enzymesEchocardiography (transthoracic/transesophageal)Chest radiograph（8）Differential diagnoses of AFERespiratoryPulmonary embolism

7、 Air embolismAspirationTension pneumothoraxAspirationPulmonary edemaCardiacAcute myocardial infarctionPeripartum cardiomyopathyAortic dissectionCardiac arrhythmiheart failure, tamponadeShockSeptic shockAnaphylactic shock: drug inducedObstetricPostpartum hemorrhageUterine rupturePlacental abruptionEc

8、lampsiaAnesthesia related - local anesthetic toxicity, high spinalOther reversible causes - toxins, hypo/hyperkalemia, metabolic,hypothermia (9)Biomarkers currently utilized for the diagnosis of amniotic fluid embolismCurrent biomarkersZinc coproporphyrinCharacteristic component ofmeconium and fetal

9、 urineElevated in AFEDetected via high performance liquidchromatographySialosyl Tn antigenFetal antigen found in meconium andamniotic fluidDetected via TKH-2 monoclonalantibodyTryptaseMast cell degranulation markerElevated in some AFE patientsComplement factorsDecreased C3 and C4 complementPossible

10、complement activationCytokinesIL-6, IL-8, and tumor necrosis factorElevated in some AFE patientsNonspecific because can be presentin systemic inflammatory responsesyndromeInsulin-like growth factorbinding protein 1Embryonic development proteinsynthesized in deciduaDetectable in amniotic fluid andmat

11、ernal serumNew biomarkersActivin A (transforming growth factor)Characteristic of maternal serum, cord blood serum, and amniotic fluidIncreased with gestational ageProopiomelanocortinCharacteristic of placental membrane10_ more concentrated in amniotic fluid than maternal serumInversely related to hu

12、man chorionic gonadotropinHigh concentrations at feto-maternal junctionProcollagen type 1 N-terminal propeptideAssociated with fetal metabolism and development>400 times more concentrated in amniotic fluid than maternal circulationCK13 (Rab); CK10/13 (Mab)Strongly expressed in squamous cells from

13、 maternal amniotic fluidBrown cytoplasmic granules when immunostainedSummary:Although AFE cannot be prevented, early diagnosis and intervention may lead to better outcomes for both the mother and the fetus. Clinical suspicion, traditional laboratory data, or intravascular cellular debris(demonstrate

14、d only in 50% of patients) are insufficient to make a definitive diagnosis of AFE. An evolving array of novel biomarkers may help differentiate AFE from other conditions, but none of them currently provide sufficient early warning ability to make real-time impact on diagnosis and/or treatment of AFE

15、.(10)Algorithm for management after diagnosis of amniotic fluid embolism附1：治療措施1.Prompt delivery（within_5 min of maternal cardiac arrest）2.Aravenous access4.hemodynamic monitoring（include:lactate、ABG、VBG、）5.fluids and vasopressors（early phase of circulatory vasodilation-Phenylephrine and v

16、asopressin、adrenaline、norepinephrine）6.blood and component replacements/( cell salvage、uterine artery embolization、Bakri balloon)7.pulmonary vasodilation（Milrinone、inhaled nitric oxide、inhaled epoprostenol）8.Heparin and steroids9.tranexamic acid or aminocaproic（undetermined）10.Sodium bicarbonate（patients unresponsive to advanced life support measures, with right ventricular failure and acidosis）11.C1INH concentrates(hereditary angioedema)12.hemofiltration or plasma exchange13.nonpne