羊水栓塞-2011八年制

AmnioticFluidEmbolism

AFEZhuJiepingShanghaiJiaotongUniversityAffiliatedSixthPeople'sHospital,DeptofObs&Gyn1可編輯版Theentryofamnioticfluidintothematernalcirculationleadstosequelaeofclinicalevents,eg,suddenonsetofseveredyspnea(呼吸困難),cyanosis(紫紺)anddisseminatedintravascularcoagulation(DIC，彌散性血管內(nèi)凝血).Occursduringlabor,deliveryorearlypuerperium.ArarebutFATALobstetricemergency,leadstoseverematernalmorbidityandmortality.Definition2可編輯版Incidence:1:8000to1:80,000deliveries70%:occurredduringlabor19%:occurredduringcaesareandelivery11%:occurredaftervaginaldeliveryRiskfactors:HighpressureinamnioticcavityRuptureofthefetalmembranesRuptureofplacentalsinusEpidemiologyandRiskFactors3可編輯版Mechanismisunclear.Amnioticfluidcontainsmanyvasoactive(血管活性因子)andprocoagulantsubstances(促凝因子),suchasplateletactivatingfactor,cytokines,thromboxane(凝血惡烷),leukotrienes(白細(xì)胞三烯)andarachidonic

acid(花生四烯酸).Entranceofthesesubstancesintothematernalcirculationcouldcausethesyndrome.Anaphylactoid

syndromeofpregnancy？妊娠期過敏綜合癥Etiology4可編輯版1.PAH:pulmonaryarterialhypertension肺動脈高壓Pathophysiology(1)右心負(fù)荷加重右心擴(kuò)張充血性右心衰竭左心回心血量減少左心排出量減少周圍循環(huán)衰竭循環(huán)衰竭休克PAH羊水中的有形物質(zhì)→肺小血管機(jī)械性阻塞血管活性物質(zhì)→肺血管痙攣血小板釋放血清素→肺動脈痙攣5可編輯版2.AnaphylacticshockI型變態(tài)反應(yīng)：平滑肌痙攣、毛細(xì)血管擴(kuò)張，過敏性休克3.DIC

羊水中促凝物質(zhì)→激活外源性凝血系統(tǒng)→微血栓形成→消耗大量凝血因子和纖維蛋白原→DIC4.MOF(multipleorganfailure)

急性肝腎功能衰竭Pathophysiology(2)6可編輯版ClinicalmanifestationCardiorespiratoryfailureCoagulopathy,DICRENALFAILURECoughDyspnea呼吸困難HypotensionCyanosis紫紺OliguriaAnuriaMaternalMortalityRateover60%7可編輯版AmJObstetGynecol1995;172:1158SignsandSymptomsofAFE

SignsorsymptomsFrequencyHypotension(低血壓)100%Fetaldistress（胎窘）100%PulmonaryedemaorARDS（肺水腫/呼吸窘迫綜合癥）93%Cardiopulmonaryarrest（心跳呼吸驟停）87%Cyanosis（紫紺）83%Coagulopathy（凝血障礙）83%Dyspnea（呼吸困難）49%Seizure（抽搐）48%Uterineatony（宮縮乏力）23%Bronchospasm（支氣管痙攣）15%Transienthypertension（一過性高血壓）11%Cough7%Headache7%Chestpain2%8可編輯版Lab:CoagulantfunctionDIC:①PLT＜100×109/Lordecreasedprogressively②Fibrinogen＜1.5g/L

③PT(prothrombintime)＞15sec

④3Ptest(+)

⑤Testtubemethod＞30min

⑥Bloodsmear血涂片可見破碎的紅細(xì)胞。Testtubemethod：venousblood5mlDiagnosis

Aclinicaldiagnosis,oneofexclusion凝血時間min纖維蛋白含量g/L6~10正常10~15>1.515~301.0~1.5>30<1.09可編輯版ECG(Electrocardiogram)orCDS(ColorDopplerSonography)OxygensaturationChestX-ray:

enlargedrightatriumandventriclepulmonaryedemaDefinitivediagnosis:demonstrationofamnioticfluidmaterialinthematernalcirculation(下腔靜脈或右心室).Diagnosis

Aclinicaldiagnosis,oneofexclusion10可編輯版ObstetriccausesAcutehemorrhagePlacentalabruptionUterineruptureUterineatonyEclampsiaPeripartumcardiomyopathy(圍產(chǎn)期心肌病)AnestheticcausesHighspinalanesthesiaLocalanesthetictoxicityNonobstetriccausesPulmonaryembolismAirembolismAnaphylaxis（過敏反應(yīng)）DifferentialDiagnosisSuddenonsetofdyspnea,cardiovascularcollapseandDICshouldbesuspectedofAFEandinitiatetreatment!11可編輯版Amelioratehypoxemia改善缺氧Oxygenadministrationwithpositivepressure正壓給氧TreatmentofPAH1.Papaverine罌粟堿：首選藥物torelaxthevascularsmoothmuscle30~90mg+50%GS20~40mliv2.Aminophylline氨茶堿torelaxbronchialsmoothmuscleanddilatecoronaryartery250~500mg+25%GS10ml

ivManagement(1)12可編輯版Antiallergictreatment抗過敏Adrenocorticalhormone腎上腺皮質(zhì)激素1.Hydrocortisone(氫化可的松)200mgiv300~800mg+5%GS500mlivgtt2.Dexamethasone(地塞米松)20mg+25%GSiv20mg+5%GS500mlivgttManagement(2)13可編輯版Anti-shocktreatment抗休克1.Supplementofbloodvolume

Fleshblood,freezedfreshplasma,dextran右旋糖酐2.Vasopressors升壓藥Dopamine(多巴胺)10~20mg+5%GS250mlivgttAramine(間羥胺)20~80mg+5%GS250mlivgtt3.Treatingheartfailure強心Cedilanid(西地蘭)0.2~0.4mg+25%GSiv,repeatedevery4~6hours4.Treatingacidosis酸中毒5%NaHco3250mlivgttManagement(3)14可編輯版PreventionandtreatmentofDICHeparinSodium肝素鈉Antifibrinolyticdrugsaminocaproicacid(氨基己酸)tranexamicacid(氨甲環(huán)酸)PlateletsFresh-frozenplasmaCoagulationfactorsCryoprecipitate(冷沉淀物，凝血Ⅷ因子)Management(4)15可編輯版PreventionofrenalfailureBloodvolumesupplementMannitol(甘露醇)20%250ml

ivgtt擴(kuò)張腎小球前小動脈

Furosemidum(速尿，呋塞米)20~40mg+5%GSivPreventiono