妊娠和产褥期动脉瘤性蛛网膜下腔出血的诊疗

1、妊娠和产褥期动脉瘤性蛛网膜下腔出血的诊疗广东省中医院神经三科 陈发军一、妊娠和产褥期蛛网膜下腔出血 是指发生在整个妊娠期及产后6周内的SAH。二、流行病学及病因 妊娠和产褥期蛛网膜下腔出血发病率约1/100000-5/100000。成为日本妊娠期妇女的第二大死因。成为美国妊娠期妇女第三大死因。 常见病因是颅内动脉瘤、AVM破裂引起出血，其次是妊娠期高血压、子痫、静脉窦血栓、烟雾病、非动脉瘤性蛛网膜下腔出血等。Perimesencephalic Subarachnoid emorrhageCase 1 40Y Headache gestational age (GA) of 8 weeks an

2、d 4 days32Y,Headache,9th week of pregnancy,seizure,loss of consciousnessEclamptic subarachnoid haemorrhage 32Y G1P0 Five days after delivery severe pounding pain over the vertex nausea 95/60-130/74妊娠和产褥期动脉瘤性蛛网膜下腔出血的流行病学妊娠和产褥期动脉瘤性蛛网膜下腔出血的流行病学 妊娠和产褥期动脉瘤性SAH发病率约3/100000。 动脉瘤性SAH的引起的妊娠期妇女死亡率约13%-15%。 妊娠

3、不会增加动脉瘤的破裂机率。 Cerebral aneurysms in the anteriorcirculation larger than 7 mm are more likely to rupture.Rupture may occur in smaller aneurysms of the posterior circulation. The risk for recurrent bleeding during the remainder of pregnancy in patients with an untreated aneurysm is 33% to 50%, with a

4、maternal mortality rate of 50% to 68%.Rebleeding within 3 to 8 weeks of initial treatment.三、临床表现与诊断 突发剧烈头痛最常见，可伴有恶心、呕吐，时有意识障碍或烦躁，可出现部分性或全面性癫痫发作。 脑膜刺激症（颈强直、Kerning征、Brudzinski征）阳性。辅助检查 首选CT检查，在放射吸收剂量50mGY下不会增加胎儿畸形、生长受限和流产的机率。 腰椎穿刺术。 MRI。 CTA、MRA、脑血管造影术明确AN，MRA推荐为未破裂动脉瘤患者的筛选。鉴别诊断 先兆子痫和子痫的临床表现很相似，难以鉴别。

5、研究显示，30妊娠期SAH可反应性引起血压升高、一过性蛋白尿。而40致命性子痫可同时并发SAH。四、治疗 与非妊娠期动脉瘤性SAH处理类似。 积极的手术治疗，文献报道：手术组孕妇死亡率11%，胎儿死亡率5%；非手术组死亡率63%，27%。 不轻易放弃胎儿，妊娠28周后可进行剖腹产，24周-28周视胎儿成熟度选择手术方式。 合并大量脑出血、脑积水等患者可以先进行脑血肿清除及脑室外引流术，但必须要做好胎儿监测，出现胎儿窘迫，需要同时进行剖腹产手术。 麻醉方式选择气管全麻，做好胎儿监测等。 多学科的协作（神经科、产科、麻醉科、新生儿科），以神经科医师为主导。动脉瘤的手术方式动脉瘤的手术方式 动脉瘤夹

6、闭术 动脉瘤栓塞术动脉瘤夹闭术动脉瘤夹闭术 文献建议对既能够栓塞又能够夹闭的AN，优先选择夹闭术。 文献建议剖腹产手术建议于动脉瘤手术前进行。 并发症：再出血、脑血管痉挛、产后心肌病等。动脉瘤栓塞术动脉瘤栓塞术 根据动脉瘤类型、形态、大小选择合适栓塞方式。 没有见到使用支架辅助栓塞的病例，有使用球囊辅助栓塞的报道。 对于一些后循环的，难以行夹闭术，优先选择栓塞术。 术后注意充分水化防止胎儿脱水。术中射线影响及防护 Embryogenesis (first two weeks of pregnancy) the death of the embryo. During organogenesis

7、(weeks 2 through 7 of gestation) congenital abnormalities in the surviving fetus. The fetal period (week 8 until birth) growth retardation with microcephaly, retardation due to neuron depletion, and development of childhood cancer. 8 to 25 weeks,the central nervous system (CNS) is particularly sensi

8、tive to radiation. According to the reference, fetal doses in excess of approximately 100 mGy may result in a verifiable decrease of intelligence quotient at 8 to 15 weeks gestation). During the same period, fetal doses in the range of 1000 mGy (1 Gy) result in a high probability of severe mental re

9、tardation. Shielding patients lower abdomen with double-layered 0.5 mm lead aprons, may reduce the received dose by more than 97%。 According to the previous reports, calculated expected value of the fetal dose was between 11.5 and 43.3 mGycm. According to the ICRP, at exposure levels below 100 mGy,

10、the radiation effect is so small that termination of pregnancy is not justified.21Y,headache, 29th week of pregnancy,caesarian section at the 38th week of gestation 39Y,18th gestational week,headache,delivered a healthy male infant 4 months34Y16th gestational week drowsy level of consciousness after experiencing a generalseizureFive coils, cesarean section at the 38th week总 结妊娠和产褥期动脉瘤性蛛网膜下腔出血是孕妇死亡的一个重要原因。