羊水栓塞和子宫破裂培训课件

1、羊水栓塞和子宫破裂羊水栓塞和子宫破裂Case Presentation(1)31y, G2P0Admitted to L&D with 40+3 Oxytocin inductionC/S for the arresting of the active stage羊水栓塞和子宫破裂2Case Presentation(1)羊水栓塞和子宫破裂2Case Presentation(1)After the baby was deliveredSudden onset:Cough dyspnea mild seizureHR(120), BP (7080/3050)Postpartum heamorr

2、ahage :2200ml Coagulopathy: FIB:1.64, PT14.1s, Hb 69,BPC:9.2羊水栓塞和子宫破裂3Case Presentation(1)After the Case Presentation(1)Diagnosis: Amniotic fluid embolismTreatment:Prognosis: Recovery羊水栓塞和子宫破裂4Case Presentation(1)羊水栓塞和子宫破裂4Case Presentation(2)26year G2P0Admitted because of PROM at 5amAt 7:am she had

3、 uterus constractionAt 7:30am she sudden complained of dyspnea and immediately comaSummon for help 羊水栓塞和子宫破裂5Case Presentation(2)羊水栓塞和子宫破裂5Case Presentation(3)36 years old,G3P1Induction for 41weeksAfter the baby was delivered by spontaneous vaginallyMassive vagina hemoarrhage BPUterus hysterectomy b

4、ut die from DIC and multi-organ failure羊水栓塞和子宫破裂6Case Presentation(3)羊水栓塞和子宫破裂6Case Presentation(4)43 years oldTermination of pregnancy because of the fetal abnormality at 33 weeks of gestationDyspnea before the delivery of the babyBP ,Postpartum Hemorrhage,comaDiagnosis: amniotic fluid embolism羊水栓塞

5、和子宫破裂7Case Presentation(4)43 years oDEFINITION羊水栓塞(amniotic fluid embolism) 在分娩过程中(产程中、产后，最迟产后48h内）突然出 现的: 急性呼吸困难、 休克、循环衰竭、 弥散性血管内凝血(DIC)、 肾功衰竭 或突发死亡的分娩严重并发症。羊水栓塞和子宫破裂8DEFINITION羊水栓塞(amniotic fluid AFE的认识过程AFE is thought to occur when amniotic fluid , fetal cells, hair, or other debris enter the mat

6、ernal circulation.Ricardo Meyer (1926); reported the presence of fetal cellular debris in the maternal pulmonary blood vessel.Steiner and Luschbaugh (1941) described the autopsy findings of eight cases of AFE.Until 1950, only 17 cases had been reported.AFE was not listed as a distinct heading in cau

7、ses of maternal mortality until 1957 when it was labeled as obstetric shock. Since then more than 400 cases have been documented, probably as a result of an increased awareness.羊水栓塞和子宫破裂9AFE的认识过程AFE is thought to occu发生率 Overall incidence ranges from 1 in 8,000 to 1 in 80,000 pregnancies. The Incide

8、nce in our department:1:8000 England:1:56500, American:1:12953 美国3百万分娩的统计显示7.7/10万14% of maternal deaths in USA(第二位的死亡原因) & 5.3% in U.K. 美国的孕产妇死亡率6.6/10万 我国统计? 第二或第三位的原因The first well-documented case with ultimate survival was published in 1976 (Resnik R, et al. Obstet Gynecol 1976;47:295-8). 羊水栓塞和子

9、宫破裂10发生率 Overall incidence rangMaternal fatality rate:1330% 61%86% before 1994 75 % of survivors are expected to have long-term neurologic deficits.Perinatal mortality:944% If the fetus is alive at the time of the event, nearly 70 % will survive the delivery but 50% of the survived neonates will inc

10、ur neurologic damage.羊水栓塞和子宫破裂11Maternal fatality rate:1330%羊 AMNIOTIC FLUID EMBOLISMTime of event: - During labor. - During C/S. - After normal vaginal delivery. - During second trimester TOP. AFE syndrome has been reported to occur as late as 48 hours following delivery.羊水栓塞和子宫破裂12 AMNIOTIC FLUID

11、EMBOLISMTime Risk factors of AFEAdvanced maternal ageMultiparity Meconium Cervical lacerationVery strong frequent or uterine tetanic contractionsSudden foetal expulsion (short labour)Placenta abnormalityPolyhydramnios Uterine ruptureMaternal history of allergy or atopy ChorioamnionitisMacrosomia Mal

12、e fetal sex Oxytocin (controversial)Operative deliveriesNevertheless, these and other frequently cited risk factors are not consistently observed and at the present time Experts agree that this condition is not preventable.羊水栓塞和子宫破裂13Risk factors of AFEAdvanced ma病理传统的观点：羊水中的有形物质进入母体循环引起肺毛细血管的物理性的阻塞

13、 循环衰竭研究不支持上述观点：动物实验不能验证；母体循环中都能找到胎儿细胞等；病理学家Steiner 和 Luschbaugh 发现很多死于其他疾病的孕产妇循环中都找到了胎儿细胞（fetal debris）；宫缩过强时子宫血流是停止的。 羊水栓塞和子宫破裂14病理传统的观点：羊水中的有形物质进入母体循环引起肺毛细血管的病理当前普遍认同的观点： Anaphylactoid Syndrome of Pregnancy对胎儿抗原的异常的母体免疫（Abnormal maternal immune response to the fetal antigen exposure common to virt

14、ually all laboring women 内源性的一系列免疫介质（endogenous-immune mediators) 引起一系列的过敏反应羊水栓塞和子宫破裂15病理当前普遍认同的观点：羊水栓塞和子宫破裂15PathophysiologyTo emphasize that the clinical findings are secondary to biochemical mediators rather than pulmonary embolic phenomenon; Clark et al have suggested renaming this clinical synd

15、rome the anaphylactoid syndrome of pregnancy 羊水栓塞和子宫破裂16PathophysiologyTo emphasize thPathophysiology呼吸循环衰竭: Amniotic fluid and fetal cells enter the maternal circulation biochemical mediators pulmonary artery vasospasm pulmonary hypertension elevated right ventricular pressure (右心衰,三尖瓣关闭不全) hypoxia

16、 myocardial and pulmonary capillary damage(左心灌注不良并缺氧) left heart failure acute respiratory distress syndrome 凝血功能障碍: biochemical mediators 消耗凝血物质,血小板聚集 DICmassive hemorrhage and uterine atony.羊水栓塞和子宫破裂17Pathophysiology呼吸循环衰竭:羊水栓塞和子Clinical presentation发生于分娩过程中、产后即刻，可以发生于正常分娩、引产、死胎等 (1) Respiratory d

17、istress(2) Cyanosis(3) Cardiovascular collapse cardiogenic shock(4) Hemorrhage (5) Coma. 羊水栓塞和子宫破裂18Clinical presentation发生于分娩过程中、Amniotic Fluid EmbolismSigns and SymptomsClark et al, Amniotic fluid embolism: analysis of a national registry. Am J Obstet Gynecol 1995;172:1158-1169羊水栓塞和子宫破裂19Amniotic

18、Fluid EmbolismSignsClinical presentationA sudden drop in O2 saturation can be the initial indication of AFE during c/s. some patients die within the first hour.Of the survivors will develop DIC which may manifest as persistent bleeding from incision or venipuncture sites.可以以DIC为首发症状 羊水栓塞和子宫破裂20Clini

19、cal presentationA sudden Clinical presentation10-15% of patients will develop seizures.CXR may be normal or show effusions, enlarged heart, or pulmonary edema. ECG may show a right strain pattern with ST-T changes and tachycardia.超声心动：肺动脉高压，急性右心衰竭，1h后出现左心衰竭 羊水栓塞和子宫破裂21Clinical presentation10-15% ofD

20、iagnosis 诊断主要依靠临床表现：分娩过程中或产后48小时内出现低血压、呼吸窘迫、DIC、抽搐、昏迷等不能用其他原因解释(排除法)临床化验：凝血分析、血气、血常规、心肌酶等胸片、经食道超声心动非特异性的检验（test）：Findings included mucin, amorphous eosinophilic material , and in some cases squamous cells.The presence of squamous cells in the pulmonary vasculature once considered pathognomonic for A

21、FE is neither sensitive nor specific (only 73% of patients dying from AFE had this finding).The monoclonal antibody TKH-2 （一种胎儿抗原）may eventually prove more useful in the rapid diagnosis of AFE. 羊水栓塞和子宫破裂22Diagnosis 诊断主要依靠临床表现：分娩过程中或产后4Laboratory investigations in suspected AFENon specific complete b

22、lood count coagulation parameters including FDP, fibrinogen arterial blood gases chest x-ray electrocardiogram V/Q scan echocardiogramSpecificserum tryptaseserum sialyl Tn antigen（一种胎儿抗原）zinc coproporphyrin（粪卟啉原）补体C3和C4（敏感性88100%，特异性100)羊水栓塞和子宫破裂23Laboratory investigations in Differential diagnosisO

23、bviously depends upon presentationDrug-induced allergic Anaphylaxis Pulmonary thromboembolism Aspiration Air embolism Myocardial infarctionAnesthetic complicationsUterine rupture Placenta abruptionPre-eclampsia or eclampsia (Fits, Coagulopathy)Haemorrhage Septic shockDrug toxicity (MgSO4）羊水栓塞和子宫破裂24

24、Differential diagnosisObviouManagement of AFEGOALS OF MANAGEMENT:Restoration of cardiovascular and pulmonary equilibrium - Maintain systolic blood pressure 90 mm Hg. - Urine output 25 ml/hr - Arterial pO2 60 mm Hg.肺动脉导管指导血液动力学的处理和监测血气Re-establishing uterine toneCorrect coagulation abnormalities羊水栓塞和

25、子宫破裂25Management of AFEGOALS OF MANAManagement of AFEAs intubation and CPR may be required it is necessary to have easy access to the patient, experienced help, and a resuscitation tray with intubation equipment, DC shock, and emergency medications.IMMEDIATE MEASURES : - Set up IV Infusion, O2 admin

26、istration. - Airway control endotracheal intubation maximal ventilation and oxygenation.LABS : CBC,ABG,PT,PTT,fibrinogen,FDP.羊水栓塞和子宫破裂26Management of AFEAs intubationManagement of AFETreat hypotension, increase the circulating volume and cardiac output with crystalloids.After correction of hypotensi

27、on, restrict fluid therapy to maintenance levels since ARDS follows in up to 40% to 70% of cases.Steroids may be indicated (recommended but no evidence as to their value)Dopamine infusion if patient remains hypotensive (myocardial support).羊水栓塞和子宫破裂27Management of AFETreat hypotenManagement of AFEIn

28、 the ICUTo assess the effectiveness of treatment and resuscitation, it is prudent to continuously monitor ECG, pO2, CO2, and urine output.There is support in literature for early placement of arterial, central venous, and pulmonary artery catheters to provide critical information and guide specific

29、therapy.羊水栓塞和子宫破裂28Management of AFEIn the ICUToManagement of AFEIn the ICUCentral venous pressure monitoring is important to diagnose right ventricular overload and guide fluid infusion and vasopressor therapy. Blood can also be sampled from the right heart for diagnostic purposes.Pulmonary artery

30、and capillary wedge pressures and echocardiography are useful to guide therapy and evaluate left ventricular function and compliance.An arterial line is useful for repeated blood sampling and blood gases to evaluate the efficacy of resuscitation.羊水栓塞和子宫破裂29Management of AFEIn the ICUCeManagement of

31、AFE CoagulopathyDIC results in the depletion of fibrinogen, platelets, and coagulation factors, especially factors V, VIII, and XIII. The fibrinolytic system is activated as well.Most patients will have hypofibrinogenemia, abnormal PT and aPTT and low Platelet counts fibrinogen level ，补充纤维蛋白原和血小板羊水栓

32、塞和子宫破裂30Management of AFE CoagulopathRestoration of uterine tone Uterine atony is best treated with massage, uterine packing, and oxytocin or prostaglandin analogues.Hysterectomy may be necessaryImprovement in cardiac output and uterine perfusion helps restore uterine tone.Extreme care should be exe

33、rcised when using prostaglandin analogues in hypoxic patients, as bronchospasm may worsen the situation.羊水栓塞和子宫破裂31Restoration of uterine tone UtSympathomimetic Vasopressor agentDopamineDopamine increases myocardial contractility and systolic BP with little increase in diastolic BP. Also dilates the

34、 renal vasculature, increasing renal blood flow and GFR.DOSE: 2-5 mcg/kg/min IV; titrate to BP and cardiac output.Contraindications: ventricular fibrillation, hypovolemia, pheochromocytoma.Precautions: Monitor urine flow, cardiac output, pulmonary wedge pressure, and BP during infusion; prior to inf

35、usion, correct hypovolemia with either whole blood or plasma, as indicated; monitoring central venous pressure or left ventricular filling pressure may be helpful羊水栓塞和子宫破裂32Sympathomimetic Vasopressor ag羊水栓塞和子宫破裂培训课件Further issues in the ManagementTransfer: Transfer to a level 3 hospital may be requ

36、ired once the patient is stable.Prevention: Amniotic fluid embolism is an unpredictable event.Risk of recurrence is unknown. The recommendation for elective cesarean delivery during future pregnancies in an attempt to avoid labor is controversial.Perimortem cesarean delivery: After 5 minutes of unsu

37、ccessful CPR in arrested mothers, abdominal delivery is recommended.羊水栓塞和子宫破裂34Further issues in the ManagemeMedical/Legal PitfallsFailure to respond emergently is a pitfall. AFE is a clinical diagnosis. Steps must be taken to stabilize the patient as soon as symptoms manifest.Failure to perform per

38、imortem cesarean delivery in a timely fashion is a pitfall. Failure to consider the diagnosis during legal abortion is a pitfall. A review of the literature indicates that most case reports of AFE have occurred during late second-trimester abortions.羊水栓塞和子宫破裂35Medical/Legal PitfallsFailure SUMMARYAF

39、E is a sudden and unexpected rare but life threatening complication of pregnancy.It has a complex pathogenesis and serious implications for both mother and infant.Associated with high rates of mortality and morbidity.Diagnosis of exclusion.Suspect AFE when confronted with any pregnant patient who ha

40、s sudden onset of respiratory distress, cardiac collapse, seizures, unexplained fetal distress, and abnormal bleeding Obstetricians should be alert to the symptoms of AFE and strive for prompt and aggressive treatment. 羊水栓塞和子宫破裂36SUMMARYAFE is a sudden and une子宫破裂Uterine Rupture 时春艳羊水栓塞和子宫破裂37子宫破裂Ut

41、erine Rupture 时春艳羊水栓塞和子 DefinitionNonsurgical complete disruption of all uterine layers which usually leads to bleeding and extrusion of all or part of the fetal-placental unit. 子宫体部或子宫下段在妊娠期或分娩期发生破裂称为子宫破裂(uterine rupture)Classified: Complete : all layers of the uterine wall seperated Incomplete (ut

42、erine dehisence): uterine muscle separated but visceral peritoneum intact) dehiscence(静止裂开） describes partial separation of the scar with minimal bleeding, with the peritoneum and fetal membranes remaining intact. _羊水栓塞和子宫破裂38 DefinitionNonsurgical completThe reported incidence：for all pregnancies i

43、s 0.05%After one previous lower segment cesarean section 0.8%After two previous lower segment cesarean section is 5% all pregnancies following myomectomy may be complicated by uterine rupture.羊水栓塞和子宫破裂39The reported incidence：羊水栓塞和子宫Etiology and high risks多发生在分娩期，与阻塞性分娩、不适当难产手术、滥用宫缩剂、妊娠子宫外伤和子宫手术瘢痕愈合

44、不良等因素有关，个别发生在晚期妊娠。子宫破裂为产科最严重并发症之一，常引起母儿死亡。92% occurred in women with a prior cesarean birth.羊水栓塞和子宫破裂40Etiology and high risks多发生在分娩期Clinical findingsRupture of the unscarred uterus: two phase threatened rupture of the uterus Pathologic contraction ring Rupture of uterus羊水栓塞和子宫破裂41Clinical findingsRupture of thClinical manifestations of