羊水栓塞和子宫破裂专家讲座

羊水栓塞

AMNIOTICFLUIDEMBOLISM

(AFE)时春艳羊水栓塞和子宫破裂第1页CasePresentation(1)31y,G2P0AdmittedtoL&Dwith40+3OxytocininductionC/Sforthearrestingoftheactivestage羊水栓塞和子宫破裂第2页CasePresentation(1)AfterthebabywasdeliveredSuddenonset:CoughdyspneamildseizureHR↑(120),↓BP(70~80/30~50)Postpartumheamorrahage:2200mlCoagulopathy:FIB:1.64,PT14.1’s,Hb69,BPC:9.2羊水栓塞和子宫破裂第3页CasePresentation(1)Diagnosis:AmnioticfluidembolismTreatment:Prognosis:Recovery羊水栓塞和子宫破裂第4页CasePresentation(2)26yearG2P0AdmittedbecauseofPROMat5amAt7:amshehaduterusconstractionAt7:30amshesuddencomplainedofdyspneaandimmediatelycomaSummonforhelp羊水栓塞和子宫破裂第5页CasePresentation(3)36yearsold,G3P1Inductionfor41weeksAfterthebabywasdeliveredbyspontaneousvaginallyMassivevaginahemoarrhage↓BPUterushysterectomybutdiefromDICandmulti-organfailure羊水栓塞和子宫破裂第6页CasePresentation(4)43yearsoldTerminationofpregnancybecauseofthefetalabnormalityat33weeksofgestationDyspneabeforethedeliveryofthebabyBP,PostpartumHemorrhage,comaDiagnosis:amnioticfluidembolism羊水栓塞和子宫破裂第7页DEFINITION羊水栓塞(amnioticfluidembolism)

在分娩过程中(产程中、产后，最迟产后48h内）突然出现: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分娩严重并发症。羊水栓塞和子宫破裂第8页AFE认识过程AFEisthoughttooccurwhenamnioticfluid,fetalcells,hair,orotherdebrisenterthematernalcirculation.RicardoMeyer(1926);reportedthepresenceoffetalcellulardebrisinthematernalpulmonarybloodvessel.SteinerandLuschbaugh(1941)describedtheautopsyfindingsofeightcasesofAFE.Until1950,only17caseshadbeenreported.AFEwasnotlistedasadistinctheadingincausesofmaternalmortalityuntil1957whenitwaslabeledasobstetricshock.Sincethenmorethan400caseshavebeendocumented,probablyasaresultofanincreasedawareness.羊水栓塞和子宫破裂第9页

发生率

Overallincidencerangesfrom1in8,000to1in80,000pregnancies.TheIncidenceinourdepartment:1:8000England:1:56500,American:1:12953

美国3百万分娩统计显示7.7/10万14%ofmaternaldeathsinUSA(第二位死亡原因)&5.3%inU.K.

美国孕产妇死亡率6.6/10万我国统计?第二或第三位原因Thefirstwell-documentedcasewithultimatesurvivalwaspublishedin1976(ResnikR,etal.ObstetGynecol1976;47:295-8).羊水栓塞和子宫破裂第10页Maternalfatalityrate:13~30%61%~86%before1994

75%ofsurvivorsareexpectedtohavelong-termneurologicdeficits.Perinatalmortality:9~44%

Ifthefetusisaliveatthetimeoftheevent,nearly70%willsurvivethedeliverybut50%ofthesurvivedneonateswillincurneurologicdamage.羊水栓塞和子宫破裂第11页

AMNIOTICFLUIDEMBOLISMTimeofevent:-Duringlabor.-DuringC/S.-Afternormalvaginaldelivery.-DuringsecondtrimesterTOP.

AFEsyndromehasbeenreportedtooccuraslateas48hoursfollowingdelivery.羊水栓塞和子宫破裂第12页RiskfactorsofAFEAdvancedmaternalageMultiparityMeconiumCervicallacerationVerystrongfrequentoruterinetetaniccontractionsSuddenfoetalexpulsion(shortlabour)PlacentaabnormalityPolyhydramniosUterineruptureMaternalhistoryofallergyoratopyChorioamnionitisMacrosomiaMalefetalsexOxytocin(controversial)OperativedeliveriesNevertheless,theseandotherfrequentlycitedriskfactorsarenotconsistentlyobservedandatthepresenttimeExpertsagreethatthisconditionisnotpreventable.羊水栓塞和子宫破裂第13页病理传统观点：羊水中有形物质进入母体循环引发肺毛细血管物理性阻塞循环衰竭研究不支持上述观点：动物试验不能验证；母体循环中都能找到胎儿细胞等；病理学家Steiner和Luschbaugh发觉很多死于其它疾病孕产妇循环中都找到了胎儿细胞（fetaldebris）；宫缩过强时子宫血流是停顿。羊水栓塞和子宫破裂第14页病理当前普遍认同观点：

AnaphylactoidSyndromeofPregnancy对胎儿抗原异常母体免疫（Abnormalmaternalimmuneresponsetothefetalantigenexposurecommontovirtuallyalllaboringwomen内源性一系列免疫介质（endogenous-immunemediators)

引发一系列过敏反应羊水栓塞和子宫破裂第15页PathophysiologyToemphasizethattheclinicalfindingsaresecondarytobiochemicalmediatorsratherthanpulmonaryembolicphenomenon;Clarketalhavesuggestedrenamingthisclinicalsyndromethe

"anaphylactoidsyndromeofpregnancy"羊水栓塞和子宫破裂第16页

Pathophysiology

呼吸循环衰竭:Amnioticfluidandfetalcellsenterthematernalcirculationbiochemicalmediatorspulmonaryarteryvasospasmpulmonaryhypertensionelevatedrightventricularpressure(右心衰,三尖瓣关闭不全))hypoxiamyocardialandpulmonarycapillarydamage(左心灌注不良并缺氧)leftheartfailureacuterespiratorydistresssyndrome

凝血功效障碍:

biochemicalmediators

消耗凝血物质,血小板聚集

DICmassivehemorrhageanduterineatony.羊水栓塞和子宫破裂第17页Clinicalpresentation发生于分娩过程中、产后即刻，能够发生于正常分娩、引产、死胎等

(1)Respiratorydistress(2)Cyanosis(3)Cardiovascularcollapsecardiogenicshock(4)Hemorrhage(5)Coma.羊水栓塞和子宫破裂第18页AmnioticFluidEmbolism

SignsandSymptomsClarketal,Amnioticfluidembolism:analysisofanationalregistry.AmJObstetGynecol1995;172:1158-1169羊水栓塞和子宫破裂第19页ClinicalpresentationAsuddendropinO2saturationcanbetheinitialindicationofAFEduringc/s.somepatientsdiewithinthefirsthour.OfthesurvivorswilldevelopDICwhichmaymanifestaspersistentbleedingfromincisionorvenipuncturesites.能够以DIC为首发症状

羊水栓塞和子宫破裂第20页Clinicalpresentation10-15%ofpatientswilldevelopseizures.CXRmaybenormalorshoweffusions,enlargedheart,orpulmonaryedema.ECGmayshowarightstrainpatternwithST-Tchangesandtachycardia.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第21页Diagnosis

诊疗主要依靠临床表现：分娩过程中或产后48小时内出现低血压、呼吸窘迫、DIC、抽搐、昏迷等不能用其它原因解释(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检验（test）：Findingsincludedmucin,amorphouseosinophilicmaterial,andinsomecasessquamouscells.ThepresenceofsquamouscellsinthepulmonaryvasculatureonceconsideredpathognomonicforAFEisneithersensitivenorspecific(only73%ofpatientsdyingfromAFEhadthisfinding).ThemonoclonalantibodyTKH-2（一个胎儿抗原）mayeventuallyprovemoreusefulintherapiddiagnosisofAFE.羊水栓塞和子宫破裂第22页Laboratoryinvestigations

insuspectedAFENonspecific•completebloodcount•coagulationparametersincludingFDP,fibrinogen•arterialbloodgases•chestx-ray•electrocardiogram•V/Qscan•echocardiogramSpecificserumtryptaseserumsialylTnantigen（一个胎儿抗原）zinccoproporphyrin（粪卟啉原）补体C3和C4（敏感性88~100%，特异性100)羊水栓塞和子宫破裂第23页

Differentialdiagnosis

Obviouslydependsuponpresentation

Drug-inducedallergicAnaphylaxisPulmonarythromboembolismAspirationAirembolismMyocardialinfarctionAnestheticcomplicationsUterinerupturePlacentaabruptionPre-eclampsiaoreclampsia(Fits,Coagulopathy)Haemorrhage

SepticshockDrugtoxicity(MgSO4）羊水栓塞和子宫破裂第24页ManagementofAFEGOALSOFMANAGEMENT:Restorationofcardiovascularandpulmonaryequilibrium-Maintainsystolicbloodpressure>90mmHg.-Urineoutput>25ml/hr-ArterialpO2>60mmHg.肺动脉导管指导血液动力学处理和监测血气Re-establishinguterinetoneCorrectcoagulationabnormalities羊水栓塞和子宫破裂第25页Management

ofAFEAsintubationandCPRmayberequireditisnecessarytohaveeasyaccesstothepatient,experiencedhelp,andaresuscitationtraywithintubationequipment,DCshock,andemergencymedications.IMMEDIATEMEASURES:-SetupIVInfusion,O2administration.-Airwaycontrolendotrachealintubation

maximalventilationandoxygenation.LABS:

CBC,ABG,PT,PTT,fibrinogen,FDP.羊水栓塞和子宫破裂第26页Management

ofAFETreathypotension,increasethecirculatingvolumeandcardiacoutputwithcrystalloids.Aftercorrectionofhypotension,restrictfluidtherapytomaintenancelevelssinceARDSfollowsinupto40%to70%ofcases.Steroidsmaybeindicated(recommendedbutnoevidenceastotheirvalue)Dopamineinfusionifpatientremainshypotensive(myocardialsupport).羊水栓塞和子宫破裂第27页Management

ofAFE

IntheICUToassesstheeffectivenessoftreatmentandresuscitation,itisprudenttocontinuouslymonitorECG,pO2,CO2,andurineoutput.Thereissupportinliteratureforearlyplacementofarterial,centralvenous,andpulmonaryarterycatheterstoprovidecriticalinformationandguidespecifictherapy.羊水栓塞和子宫破裂第28页Management

ofAFE

IntheICUCentralvenouspressuremonitoringisimportanttodiagnoserightventricularoverloadandguidefluidinfusionandvasopressortherapy.Bloodcanalsobesampledfromtherightheartfordiagnosticpurposes.Pulmonaryarteryandcapillarywedgepressuresandechocardiographyareusefultoguidetherapyandevaluateleftventricularfunctionandcompliance.Anarteriallineisusefulforrepeatedbloodsamplingandbloodgasestoevaluatetheefficacyofresuscitation.羊水栓塞和子宫破裂第29页Management

ofAFE

CoagulopathyDICresultsinthedepletionoffibrinogen,platelets,andcoagulationfactors,especiallyfactorsV,VIII,andXIII.Thefibrinolyticsystemisactivatedaswell.Mostpatientswillhavehypofibrinogenemia,abnormalPTandaPTTandlowPlateletcountsfibrinogenlevel

，补充纤维蛋白原和血小板羊水栓塞和子宫破裂第30页Restorationofuterinetone

Uterineatonyisbesttreatedwithmassage,uterinepacking,andoxytocinorprostaglandinanalogues.HysterectomymaybenecessaryImprovementincardiacoutputanduterineperfusionhelpsrestoreuterinetone.Extremecareshouldbeexercisedwhenusingprostaglandinanaloguesinhypoxicpatients,asbronchospasmmayworsenthesituation.羊水栓塞和子宫破裂第31页SympathomimeticVasopressoragent

DopamineDopamineincreasesmyocardialcontractilityandsystolicBPwithlittleincreaseindiastolicBP.Alsodilatestherenalvasculature,increasingrenalbloodflowandGFR.DOSE:2-5mcg/kg/minIV;titratetoBPandcardiacoutput.Contraindications:ventricularfibrillation,hypovolemia,pheochromocytoma.Precautions:Monitorurineflow,cardiacoutput,pulmonarywedgepressure,andBPduringinfusion;priortoinfusion,correcthypovolemiawitheitherwholebloodorplasma,asindicated;monitoringcentralvenouspressureorleftventricularfillingpressuremaybehelpful羊水栓塞和子宫破裂第32页MaternalMortalityinAFEMaternaldeathusuallyoccursinoneofthreeways:(1)suddencardiacarrest,(2)hemorrhageduetocoagulopathy,or(3)initialsurvivalwithdeathduetoacuterespiratorydistresssyndrome(ARDS)andmultipleorganfailureForwomendiagnosedashavingAFE,mortalityratesrangingfrom26%toashighas86%havebeenreported.

Thevarianceinthesenumbersisexplainedbydissimilarcasedefinitionsandpossiblyimprovementsinintensivecaremanagementofaffectedpatients.羊水栓塞和子宫破裂第33页FurtherissuesintheManagementTransfer:Transfertoalevel3hospitalmayberequiredoncethepatientisstable.Prevention:

Amnioticfluidembolismisanunpredictableevent.Riskofrecurrenceisunknown.Therecommendationforelectivecesareandeliveryduringfuturepregnanciesinanattempttoavoidlaboriscontroversial.Perimortemcesareandelivery:After5minutesofunsuccessfulCPRinarrestedmothers,abdominaldeliveryisrecommended.羊水栓塞和子宫破裂第34页Medical/LegalPitfallsFailuretorespondemergentlyisapitfall.AFEisaclinicaldiagnosis.Stepsmustbetakentostabilizethepatientassoonassymptomsmanifest.Failuretoperformperimortemcesareandeliveryinatimelyfashionisapitfall.Failuretoconsiderthediagnosisduringlegalabortionisapitfall.AreviewoftheliteratureindicatesthatmostcasereportsofAFEhaveoccurredduringlatesecond-trimesterabortions.

羊水栓塞和子宫破裂第35页SUMMARYAFEisasuddenandunexpectedrarebutlifethreateningcomplicationofpregnancy.Ithasacomplexpathogenesisandseriousimplicationsforbothmotherandinfant.Associatedwithhighratesofmortalityandmorbidity.Diagnosisofexclusion.SuspectAFEwhenconfrontedwithanypregnantpatientwhohassuddenonsetofrespiratorydistress,cardiaccollapse,seizures,unexplainedfetaldistress,andabnormalbleedingObstetriciansshouldbealerttothesymptomsofAFEandstriveforpromptandaggressivetreatment.羊水栓塞和子宫破裂第36页子宫破裂

UterineRupture时春艳羊水栓塞和子宫破裂第37页

DefinitionNonsurgicalcompletedisruptionofalluterinelayerswhichusuallyleadstobleedingandextrusionofallorpartofthefetal-placentalunit.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(uterinerupture)Classified:Complete:alllayersoftheuterinewallseperatedIncomplete(uterinedehisence):uterinemuscleseparatedbutvisceralperitoneumintact)dehiscence(静止裂开）describespartialseparationofthescarwithminimalbleeding,withtheperitoneumandfetalmembranesremainingintact._羊水栓塞和子宫破裂第38页Thereportedincidence：forall

pregnancies

is0.05%Afteronepreviouslowersegmentcesareansection0.8%Aftertwopreviouslowersegmentcesareansectionis5%allpregnanciesfollowingmyomectomymaybecomplicatedbyuterinerupture.羊水栓塞和子宫破裂第39页Etiologyandhighrisks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不良等原因相关，个别发生在晚期妊娠。子宫破裂为产科最严重并发症之一，常引发母儿死亡。92%occurredinwomenwithapriorcesareanbirth.羊水栓塞和子宫破裂第40页ClinicalfindingsRuptureoftheunscarreduterus:twophasethreatenedruptureoftheuterusPathologiccontractionringRuptureofuterus羊水栓塞和子宫破裂第41页ClinicalmanifestationsofuterineruptureFetalbradycardiaVariableorlatedecelerationsMaternalhypotension/shockVaginal