羊水栓塞与子宫破裂.ppt

羊水栓塞AMNIOTIC FLUID EMBOLISM(AFE),时春艳,Case Presentation(1),31y, G2P0 Admitted to L 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 causes 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.,发生率,Overall incidence ranges from 1 in 8,000 to 1 in 80,000 pregnancies. The Incidence 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) 47:295-8).,Maternal 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 incur neurologic damage.,AMNIOTIC FLUID EMBOLISM,Time 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.,Risk factors of AFE,Advanced maternal age Multiparity Meconium Cervical laceration Very strong frequent or uterine tetanic contractions Sudden foetal expulsion (short labour),Placenta abnormality Polyhydramnios Uterine rupture Maternal history of allergy or atopy Chorioamnionitis Macrosomia Male fetal sex Oxytocin (controversial) Operative deliveries,Nevertheless, these and other frequently cited risk factors are not consistently observed and at the present time Experts agree that this condition is not preventable.,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 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。,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 virtually 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,Pathophysiology,To emphasize that the clinical findings are secondary to biochemical mediators rather than pulmonary embolic phenomenon; Clark et al have suggested renaming this clinical syndrome the anaphylactoid syndrome of pregnancy,Pathophysiology,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 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.,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 distress (2) Cyanosis (3) Cardiovascular collapse cardiogenic shock (4) Hemorrhage (5) Coma.,Amniotic Fluid EmbolismSigns and Symptoms,Clark et al, Amniotic fluid embolism: analysis of a national registry. Am J Obstet Gynecol 1995;172:1158-1169,Clinical presentation,A 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,Clinical presentation,10-15% 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,Diagnosis,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 AFE 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.,Laboratory investigations in suspected AFE,Non specific complete blood count coagulation parameters including FDP, fibrinogen arterial blood gases chest x-ray electrocardiogram V/Q scan echocardiogram,Specific serum tryptase serum 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),Differential diagnosisObviously depends upon presentation,Drug-induced allergic Anaphylaxis Pulmonary thromboembolism Aspiration Air embolism Myocardial infarction Anesthetic complications,Uterine rupture Placenta abruption Pre-eclampsia or eclampsia (Fits, Coagulopathy) Haemorrhage Septic shock Drug toxicity (MgSO4）,Management of AFE,GOALS 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 tone Correct coagulation abnormalities,Management of AFE,As 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 administration. - Airway control endotracheal intubation maximal ventilation and oxygenation. LABS : CBC,ABG,PT,PTT,fibrinogen,FDP.,Management of AFE,Treat hypotension, increase the circulating volume and cardiac output with crystalloids. After correction of hypotension, 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).,Management of AFEIn the ICU,To 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 therapy.,Management of AFEIn the ICU,Central 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 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.,Management of AFE Coagulopathy,DIC 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,Restoration of uterine tone,Uterine atony is best treated with massage, uterine packing, and oxytocin or prostaglandin analogues. Hysterectomy may be necessary Improvement in cardiac output and uterine perfusion helps restore uterine tone. Extreme care should be exercised when using prostaglandin analogues in hypoxic patients, as bronchospasm may worsen the situation.,Sympathomimetic Vasopressor agentDopamine,Dopamine increases myocardial contractility and systolic BP with little increase in diastolic BP. Also dilates the 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 infusion, correct hypovolemia with either whole blood or plasma, as indicated; monitoring central venous pressure or left ventricular filling pressure may be helpful,Maternal Mortality in AFE,Maternal death usually occurs in one of three ways: (1) sudden cardiac arrest, (2) hemorrhage due to coagulopathy, or (3) initial survival with death due to acute respiratory distress syndrome (ARDS) and multiple organ failure For women diagnosed as having AFE, mortality rates ranging from 26% to as high as 86% have been reported. The variance in these numbers is explained by dissimilar case definitions and possibly improvements in intensive care management of affected patients.,Further issues in the Management,Transfer: Transfer to a level 3 hospital may be required 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 unsuccessful CPR in arrested mothers, abdominal delivery is recommended.,Medical/Legal Pitfalls,Failure 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 perimortem 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.,SUMMARY,AFE 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 has 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.,子宫破裂Uterine Rupture,时春艳,Definition,Nonsurgical 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 (uterine 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. _,The reported incidence： for all pregnancies is 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.,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.,Clinical findings,Rupture of the unscarred uterus: two phase threatened rupture of the uterus Pathologic contraction ring Rupture of uterus,Clinical manifestations of uterine rupture,Fetal bradycardia Variable or late decelerations Maternal hypotension/shock Vaginal bleeding Cessation of contractions Loss of station/fetal presenting part Abdominal pain,Complications of uterine rupture,Maternal mortality very rare Fetal morbidity/mortality more common - Fetal asphyxia occurs in 5% - Perinatal morbidity/mortality highest when fetus extruded into abdomen or when interval between bradycardia & delivery exceeded 18 minutes,Diagnosis and differential diagnosis,abruption rupture dystocia and infection abd. pain present variable variable vag. blood old fresh no DIC common rare rare acute fetal common common common distress infection signs no no yes,Management,The identification or suspicion of uterine rupture must be followed by an immediate and simultaneous response from the obstetric team. Surgery should not be delayed owing to hypovolemic shock because it may not be easily reversible until the hemorrhage is controlled,Management,Surgery : hysterectomy or to repair the rupture site, bladder rupture must be ruled out Oxytocin ? Hemostasis,Prevention,Prenatal care Observing the labor Indication for the TOL ofter the CS Avoiding the abuse of the Oxytocin 腹腔镜剔肌瘤缝合严密,THANK YOU,