羊水栓塞和子宫破裂培训ppt课件

羊水栓塞和子羊水栓塞和子宫宫破裂破裂羊水栓塞和子宫破裂1 1CasePresentation(1)l l31y,G2P0l lAdmittedtoL&Dwith40+3l lOxytocininductionl lC/Sforthearrestingoftheactivestage羊水栓塞和子宫破裂2CasePresentation(1)羊水栓塞和子宫破裂2CasePresentation(1)l lAfterthebabywasdeliveredl lSuddenonset:l lCoughCoughdyspneadyspneamildseizuremildseizurel lHR(120),HR(120),BP(7080/3050)BP(7080/3050)l lPostpartumheamorrahage:2200mlPostpartumheamorrahage:2200mll lCoagulopathy:FIB:1.64,PT14.1s,HbCoagulopathy:FIB:1.64,PT14.1s,Hb69,BPC:9.269,BPC:9.2羊水栓塞和子宫破裂3CasePresentation(1)AftertheCasePresentation(1)l lDiagnosis:Amnioticfluidembolisml lTreatment:l lPrognosis:Recovery羊水栓塞和子宫破裂4CasePresentation(1)羊水栓塞和子宫破裂4CasePresentation(2)l l26yearG2P0l lAdmittedbecauseofPROMat5aml lAt7:amshehaduterusconstractionl lAt7:30amshesuddencomplainedofdyspneaandimmediatelycomal lSummonforhelp羊水栓塞和子宫破裂5CasePresentation(2)羊水栓塞和子宫破裂5CasePresentation(3)l l36 years old,G3P136 years old,G3P1l lInduction for 41weeksInduction for 41weeksl lAfter the baby was delivered by After the baby was delivered by spontaneous vaginallyspontaneous vaginallyl lMassive vagina hemoarrhage Massive vagina hemoarrhage l l BPBPl lUterus hysterectomy but die from DIC and Uterus hysterectomy but die from DIC and multi-organ failuremulti-organ failure羊水栓塞和子宫破裂6CasePresentation(3)羊水栓塞和子宫破裂6CasePresentation(4)l l43yearsoldl lTerminationofpregnancybecauseofthefetalabnormalityat33weeksofgestationl lDyspneabeforethedeliveryofthebabyl lBP,PostpartumHemorrhage,comal lDiagnosis:amnioticfluidembolism羊水栓塞和子宫破裂7CasePresentation(4)43yearsoDEFINITIONl l羊水栓塞羊水栓塞羊水栓塞羊水栓塞(amniotic fluid embolism)(amniotic fluid embolism)在分娩过程中在分娩过程中在分娩过程中在分娩过程中(产程中、产后，最迟产后产程中、产后，最迟产后产程中、产后，最迟产后产程中、产后，最迟产后48h48h内）突然出内）突然出内）突然出内）突然出 现的现的现的现的:急性呼吸困难、急性呼吸困难、急性呼吸困难、急性呼吸困难、休克、循环衰竭、休克、循环衰竭、休克、循环衰竭、休克、循环衰竭、弥散性血管内凝血弥散性血管内凝血弥散性血管内凝血弥散性血管内凝血(DIC)(DIC)、肾功衰竭肾功衰竭肾功衰竭肾功衰竭 或突发死亡的分娩严重并发症。或突发死亡的分娩严重并发症。或突发死亡的分娩严重并发症。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(amnioticfluidAFE的认识过程l lAFEisthoughttooccurwhenamnioticfluid,fetalAFEisthoughttooccurwhenamnioticfluid,fetalcells,hair,orotherdebrisenterthematernalcells,hair,orotherdebrisenterthematernalcirculation.circulation.l lRicardoMeyer(1926);reportedthepresenceoffetalRicardoMeyer(1926);reportedthepresenceoffetalcellulardebrisinthematernalpulmonarybloodcellulardebrisinthematernalpulmonarybloodvessel.vessel.l lSteinerandLuschbaugh(1941)describedtheSteinerandLuschbaugh(1941)describedtheautopsyfindingsofeightcasesofAFE.autopsyfindingsofeightcasesofAFE.l lUntil1950,only17caseshadbeenreported.Until1950,only17caseshadbeenreported.l lAFEwasnotlistedasadistinctheadingincausesofAFEwasnotlistedasadistinctheadingincausesofmaternalmortalityuntil1957whenitwaslabeledasmaternalmortalityuntil1957whenitwaslabeledasobstetricshock.obstetricshock.l lSincethenmorethan400caseshavebeenSincethenmorethan400caseshavebeendocumented,probablyasaresultofanincreaseddocumented,probablyasaresultofanincreasedawareness.awareness.羊水栓塞和子宫破裂9AFE的认识过程AFEisthoughttooccu发生率l lOverallincidencerangesfrom1in8,000to1Overallincidencerangesfrom1in8,000to1in80,000pregnancies.in80,000pregnancies.TheIncidenceinourTheIncidenceinourdepartment:1:8000department:1:8000England:1:56500,American:1:12953England:1:56500,American:1:12953美国美国美国美国3 3百万分娩的百万分娩的百万分娩的百万分娩的统计显统计显示示示示7.7/107.7/10万万万万l l14%ofmaternaldeathsinUSA(14%ofmaternaldeathsinUSA(第二位的死亡第二位的死亡第二位的死亡第二位的死亡原因原因原因原因)&5.3%inU.K.)&5.3%inU.K.美国的孕产妇死亡率美国的孕产妇死亡率美国的孕产妇死亡率美国的孕产妇死亡率6.6/106.6/10万万万万我国统计我国统计我国统计我国统计?第二或第三位的原因第二或第三位的原因第二或第三位的原因第二或第三位的原因l lThefirstwell-documentedcasewithThefirstwell-documentedcasewithultimatesurvivalwaspublishedin1976ultimatesurvivalwaspublishedin1976(ResnikR,etal.ObstetGynecol1976;47:295-8).(ResnikR,etal.ObstetGynecol1976;47:295-8).羊水栓塞和子宫破裂10发生率Overallincidencerangl lMaternalfatalityrate:1330%Maternalfatalityrate:1330%61%86%before199461%86%before199475%ofsurvivorsareexpectedtohavelong-term75%ofsurvivorsareexpectedtohavelong-termneurologicdeficits.neurologicdeficits.l lPerinatalmortality:944%Perinatalmortality:944%Ifthefetusisaliveatthetimeoftheevent,nearly70Ifthefetusisaliveatthetimeoftheevent,nearly70%willsurvivethedeliverybut50%ofthesurvived%willsurvivethedeliverybut50%ofthesurvivedneonateswillincurneurologicdamage.neonateswillincurneurologicdamage.羊水栓塞和子宫破裂11Maternalfatalityrate:1330%羊AMNIOTICFLUIDEMBOLISMl lTimeofevent:-Duringlabor.-DuringC/S.-Afternormalvaginaldelivery.-DuringsecondtrimesterTOP.l lAFEsyndromehasbeenreportedtooccuraslateas48hoursfollowingdelivery.羊水栓塞和子宫破裂12AMNIOTICFLUIDEMBOLISMTimeRiskfactorsofAFEl lAdvancedmaternalAdvancedmaternalageagel lMultiparityMultiparityl lMeconiumMeconiuml lCervicallacerationCervicallacerationl lVerystrongfrequentVerystrongfrequentoruterinetetanicoruterinetetaniccontractionscontractionsl lSuddenfoetalSuddenfoetalexpulsion(shortexpulsion(shortlabour)labour)l lPlacentaabnormalityPlacentaabnormalityl lPolyhydramniosPolyhydramniosl lUterineruptureUterinerupturel lMaternalhistoryofallergyMaternalhistoryofallergyoratopyoratopyl lChorioamnionitisChorioamnionitisl lMacrosomiaMacrosomial lMalefetalsexMalefetalsexl lOxytocin(controversial)Oxytocin(controversial)l lOperativedeliveriesOperativedeliveriesNevertheless,theseandotherfrequentlycitedriskfactorsarenotconsistentlyobservedandatthepresenttimeExperts agree that this condition is not preventable.羊水栓塞和子宫破裂13RiskfactorsofAFEAdvancedma病理病理l l传统的观点：羊水中的有形物质进入母体循环引传统的观点：羊水中的有形物质进入母体循环引传统的观点：羊水中的有形物质进入母体循环引传统的观点：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起肺毛细血管的物理性的阻塞起肺毛细血管的物理性的阻塞起肺毛细血管的物理性的阻塞 循环衰竭循环衰竭循环衰竭循环衰竭研究不支持上述观点：动物实验不能验证；母体循研究不支持上述观点：动物实验不能验证；母体循研究不支持上述观点：动物实验不能验证；母体循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；病理学家环中都能找到胎儿细胞等；病理学家环中都能找到胎儿细胞等；病理学家环中都能找到胎儿细胞等；病理学家Steiner Steiner 和和和和 Luschbaugh Luschbaugh 发现很多死于其他疾病的孕产妇循发现很多死于其他疾病的孕产妇循发现很多死于其他疾病的孕产妇循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（环中都找到了胎儿细胞（环中都找到了胎儿细胞（环中都找到了胎儿细胞（fetal debrisfetal debris）；宫缩）；宫缩）；宫缩）；宫缩过强时子宫血流是停止的。过强时子宫血流是停止的。过强时子宫血流是停止的。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l l当前普遍认同的观点：AnaphylactoidSyndromeofPregnancy对胎儿抗原的异常的母体免疫（Abnormalmaternalimmuneresponsetothefetalantigenexposurecommontovirtuallyalllaboringwomen内源性的一系列免疫介质（endogenous-immunemediators)引起一系列的过敏反应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15Pathophysiologyl lToemphasizethatToemphasizethattheclinicalfindingstheclinicalfindingsaresecondarytoaresecondarytobiochemicalbiochemicalmediatorsrathermediatorsratherthanpulmonarythanpulmonaryembolicembolicphenomenon;Clarkphenomenon;Clarketalhavesuggestedetalhavesuggestedrenamingthisrenamingthisclinicalsyndromeclinicalsyndromethethe anaphylactoid anaphylactoid syndrome of syndrome of pregnancy pregnancy 羊水栓塞和子宫破裂16PathophysiologyToemphasizethPathophysiology呼吸循环衰竭呼吸循环衰竭呼吸循环衰竭呼吸循环衰竭:AmnioticfluidandfetalcellsentertheAmnioticfluidandfetalcellsenterthematernalmaternalcirculationcirculation biochemicalmediatorsbiochemicalmediators pulmonaryarteryvasospasmpulmonaryarteryvasospasm pulmonarypulmonaryhypertensionhypertensionelevatedrightelevatedrightventricularpressure(ventricularpressure(右心衰右心衰右心衰右心衰,三尖瓣关闭不全三尖瓣关闭不全三尖瓣关闭不全三尖瓣关闭不全)hypoxiahypoxiamyocardialandpulmonarymyocardialandpulmonarycapillarydamage(capillarydamage(左心灌注不良并缺氧左心灌注不良并缺氧左心灌注不良并缺氧左心灌注不良并缺氧)leftleftheartfailureheartfailureacuterespiratorydistressacuterespiratorydistresssyndromesyndrome 凝血功能障碍凝血功能障碍凝血功能障碍凝血功能障碍:biochemicalmediatorsbiochemicalmediators 消耗凝血物质消耗凝血物质消耗凝血物质消耗凝血物质,血血血血小板聚集小板聚集小板聚集小板聚集 DICDICmassivehemorrhageandmassivehemorrhageanduterineatony.uterineatony.羊水栓塞和子宫破裂17Pathophysiology呼吸循环衰竭:羊水栓塞和子Clinicalpresentation发生于分娩过程中、产后即刻，可以发生发生于分娩过程中、产后即刻，可以发生于正常分娩、引产、死胎等于正常分娩、引产、死胎等 (1)Respiratorydistress(2)Cyanosis(3)Cardiovascularcollapsecardiogenic shock(4)Hemorrhage(5)Coma.羊水栓塞和子宫破裂18Clinicalpresentation发生于分娩过程中、AmnioticFluidEmbolismSignsandSymptomsl lClarketal,Amnioticfluidembolism:analysisofanationalClarketal,Amnioticfluidembolism:analysisofanationalregistry.AmJObstetGynecol1995;172:1158-1169registry.AmJObstetGynecol1995;172:1158-1169羊水栓塞和子宫破裂19AmnioticFluidEmbolismSignsClinicalpresentationl lAsuddendropinO2saturationcanbetheinitialindicationofAFEduringc/s.l lsomepatientsdiewithinthefirsthour.l lOfthesurvivorswilldevelopDICwhichmaymanifestaspersistentbleedingfromincisionorvenipuncturesites.l l可以以可以以DIC为首发症状为首发症状羊水栓塞和子宫破裂20ClinicalpresentationAsuddenClinicalpresentationl l10-15%ofpatientswilldevelopseizures.l lCXRmaybenormalorshoweffusions,enlargedheart,orpulmonaryedema.l lECGmayshowarightstrainpatternwithST-Tchangesandtachycardia.l l超声心动：肺动脉高压，急性右心衰竭，超声心动：肺动脉高压，急性右心衰竭，1h后出现左心衰竭后出现左心衰竭羊水栓塞和子宫破裂21Clinicalpresentation10-15%ofDiagnosisl l诊断主要依靠临床表现：分娩过程中或产后诊断主要依靠临床表现：分娩过程中或产后诊断主要依靠临床表现：分娩过程中或产后诊断主要依靠临床表现：分娩过程中或产后4848小时内出小时内出小时内出小时内出现低血压、呼吸窘迫、现低血压、呼吸窘迫、现低血压、呼吸窘迫、现低血压、呼吸窘迫、DICDIC、抽搐、昏迷等不能用其他抽搐、昏迷等不能用其他抽搐、昏迷等不能用其他抽搐、昏迷等不能用其他原因解释原因解释原因解释原因解释(排除法排除法排除法排除法)l l临床化验：凝血分析、血气、血常规、心肌酶等临床化验：凝血分析、血气、血常规、心肌酶等临床化验：凝血分析、血气、血常规、心肌酶等临床化验：凝血分析、血气、血常规、心肌酶等l l胸片、经食道超声心动胸片、经食道超声心动胸片、经食道超声心动胸片、经食道超声心动l l非特异性的检验（非特异性的检验（非特异性的检验（非特异性的检验（testtest）：）：）：）：Findingsincludedmucin,Findingsincludedmucin,amorphouseosinophilicmaterial,andinsomeamorphouseosinophilicmaterial,andinsomecasessquamouscells.casessquamouscells.l lThepresenceofsquamouscellsinthepulmonaryThepresenceofsquamouscellsinthepulmonaryvasculatureonceconsideredpathognomonicforvasculatureonceconsideredpathognomonicforAFEisneithersensitivenorspecific(only73%ofAFEisneithersensitivenorspecific(only73%ofpatientsdyingfromAFEhadthisfinding).patientsdyingfromAFEhadthisfinding).l lThemonoclonalantibodyTKH-2ThemonoclonalantibodyTKH-2（一种胎儿抗原）（一种胎儿抗原）（一种胎儿抗原）（一种胎儿抗原）mayeventuallyprovemoreusefulintherapidmayeventuallyprovemoreusefulintherapiddiagnosisofAFE.diagnosisofAFE.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4LaboratoryinvestigationsinsuspectedAFENon specificcompletebloodcompletebloodcountcountcoagulationcoagulationparametersparametersincludingFDP,includingFDP,fibrinogenfibrinogenarterialbloodgasesarterialbloodgaseschestx-raychestx-rayelectrocardiogramelectrocardiogramV/QscanV/QscanechocardiogramechocardiogramSpecificSpecificl lserumtryptaseserumtryptasel lserumsialylTnserumsialylTnantigenantigen（一种胎儿抗原）（一种胎儿抗原）（一种胎儿抗原）（一种胎儿抗原）l lzinccoproporphyrinzinccoproporphyrin（粪卟啉原）（粪卟啉原）（粪卟啉原）（粪卟啉原）l l补体补体补体补体C3C3和和和和C4C4（敏感性（敏感性（敏感性（敏感性88100%88100%，特异性，特异性，特异性，特异性100)100)羊水栓塞和子宫破裂23LaboratoryinvestigationsinDifferentialdiagnosisObviouslydependsuponpresentationObviouslydependsuponpresentationl lDrug-inducedDrug-inducedallergicallergicAnaphylaxisAnaphylaxisl lPulmonaryPulmonarythromboembolismthromboembolismAspirationAspirationl lAirembolismAirembolisml lMyocardialMyocardialinfarctioninfarctionl lAnestheticAnestheticcomplicationscomplicationsl lUterineruptureUterinerupturel lPlacentaabruptionPlacentaabruptionl lPre-eclampsiaorPre-eclampsiaoreclampsia(Fits,eclampsia(Fits,Coagulopathy)Coagulopathy)l lHaemorrhageHaemorrhage l lSepticshockSepticshockl lDrugtoxicityDrugtoxicity(MgSO(MgSO4 4）羊水栓塞和子宫破裂24DifferentialdiagnosisObviouManagementofAFEGOALSOFMANAGEMENT:GOALSOFMANAGEMENT:l lRestorationofcardiovascularandRestorationofcardiovascularandpulmonaryequilibriumpulmonaryequilibrium-Maintainsystolicbloodpressure-Maintainsystolicbloodpressure90mmHg.90mmHg.-Urineoutput25ml/hr-Urineoutput25ml/hr-ArterialpO-ArterialpO2260mmHg.60mmHg.肺动脉导管指导血液动力学的处理和监测血气肺动脉导管指导血液动力学的处理和监测血气肺动脉导管指导血液动力学的处理和监测血气肺动脉导管指导血液动力学的处理和监测血气l lRe-establishinguterinetoneRe-establishinguterinetonel lCorrectcoagulationabnormalitiesCorrectcoagulationabnormalities羊水栓塞和子宫破裂25ManagementofAFEGOALSOFMANAManagementofAFEl lAsintubationandCPRmayberequireditisAsintubationandCPRmayberequireditisnecessarytohaveeasyaccesstothepatient,necessarytohaveeasyaccesstothepatient,experiencedhelp,andaresuscitationtrayexperiencedhelp,andaresuscitationtraywithintubationequipment,DCshock,andwithintubationequipment,DCshock,andemergencymedications.emergencymedications.l lIMMEDIATEMEASURES:IMMEDIATEMEASURES:-SetupIVInfusion,O-SetupIVInfusion,O2 2administration.administration.-Airwaycontrol-Airwaycontrolendotrachealintubationendotrachealintubationmaximalventilationandoxygenation.maximalventilationandoxygenation.l lLABS:LABS:CBC,ABG,PT,PTT,fibrinogen,FDP.CBC,ABG,PT,PTT,fibrinogen,FDP.羊水栓塞和子宫破裂26ManagementofAFEAsintubationManagementofAFEl lTreathypotension,increasetheTreathypotension,increasethecirculatingvolumeandcardiacoutputcirculatingvolumeandcardiacoutputwithcrystalloids.withcrystalloids.l lAftercorrectionofhypotension,restrictAftercorrectionofhypotension,restrictfluidtherapytomaintenancelevelssincefluidtherapytomaintenancelevelssinceARDSfollowsinupto40%to70%ofARDSfollowsinupto40%to70%ofcases.cases.l lSteroidsmaybeindicated(recommendedSteroidsmaybeindicated(recommendedbutnoevidenceastotheirvalue)butnoevidenceastotheirvalue)l lDopamineinfusionifpatientremainsDopamineinfusionifpatientremainshypotensivehypotensive(myocardialsupport).(myocardialsupport).羊水栓塞和子宫破裂27ManagementofAFETreathypotenManagementofAFEIntheICUl lToassesstheeffectivenessoftreatmentandToassesstheeffectivenessoftreatmentandresuscitation,itisprudenttocontinuouslyresuscitation,itisprudenttocontinuouslymonitorECG,pOmonitorECG,pO2 2,CO,CO2 2,andurineoutput.,andurineoutput.l lThereissupportinliteratureforearlyplacementThereissupportinliteratureforearlyplacementofarterial,centralvenous,andpulmonaryarteryofarterial,centralvenous,andpulmonaryarterycatheterstoprovidecriticalinformationandguidecatheterstoprovidecriticalinformationandguidespecifictherapy.specifictherapy.羊水栓塞和子宫破裂28ManagementofAFEIntheICUToManagementofAFEIntheICUl lCentralvenouspressuremonitoringisimportanttoCentralvenouspressuremonitoringisimportanttodiagnoserightventricularoverloadandguidefluiddiagnoserightventricularoverloadandguidefluidinfusionandvasopressortherapy.Bloodcanalsobeinfusionandvasopressortherapy.Bloodcanalsobesampledfromtherightheartfordiagnosticsampledfromtherightheartfordiagnosticpurposes.purposes.l lPulmonaryarteryandcapillarywedgepressuresandPulmonaryarteryandcapillarywedgepressuresandechocardiographyareusefultoguidetherapyandechocardiographyareusefultoguidetherapyandevaluateleftventricularfunctionandcompliance.evaluateleftventricularfunctionandcompliance.l lAnarteriallineisusefulforrepeatedbloodsamplingAnarteriallineisusefulforrepeatedbloodsamplingandbloodgasestoevaluatetheefficacyofandbloodgasestoevaluatetheefficacyofresuscitation.resuscitation.羊水栓塞和子宫破裂29ManagementofAFEIntheICUCeManagement of AFE CoagulopathyDICresultsinthedepletionoffibrinogen,platelets,andcoagulationfactors,especiallyfactorsV,VIII,andXIII.Thefibrinolyticsystemisactivatedaswell.Mostpatientswillhavehypofibrinogenemia,abnormalPTandaPTTandlowPlateletcountsfibrinogen level，补充纤维蛋白原和血小板，补充纤维蛋白原和血小板羊水栓塞和子宫破裂30ManagementofAFECoagulopathRestorationofuterinetonel lUterineatonyisbesttreatedwithmassage,Uterineatonyisbesttreatedwithmassage,uterinepacking,andoxytocinorprostaglandinuterinepacking,andoxytocinorprostaglandinanalogues.analogues.l lHysterectomymaybenecessaryHysterectomymaybenecessaryl lImprovementincardiacoutputanduterineImprovementincardiacoutputanduterineperfusionhelpsrestoreuterinetone.perfusionhelpsrestoreuterinetone.l lExtremecareshouldbeexercisedwhenusingExtremecareshouldbeexercisedwhenusingprostaglandinanaloguesinhypoxicpatients,asprostaglandinanaloguesinhypoxicpatients,asbronchospasmmayworsenthesituation.bronchospasmmayworsenthesituation.羊水栓塞和子宫破裂31RestorationofuterinetoneUtSympathomimetic Vasopressor agentDopamineDopamineincreasesmyocardialcontractilityandsystolicBPwithlittleincreaseindiastolicBP.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32SympathomimeticVasopressorag羊水栓塞和子宫破裂培训ppt课件33FurtherissuesintheManagementl lTransfer:Transfer:Transfertoalevel3hospitalmayberequiredTransfertoalevel3hospitalmayberequiredoncethepatientisstable.oncethepatientisstable.l lPrevention:Prevention:AmnioticfluidembolismisanunpredictableAmnioticfluidembolismisanunpredictableevent.event.l lRiskofRiskofrecurrencerecurrenceisunknown.Theisunknown.Therecommendationforelectivecesareanrecommendationforelectivecesareandeliveryduringfuturepregnanciesinandeliveryduringfuturepregnanciesinanattempttoavoidlaboriscontroversial.attempttoavoidlaboriscontroversial.l lPerimortemcesareandelivery:Perimortemcesareandelivery:After5minutesofunsuccessfulCPRinAfter5minutesofunsuccessfulCPRinarrestedmothers,abdominaldeliveryisarrestedmothers,abdominaldeliveryisrecommended.recommended.羊水栓塞和子宫破裂34FurtherissuesintheManagemeMedical/LegalPitfallsFailuretorespondemergentlyisapitfall.AFEisaclinicaldiagnosis.Stepsmustbetakentostabilizethepatientassoonassymptomsmanifest.Failuretoperformperimortemcesareandeliveryinatimelyfashionisapitfall.Failuretoconsiderthediagnosisduringlegalabortionisapitfall.AreviewoftheliteratureindicatesthatmostcasereportsofAFEhaveoccurredduringlatesecond-trimesterabortions.羊水栓塞和子宫破裂35Medical/LegalPitfallsFailureSUMMARYAFEisasuddenandunexpectedrarebutlifethreateningcomplicationofpregnancy.Ithasacomplexpathogenesisandseriousimplicationsforbothmotherandinfant.Associatedwithhighratesofmortalityandmorbidity.Diagnosisofexclusion.SuspectAFEwhenconfrontedwithanypregnantpatientwhohassuddenonsetofrespiratorydistress,cardiaccollapse,seizures,unexplainedfetaldistress,andabnormalbleedingObstetriciansshouldbealerttothesymptomsofAFEandstriveforpromptandaggressivetreatment.羊水栓塞和子宫破裂36SUMMARYAFEisasuddenandune子宫破裂UterineRupture时春艳羊水栓塞和子宫破裂羊水栓塞和子宫破裂3737子宫破裂UterineRupture时春艳羊水栓塞和子DefinitionNonsurgical complete disruption of all uterine Nonsurgical complete disruption of all uterine layers which usually leads to bleeding and layers which usually leads to bleeding and extrusion of all or part of the fetal-placental extrusion of all or part of the fetal-placental unit.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)(uterine rupture)Classified:Classified:Complete:all layers of the uterine wall seperated Complete:all layers of the uterine wall seperated Incomplete(uterine dehisence):uterine muscle Incomplete(uterine dehisence):uterine muscle separated but visceral peritoneum intact)separated but visceral peritoneum intact)dehiscence(dehiscence(静止裂开）静止裂开）静止裂开）静止裂开）describespartialseparationofthedescribespartialseparationofthescarwithminimalbleeding,withtheperitoneumandfetalscarwithminimalbleeding,withtheperitoneumandfetalmembranesremainingintact.membranesremainingintact._ _羊水栓塞和子宫破裂38DefinitionNonsurgicalcompletThereportedincidence：forallforallpregnanciespregnanciesis0.05%is0.05%AfteronepreviouslowersegmentcesareansectionAfteronepreviouslowersegmentcesareansection0.8%0.8%After two previous After two previous lowersegmentcesareansectionislowersegmentcesareansectionis5%5%plicatedbyuterinerupture.羊水栓塞和子宫破裂39Thereportedincidence：羊水栓塞和子宫Etiologyandhighrisksl l多发生在分娩期，与阻塞性分娩、不适当难产手多发生在分娩期，与阻塞性分娩、不适当难产手多发生在分娩期，与阻塞性分娩、不适当难产手多发生在分娩期，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术、滥用宫缩剂、妊娠子宫外伤和子宫手术瘢痕术、滥用宫缩剂、妊娠子宫外伤和子宫手术瘢痕术、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。子愈合不良等因素有关，个别发生在晚期妊娠。子愈合不良等因素有关，个别发生在晚期妊娠。子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，常引起母儿死宫破裂为产科最严重并发症之一，常引起母儿死宫破裂为产科最严重并发症之一，常引起母儿死宫破裂为产科最严重并发症之一，常引起母儿死亡。亡。亡。亡。l l92%occurred in women with a prior cesarean birth.羊水栓塞和子宫破裂40Etiologyandhighrisks多发生在分娩期ClinicalfindingsRuptureoftheunscarreduterus:twophasel lthreatenedruptureoftheuterusPathologiccontractionringl lRuptureofuterus羊水栓塞和子宫破裂41ClinicalfindingsRuptureofthClinicalmanifestationsofuterinerupture Fetalbradycardia Variableorlatedecelerations Maternalhypotension/shock Vaginalbleeding Cessationofcontractions Lossofstation/fetalpresentingpart Abdominalpain羊水栓塞和子宫破裂42ClinicalmanifestationsofuteComplicationsofuterinerupture Maternalmortalityveryrare Fetalmorbidity/mortalitymorecommon-Fetalasphyxiaoccursin5%-Perinatalmorbidity/mortalityhighestwhenfetusextrudedintoabdomenorwhenintervalbetweenbradycard