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单击此处编辑母版标题样式,编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,大家好,1,大家好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,2,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,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。,3,一、妊娠和产褥期蛛网膜下腔出血 是指发生在整个妊娠期,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。,4,二、流行病学及病因妊娠和产褥期蛛网膜下腔出血发病率约1/10,Perimesencephalic Subarachnoid,emorrhage,Case 1,40Y Headache gestational age(GA)of 8 weeks and 4 days,5,Perimesencephalic Subarachnoid,6,6,32,Y,Headache,9th week of pregnancy,seizure,loss of consciousness,7,32Y,Headache,9th week of pregn,Eclamptic subarachnoid haemorrhage,32,Y,G1P0,Five days after delivery severe pounding pain over the vertex nausea 95/60-130/74,8,Eclamptic subarachnoid haemorr,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,/100,0,00。,动脉瘤性SAH的引起的妊娠期妇女死亡率约13%-15%。,妊娠不会增加动脉瘤的破裂机率。,9,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,10,10,11,11,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 maternal mortality rate of 50%to 68%.,R,ebleeding within 3 to,8 weeks of initial treatment,.,12,Cerebral aneurysms in the ante,13,13,三,、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。,14,三、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,辅助检查,首选,C,T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。,15,辅助检查首选CT检查，在放射吸收剂量50mGY下不会增加胎,鉴别诊断,先兆子痫和子痫的临床表现很相似，难以鉴别。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,。,16,鉴别诊断先兆子痫和子痫的临床表现很相似，难以鉴别。研究显示，,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。,17,四、治疗与非妊娠期动脉瘤性SAH处理类似。17,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。,18,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,动脉瘤的手术方式,动脉瘤夹闭术,动脉瘤栓塞术,19,动脉瘤的手术方式动脉瘤夹闭术19,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。,20,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,21,21,22,22,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。,23,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。23,24,24,术中射线影响及防护,E,mbryogenesis(first two weeks of pregnancy),the death of the embryo.,During organogenesis(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.,25,术中射线影响及防护Embryogenesis(first,8 to 25 weeks,the central nervous system(CNS)is particularly sensitive 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 retardation.,26,8 to 25 weeks,the central ner,S,hielding 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,the radiation effect is so small that termination of pregnancy is not justified.,27,Shielding patients lower abd,21,Y,headache,29th week of pregnancy,caesarian section at the 38th week of gestation,28,21Y,headache,29th week of pre,39,Y,18th gestational week,headache,delivered a healthy male infant 4 months,29,39Y,18th gestational week,head,34,Y16th gestational week drowsy level of consciousness after experiencing a generalseizure,30,34Y16th gestational week drows,Five coils,cesarean section at the 38th week,31,Five coils,cesarean section a,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。,该阶段以颈内动脉瘤为常见，破裂时期以妊娠第3个3月为常见，妊娠期再破裂机率高，死亡率高。,诊断要结合临床表现及影像学检查。,治疗方面，积极治疗，手术方式可选择夹闭术及栓塞术，可视情况选择手术方式，并做好胎儿监测及相关防护。,妊娠16周进行手术且母子平安的病例是笔者能查到最早的病例。,32,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,
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