麻醉及麻醉药对胎儿和新生儿的影响-首都医大

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,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,*,麻醉及麻醉药对胎儿和新生儿的影响,首都医科大学北京妇产医院,徐铭军,胎盘屏障与胎盘血液循环,一、胎盘与胎盘屏障,胎盘是哺乳动物妊娠期特有的器官，它连接母体与胎儿，通过子宫和滋养层血管化部分的对合，实现提供内分泌激素，,选择性交换可溶性非颗粒物质，,保证胎儿的正常营养供应和废物排泄。,胎盘屏障与胎盘血液循环,围 产 期 药 理 学,围产期药理学：涉及药物在母亲及胎儿两者体内的吸收、分布、生物转化及排泄。,围产期 ：,胎盘药物转运的决定因素：母体、胎盘、胎儿三方面因素来决定。,围 产 期 药 理 学,母体因素,剂量：,注射部位：,佐剂：,药动学：,围 产 期 药 理 学,胎盘因素,扩散,主动运输,大量运输,吞饮作用,中断,围 产 期 药 理 学,胎盘因素,一、扩散,Fick公式 ：,Q/t=KA,（,Cm-Cf,）,/D,决定通透性的三个方面,分子量,通透性,脂溶性,离子化,麻醉药,分子量,蛋白结合率(%),脂溶性,盐酸利多卡因,288.82,70,2.9,盐酸丁卡因,300.83,76,80,盐酸布比卡因,342.91,95,28,盐酸罗哌卡因,328.93,94,-,丙泊酚,178.3,98,咪达唑仑,362.2,95,吗啡,23-26,枸橼酸芬太尼,528.60,84,舒芬太尼,578.69,93,瑞芬太尼,412.91,70,围 产 期 药 理 学,胎儿因素,一旦药物透过胎盘，胎儿对药物的摄取、分布、代谢、排泄决定药物的清除和生理作用。,流向胎盘组织物质交换部位的脐血流是影响胎儿药物摄取的根本因素。,胎儿红细胞和血清蛋白比母体红细胞和血清蛋白与局麻药的结合程度低。,胎儿药物代谢和排泄。,妊娠期麻醉及药物对胎儿的影响,妊娠期间接受外科手术：0.3%2.2%,未知妊娠接受外科手术：0.3%,1-2%的孕妇在孕期需要接受手术 ：,阑尾切除术（1:1500次妊娠）,胆囊切除术（1:2000-10000次妊娠）,妊娠期麻醉及药物对胎儿的影响,妊娠各孕期的孕妇常进行的外科手术,手术类型第一孕期第二孕期第三孕期,月（%） 46月（%） 79月（%）,CNS 6.7 5.4 5.6,耳鼻喉 7.6 6.4 9.5,腹部 19.9 30.1 22.6,泌尿生殖-妇科 10.6 23.3 24.4,腹腔镜检查 34.1 1.5 5.6,矫形外科 8.9 9.3 13.7,内镜检查 3.6 11 8.6,皮肤 3.8 3.2 4.1,Mazze RL,Kallen B:Reproductive outcome after anesthesia and operation during pregancy. A registry study of 5405 case. Am J Obstet Gynecol 161:1178-1185,1989.,妊娠期麻醉及药物对胎儿的影响,妊娠期麻醉及药物对胎儿的影响,麻醉医师应注意以下几点：,母体安全；,避免应用致畸药物；,避免发生胎儿宫内窘迫；,防止流产和早产。,剖宫产麻醉及药物对新生儿的影响,新生儿状况的评价指标:,Apgar评分,碳酸氢根,神经和适应能力评分（ NACS）,剖宫产麻醉及药物对新生儿的影响,Apgar Scoring,Sign,0 points,1 point,2 points,A,Activity(Muscle tone),limp,limbs flexed,active movement,P,Pulse(heart rate),absent, 100 /min,G,Grimace(response to smell or foot slap),absent,grimace,cough or sneeze (nose)cry and withdrawal of foot (foot slap),A,Appearance(color),blue,body pinkextremities blue,pink all over,R,Respiration(breathing),absent,irregularweak crying,good strong cry,FOR IMMEDIATE RELEASE,Stamp News Release #94-041,NEW STAMP SCORES A 10 ON THE APGAR SCALE,WASHINGTON, DC (AUGUST 15, 1994),A 20-cent definitive stamp honoring Dr.Viriginia Apgar will be issued,by the Postal Service on October 24, 1994. A first day of issue,ceremony for the new stamp will be held at the American Academy,of Pediatrics annual meeting in Dallas on October 24. Millions of,babies around the world have already been blessed with Dr.Apgars,ownstamp of approval. In 1953, she published the Apgar score, a simple,assessment method that allows doctors and nurses in the delivery room to make an immediate evaluation of a newborn babys general condition, aiding identification of those infants who need immediate medical attention. Dr. Apgar was born on June 7, 1909 in Westfield, New Jersey. She graduated from Mount Holyoke College in 1929 and went on to Columbia for her medical degree, and was the first women selected for a full professorship at Columbia University College of Physicians and Surgeons. She aspired to be a surgeon, and then moved into the then relatively new field of anesthesiology, placing special emphasis on the effects of obsteric anesthesia on newborn babies. Dr. Apgar continued her contributions to medicine by serving the National Foundation-March of Dimes, where she directed programs of research in the causes, prevention and treatment of birth defects. The Perinatal Sectiion of the American Academy of Pediatrics named its annual award to her. The Apgar Award is given annually to the person who has done the most to further the cause to care of newborn babies and their mothers. In addition to her medical achievements, Dr. Apgar was known for her sense of humor and empathy for humanity. Some of her other interests included chamber music and stamp collecting. As a prelude to the stamp dedication ceremony, a group of physicians/musicians called the Apgar String Quartest will perform some of Dr. Apgars favorite selections on instruments she crafted herself.,Dr. Apgar died on August 7, 1974.,剖宫产麻醉及药物对新生儿的影响,Brigham妇产医院,剖宫产麻醉及药物对新生儿的影响,476/510,93.3%,34/510,6.7%,剖宫产麻醉及药物对新生儿的影响,麻醉剂对孕妇及胎儿的影响（全身麻醉）,硫喷妥钠：,氯胺酮：,依托咪酯：,氧化亞氮：,卤化剂：,剖宫产麻醉及药物对新生儿的影响,丙泊酚,丙泊酚是美国FDA确认的对孕妇及胎儿不良影响比较小的一种麻醉药物。,丙泊酚在产妇全身麻醉中的应用以及对母体、胎儿的影响均有研究，认为采用常规剂量时，对胎儿、新生儿没有明显影响。,Hein HAT, Putman JM. Is propofol a proper proposition for reproductive procedures.J C lin Anesth, 1997, 9: 611-613.,宴馥霞.异丙酚在剖宫产全麻中的应用.国外医学麻醉学与复苏分册,1997, 18: 293-295.,Alcaraz AS, Quintana MB, Laguarda M. Placental transfer and neonatal effects of propofol in caesarean sectionJ Clin Phar Therapeut,i 1998, 3: 19-23.,剖宫产麻醉及药物对新生儿的影响,麻醉剂对孕妇及胎儿的影响（全身麻醉）,丙泊酚：UV/MA =0.7,100ug/Kg/min or 2.5 mg/Kg, ,150 ug/Kg/min,99.45,29.40min,3.36,1.87LKg,81.27,18.87min,2.66,0.63L/Kg,39.32,8.07ml/min/kg,29.40,8.72ml/min/kg,晏馥霞, 李树人.异丙酚在剖宫产全麻中的应用. 国外医学麻醉学与复苏分册,1997,18(5):293-295.,剖宫产麻醉及药物对新生儿的影响,瑞芬太尼,表 瑞芬太尼血液浓度与胎盘转运,n 瑞芬太尼,MA(ug/ml) 16 1.32,0.80,UV(ug/ml) 15 0.73,0.27,UA(ug/ml) 10 0.20,0.07,UV/MA 15 0.88,0.78,0.850.18,UA/UV 10 0.29,0.07,0.810.18,MA.母体动脉；UV，脐带静脉，UA，脐带动脉,Kan RE,Hughes SC,Rosen C,en MA,et al.Intravenenous remifentanil:Placental transfer,maternal and neonatal effects. Anesthesiology 1998;88:1467-1474.,剖宫产麻醉及药物对新生儿的影响,肌松药,肌松药由于其分子量大，蛋白结合率高，1025min内经胎盘转运至胎儿的量很小而并不具有临床效应。,Iwama H,Kaneko T,Tobishima S,et al. timedependency of the ratio of umbilical vein/maternalartery concentrations of vecuronium in cesarean section J. Acta Anesthsiol Scand,1999;43(1):9.,剖宫产麻醉及药物对新生儿的影响,表2两组新生儿NBNA测定结果比较(xs),组别分娩后天数总评分,第2天第14天第28天,E组,36.822.52 38.611.85 39.061.42 38.161.98,G组,38.171.50 39.451.02 39.780.4839.131.08,与硬膜外组相比,P0.05,剖宫产麻醉及药物对新生儿的影响,表 两组新生儿NBNA比较(分,xs),组别 行为能力 被动肌张力 主动肌张力 原始反射 一般状态 总分,G组 12607 7207 7406 5608 5903 38214,E组 13408 7305 7308 5606 5903 39516,李崇华,朱春仙,贺晶.,全身麻醉对剖宫产产妇分娩新生儿的影响.中华妇产科杂志,2006,41(3):162-164.,剖宫产麻醉及药物对新生儿的影响,剖宫产全身麻醉关键点：,时间：,10min,时间：,3min,Kamat SK,Shah MV,Chaudhary LS,et al. Effect of induction delivery and uterine-delivery on apgar scoring of the newbornJ,J Postgrad Med,1991;37:125.,剖宫产麻醉及药物对新生儿的影响,剖宫产麻醉及药物对新生儿的影响,术后镇痛对新生儿的影响,母乳是婴儿最理想的食品 。,术后镇痛利于泌乳素（PRL）的分泌，利于母乳喂养。,水溶性药物在初乳中浓度高，脂溶性药物在成熟乳汁中浓度较高。,术后镇痛对新生儿的影响,不同镇痛方式对剖宫产术后哺乳的影响,PCEA组：,芬太尼0.4 mg+氟哌利多2.5 mg + 0.75%布比卡因25 ml +生理盐水至100 ml持续剂量2 ml/h，PCA剂量05 ml/次。,PCIA组：芬太尼1.2mg +氟哌利多2.5 mg +生理盐水至100 ml持续剂量2.5ml/h,PCA剂量1.0ml/次。,术后镇痛对新生儿的影响,不同镇痛方式对剖宫产术后哺乳的影响,表1 两组产妇及新生儿尿液药物及代谢产物阳性率比较,新生儿尿液阳性率(% )产妇尿液阳性率(% ),硬膜外组4835 6032,静脉组8684 9718,P 001 001,术后镇痛对新生儿的影响,不同镇痛方式对剖宫产术后哺乳的影响,表2两组术后3小时新生儿呼吸、心率、睁眼时间、尿量比较,呼吸(分/次) 心率(分/次) 睁眼时间(分钟) 尿量(ml),硬膜外组 25.342.14 150.362.49 120.372.95 60.682.26,静脉组 26.511.84 153.271.92 121.361.84 61.821.67,t 1.61 1.78 1.92 1.54,P0.05,术后镇痛对新生儿的影响,不同镇痛方式对剖宫产术后哺乳的影响,表3,两组产妇术后1天泌乳量比较,开始泌乳时间(分钟) 喂养次数(次),硬膜外组 189.323.52 8.170.13,静脉组 185.645.65 7.460.69,t 1.74 1.68,P0.05,术后镇痛对新生儿的影响,药品说明书提示：如果哺乳期妇女必须使用舒芬太尼，则应在用药后24h方能再次哺乳婴儿。,舒芬太尼不经乳汁分泌对哺乳产妇是安全的。,分娩镇痛对新生儿的影响,妊娠期麻醉及药物对胎儿的影响,麻醉药物的致畸作用,阿片类药造成的低氧血症和高二氧化碳血症可能是实际上的致畸因素，而鸦片本身却不是。,芬太尼、舒芬太尼及阿芬太尼在大鼠不造成呼吸抑制，剂量多达500ug/kg的芬太尼（自孕前至整个孕期使用），100ug/kg的舒芬太尼及800ug/kg的阿芬太尼（后两种药均自妊娠第5天应用至20天），在大鼠中并无致畸作用。,妊娠期麻醉及药物对胎儿的影响,麻醉药物的致畸作用,笑气会使B12失活，而B12是蛋氨酸合成酶的主要辅助因子。蛋氨酸合成酶的暂时失活会影响叶酸代谢，并影响尿嘧啶与胸腺嘧啶的转化，因此影响DNA合成。,局麻药通过稳定细胞膜而发挥作用，理论上可能会影响细胞分裂及胚胎形成。,肌松药不能大量地通过胎盘。,妊娠期麻醉及药物对胎儿的影响,母体氧饱和度：,母体CO2分压：,母体低血压：,子宫血管收缩：,妊娠期麻醉及药物对胎儿的影响,个案报道提示：孕期进行手术及麻醉，会导致术后流产或早产。,在孕早期行卵巢囊肿切除术者，有较高的流产发病率。,妊娠各个时期均可安全地行腹腔镜手术。,麻醉是刺激还是抑制早产？,？,？,BACK,THANK YOU,谢谢观看,/,欢迎下载,BY FAITH I MEAN A VISION OF GOOD ONE CHERISHES AND THE ENTHUSIASM THAT PUSHES ONE TO SEEK ITS FULFILLMENT REGARDLESS OF OBSTACLES. BY FAITH I BY FAITH,内容总结,麻醉及麻醉药对胎儿和新生儿的影响。徐铭军。Fick公式 ：Q/t=KA（Cm-Cf）/D。胎儿红细胞和血清蛋白比母体红细胞和血清蛋白与局麻药的结合程度低。宴馥霞.异丙酚在剖宫产全麻中的应用.国外医学麻醉学与复苏分册,1997, 18: 293-295.。150 ug/Kg/min。29.408.72ml/min/kg。晏馥霞, 李树人.异丙酚在剖宫产全麻中的应用. 国外医学麻醉学与复苏分册,1997,18(5):293-295.。表 瑞芬太尼血液浓度与胎盘转运。李崇华,朱春仙,贺晶.全身麻醉对剖宫产产妇分娩新生儿的影响.中华妇产科杂志,2006,41(3):162-164.。表1 两组产妇及新生儿尿液药物及代谢产物阳性率比较。谢谢观看/欢迎下载,