羊水栓塞和子宮破裂培訓(xùn)課件

1、羊水栓塞和子宮破裂羊水栓塞和子宮破裂Case Presentation(1)31y, G2P0Admitted to L&D with 40+3 Oxytocin inductionC/S for the arresting of the active stage羊水栓塞和子宮破裂2Case Presentation(1)羊水栓塞和子宮破裂2Case Presentation(1)After the baby was deliveredSudden onset:Cough dyspnea mild seizureHR(120), BP (7080/3050)Postpartum heamorr

2、ahage :2200ml Coagulopathy: FIB:1.64, PT14.1s, Hb 69,BPC:9.2羊水栓塞和子宮破裂3Case Presentation(1)After the Case Presentation(1)Diagnosis: Amniotic fluid embolismTreatment:Prognosis: Recovery羊水栓塞和子宮破裂4Case Presentation(1)羊水栓塞和子宮破裂4Case Presentation(2)26year G2P0Admitted because of PROM at 5amAt 7:am she had

3、 uterus constractionAt 7:30am she sudden complained of dyspnea and immediately comaSummon for help 羊水栓塞和子宮破裂5Case Presentation(2)羊水栓塞和子宮破裂5Case Presentation(3)36 years old,G3P1Induction for 41weeksAfter the baby was delivered by spontaneous vaginallyMassive vagina hemoarrhage BPUterus hysterectomy b

4、ut die from DIC and multi-organ failure羊水栓塞和子宮破裂6Case Presentation(3)羊水栓塞和子宮破裂6Case Presentation(4)43 years oldTermination of pregnancy because of the fetal abnormality at 33 weeks of gestationDyspnea before the delivery of the babyBP ,Postpartum Hemorrhage,comaDiagnosis: amniotic fluid embolism羊水栓塞

5、和子宮破裂7Case Presentation(4)43 years oDEFINITION羊水栓塞(amniotic fluid embolism) 在分娩過程中(產(chǎn)程中、產(chǎn)后，最遲產(chǎn)后48h內(nèi)）突然出 現(xiàn)的: 急性呼吸困難、 休克、循環(huán)衰竭、 彌散性血管內(nèi)凝血(DIC)、 腎功衰竭 或突發(fā)死亡的分娩嚴(yán)重并發(fā)癥。羊水栓塞和子宮破裂8DEFINITION羊水栓塞(amniotic fluid AFE的認(rèn)識過程AFE is thought to occur when amniotic fluid , fetal cells, hair, or other debris enter the mat

6、ernal circulation.Ricardo Meyer (1926); 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 cau

7、ses 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.羊水栓塞和子宮破裂9AFE的認(rèn)識過程AFE is thought to occu發(fā)生率 Overall incidence ranges from 1 in 8,000 to 1 in 80,000 pregnancies. The Incide

8、nce in our department:1:8000 England:1:56500, American:1:12953 美國3百萬分娩的統(tǒng)計顯示7.7/10萬14% of maternal deaths in USA(第二位的死亡原因) & 5.3% in U.K. 美國的孕產(chǎn)婦死亡率6.6/10萬 我國統(tǒng)計? 第二或第三位的原因The first well-documented case with ultimate survival was published in 1976 (Resnik R, et al. Obstet Gynecol 1976;47:295-8). 羊水栓塞和子

9、宮破裂10發(fā)生率 Overall incidence rangMaternal 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 inc

10、ur neurologic damage.羊水栓塞和子宮破裂11Maternal fatality rate:1330%羊 AMNIOTIC FLUID EMBOLISMTime 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.羊水栓塞和子宮破裂12 AMNIOTIC FLUID

11、EMBOLISMTime Risk factors of AFEAdvanced maternal ageMultiparity Meconium Cervical lacerationVery strong frequent or uterine tetanic contractionsSudden foetal expulsion (short labour)Placenta abnormalityPolyhydramnios Uterine ruptureMaternal history of allergy or atopy ChorioamnionitisMacrosomia Mal

12、e fetal sex Oxytocin (controversial)Operative deliveriesNevertheless, these and other frequently cited risk factors are not consistently observed and at the present time Experts agree that this condition is not preventable.羊水栓塞和子宮破裂13Risk factors of AFEAdvanced ma病理傳統(tǒng)的觀點：羊水中的有形物質(zhì)進(jìn)入母體循環(huán)引起肺毛細(xì)血管的物理性的阻塞

13、 循環(huán)衰竭研究不支持上述觀點：動物實驗不能驗證；母體循環(huán)中都能找到胎兒細(xì)胞等；病理學(xué)家Steiner 和 Luschbaugh 發(fā)現(xiàn)很多死于其他疾病的孕產(chǎn)婦循環(huán)中都找到了胎兒細(xì)胞（fetal debris）；宮縮過強(qiáng)時子宮血流是停止的。 羊水栓塞和子宮破裂14病理傳統(tǒng)的觀點：羊水中的有形物質(zhì)進(jìn)入母體循環(huán)引起肺毛細(xì)血管的病理當(dāng)前普遍認(rèn)同的觀點： Anaphylactoid Syndrome of Pregnancy對胎兒抗原的異常的母體免疫（Abnormal maternal immune response to the fetal antigen exposure common to virt

14、ually all laboring women 內(nèi)源性的一系列免疫介質(zhì)（endogenous-immune mediators) 引起一系列的過敏反應(yīng)羊水栓塞和子宮破裂15病理當(dāng)前普遍認(rèn)同的觀點：羊水栓塞和子宮破裂15PathophysiologyTo emphasize that the clinical findings are secondary to biochemical mediators rather than pulmonary embolic phenomenon; Clark et al have suggested renaming this clinical synd

15、rome the anaphylactoid syndrome of pregnancy 羊水栓塞和子宮破裂16PathophysiologyTo emphasize thPathophysiology呼吸循環(huán)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,三尖瓣關(guān)閉不全) hypoxia

16、 myocardial and pulmonary capillary damage(左心灌注不良并缺氧) left heart failure acute respiratory distress syndrome 凝血功能障礙: biochemical mediators 消耗凝血物質(zhì),血小板聚集 DICmassive hemorrhage and uterine atony.羊水栓塞和子宮破裂17Pathophysiology呼吸循環(huán)衰竭:羊水栓塞和子Clinical presentation發(fā)生于分娩過程中、產(chǎn)后即刻，可以發(fā)生于正常分娩、引產(chǎn)、死胎等 (1) Respiratory d

17、istress(2) Cyanosis(3) Cardiovascular collapse cardiogenic shock(4) Hemorrhage (5) Coma. 羊水栓塞和子宮破裂18Clinical presentation發(fā)生于分娩過程中、Amniotic Fluid EmbolismSigns and SymptomsClark et al, Amniotic fluid embolism: analysis of a national registry. Am J Obstet Gynecol 1995;172:1158-1169羊水栓塞和子宮破裂19Amniotic

18、Fluid EmbolismSignsClinical presentationA 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為首發(fā)癥狀 羊水栓塞和子宮破裂20Clini

19、cal presentationA sudden Clinical presentation10-15% 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.超聲心動：肺動脈高壓，急性右心衰竭，1h后出現(xiàn)左心衰竭 羊水栓塞和子宮破裂21Clinical presentation10-15% ofD

20、iagnosis 診斷主要依靠臨床表現(xiàn)：分娩過程中或產(chǎn)后48小時內(nèi)出現(xiàn)低血壓、呼吸窘迫、DIC、抽搐、昏迷等不能用其他原因解釋(排除法)臨床化驗：凝血分析、血氣、血常規(guī)、心肌酶等胸片、經(jīng)食道超聲心動非特異性的檢驗（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 A

21、FE is neither sensitive nor specific (only 73% of patients dying from AFE had this finding).The monoclonal antibody TKH-2 （一種胎兒抗原）may eventually prove more useful in the rapid diagnosis of AFE. 羊水栓塞和子宮破裂22Diagnosis 診斷主要依靠臨床表現(xiàn)：分娩過程中或產(chǎn)后4Laboratory investigations in suspected AFENon specific complete b

22、lood count coagulation parameters including FDP, fibrinogen arterial blood gases chest x-ray electrocardiogram V/Q scan echocardiogramSpecificserum tryptaseserum sialyl Tn antigen（一種胎兒抗原）zinc coproporphyrin（糞卟啉原）補(bǔ)體C3和C4（敏感性88100%，特異性100)羊水栓塞和子宮破裂23Laboratory investigations in Differential diagnosisO

23、bviously depends upon presentationDrug-induced allergic Anaphylaxis Pulmonary thromboembolism Aspiration Air embolism Myocardial infarctionAnesthetic complicationsUterine rupture Placenta abruptionPre-eclampsia or eclampsia (Fits, Coagulopathy)Haemorrhage Septic shockDrug toxicity (MgSO4）羊水栓塞和子宮破裂24

24、Differential diagnosisObviouManagement of AFEGOALS 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.肺動脈導(dǎo)管指導(dǎo)血液動力學(xué)的處理和監(jiān)測血氣Re-establishing uterine toneCorrect coagulation abnormalities羊水栓塞和

25、子宮破裂25Management of AFEGOALS OF MANAManagement of AFEAs 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 admin

26、istration. - Airway control endotracheal intubation maximal ventilation and oxygenation.LABS : CBC,ABG,PT,PTT,fibrinogen,FDP.羊水栓塞和子宮破裂26Management of AFEAs intubationManagement of AFETreat hypotension, increase the circulating volume and cardiac output with crystalloids.After correction of hypotensi

27、on, 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).羊水栓塞和子宮破裂27Management of AFETreat hypotenManagement of AFEIn

28、 the ICUTo 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

29、therapy.羊水栓塞和子宮破裂28Management of AFEIn the ICUToManagement of AFEIn the ICUCentral 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

30、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.羊水栓塞和子宮破裂29Management of AFEIn the ICUCeManagement of

31、AFE CoagulopathyDIC 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 ，補(bǔ)充纖維蛋白原和血小板羊水栓

32、塞和子宮破裂30Management of AFE CoagulopathRestoration of uterine tone Uterine atony is best treated with massage, uterine packing, and oxytocin or prostaglandin analogues.Hysterectomy may be necessaryImprovement in cardiac output and uterine perfusion helps restore uterine tone.Extreme care should be exe

33、rcised when using prostaglandin analogues in hypoxic patients, as bronchospasm may worsen the situation.羊水栓塞和子宮破裂31Restoration of uterine tone UtSympathomimetic Vasopressor agentDopamineDopamine increases myocardial contractility and systolic BP with little increase in diastolic BP. Also dilates the

34、 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 inf

35、usion, correct hypovolemia with either whole blood or plasma, as indicated; monitoring central venous pressure or left ventricular filling pressure may be helpful羊水栓塞和子宮破裂32Sympathomimetic Vasopressor ag羊水栓塞和子宮破裂培訓(xùn)課件Further issues in the ManagementTransfer: Transfer to a level 3 hospital may be requ

36、ired 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 unsu

37、ccessful CPR in arrested mothers, abdominal delivery is recommended.羊水栓塞和子宮破裂34Further issues in the ManagemeMedical/Legal PitfallsFailure 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 per

38、imortem 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.羊水栓塞和子宮破裂35Medical/Legal PitfallsFailure SUMMARYAF

39、E 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 ha

40、s 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. 羊水栓塞和子宮破裂36SUMMARYAFE is a sudden and une子宮破裂Uterine Rupture 時春艷羊水栓塞和子宮破裂37子宮破裂Ut

41、erine Rupture 時春艷羊水栓塞和子 DefinitionNonsurgical complete disruption of all uterine layers which usually leads to bleeding and extrusion of all or part of the fetal-placental unit. 子宮體部或子宮下段在妊娠期或分娩期發(fā)生破裂稱為子宮破裂(uterine rupture)Classified: Complete : all layers of the uterine wall seperated Incomplete (ut

42、erine dehisence): uterine muscle separated but visceral peritoneum intact) dehiscence(靜止裂開） describes partial separation of the scar with minimal bleeding, with the peritoneum and fetal membranes remaining intact. _羊水栓塞和子宮破裂38 DefinitionNonsurgical completThe reported incidence：for all pregnancies i

43、s 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.羊水栓塞和子宮破裂39The reported incidence：羊水栓塞和子宮Etiology and high risks多發(fā)生在分娩期，與阻塞性分娩、不適當(dāng)難產(chǎn)手術(shù)、濫用宮縮劑、妊娠子宮外傷和子宮手術(shù)瘢痕愈合

44、不良等因素有關(guān)，個別發(fā)生在晚期妊娠。子宮破裂為產(chǎn)科最嚴(yán)重并發(fā)癥之一，常引起母兒死亡。92% occurred in women with a prior cesarean birth.羊水栓塞和子宮破裂40Etiology and high risks多發(fā)生在分娩期Clinical findingsRupture of the unscarred uterus: two phase threatened rupture of the uterus Pathologic contraction ring Rupture of uterus羊水栓塞和子宮破裂41Clinical findingsRupture of thClinical manifestations of