羊水栓塞2011八年制.pptVIP

Zhu Jieping Shanghai Jiaotong University Affiliated Sixth Peoples Hospital, Dept of Obs Gyn The entry of amniotic fluid into the maternal circulation leads to sequelae of clinical events, eg, sudden onset of severe dyspnea(呼吸困难), cyanosis(紫绀) and disseminated intravascular coagulation (DIC，弥散性血管内凝血). Occurs during labor, delivery or early puerperium. A rare but FATAL obstetric emergency, leads to severe maternal morbidity and mortality. Incidence: 1: 8000 to 1: 80,000 deliveries 70% : occurred during labor 19% : occurred during caesarean delivery 11% : occurred after vaginal delivery Risk factors: High pressure in amniotic cavity Rupture of the fetal membranes Rupture of placental sinus 1. PAH: pulmonary arterial hypertension 肺动脉高压 右心负荷加重 右心扩张 充血性右心衰竭 左心回心血量减少 左心排出量减少 周围循环衰竭 循环衰竭 休克 PAH 羊水中的有形物质→肺小血管机械性阻塞 血管活性物质 →肺血管痉挛 血小板释放血清素→肺动脉痉挛 2. Anaphylactic shock I型变态反应：平滑肌痉挛、毛细血管扩张，过敏性休克 3. DIC 羊水中促凝物质→激活外源性凝血系统→微血栓形成→消耗大量凝血因子和纤维蛋白原→DIC 4. MOF (multiple organ failure) 急性肝肾功能衰竭 Cardiorespiratory failure Coagulopathy, DIC RENAL FAILURE Cough Dyspnea 呼吸困难 Hypotension Cyanosis 紫绀 Oliguria Anuria Maternal Mortality Rate over 60% Am J Obstet Gynecol 1995;172:1158 Signs or symptoms Frequency Hypotension (低血压) 100% Fetal distress （胎窘） 100% Pulmonary edema or ARDS （肺水肿/呼吸窘迫综合症） 93% Cardiopulmonary arrest （心跳呼吸骤停） 87% Cyanosis （紫绀） 83% Coagulopathy （凝血障碍） 83% Dyspnea （呼吸困难） 49% Seizure （抽搐） 48% Uterine atony （宫缩乏力） 23% Bronchospasm （支气管痉挛） 15% Transient hypertension （一过性高血压） 11% Cough 7% Headache 7% Chest pain 2% Lab: Coagulant function DIC :① PLT＜100×109/L or decreased progressively ② Fibrinogen ＜1.5g/L ③ PT(prothrombin time)＞15sec ④ 3P test (+) ⑤ Test tube method ＞30min ⑥ Blood smear 血涂片可见破碎的红细胞。 Test tube method ：venous blood 5ml 凝血时间 min 纤维蛋白含量 g/L 6~10 正常 10~15 1.5 15~30 1.0~1.5 30 1.0 Obstetric causes Acute hemorrhage Placental abruption Uterine rupture Uterine atony Eclam