丁正年羊水栓塞课件

羊水栓塞 住院医师规范化培训 南京医科大学第一附属医院麻醉科 丁正年 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水栓塞 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水栓塞 发病率：1/1.5万。 目前尚未完全清楚其机制。 发生率有争议，没有敏感而特异的方法来 确认羊水栓塞。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水栓塞调查分析 时机 - 产时 70%。 - 产后 11%。 - 剖宫产胎儿取出后19%。 可发生于宫腔内倒转病人。 可发生在人工破膜后。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水栓塞发生时机 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 相关因素 大龄产妇。 胎盘异常。 手术分娩。 子痫。 羊水过多。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 相关因素 宫颈撕裂。 子宫破裂等。 与产程和缩宫素无关。 男性胎儿有关。 41%的病人有过敏史。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水如何进入母体循环？ 有来源：（羊水），胎膜已经不完整。 有压力：（宫缩），促进羊水进入母体。 有路径：开放的子宫静脉窦（胎盘剥离）。 临产.具备上述三项条件，易于发生。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 临床表现 非特异性症状：寒战、恶心、呕吐、躁动 突发低血压、心跳停止。 突发低氧血症、呼吸困难、紫绀、呼吸停止。 凝血功能障碍、DIC、严重出血。 抽搐、昏迷，存活下来的人可能留有后遗症。也 可以直接进入抽搐、昏迷。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. N=60发生例数首发例数 母体出血391 低血压385 呼吸短促3712 出血不止370 不安、烦躁麻木、针刺感2818 胎儿窘迫2612 心跳停止245 心律失常163 抽搐94 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 纤维支气管镜（例） 粘膜充血。 粘膜下瘀点。 支气管肺泡冲洗液显示胎毛。 - 羊水栓塞 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水性状 妊娠早期：无色透明液体。 妊娠足月：羊水略混浊，不透明。 羊水比重：l.0071.025。 pH：中性或弱碱性，pH值为7.20。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 足月时的羊水 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水的作用 缓和外来冲击，避免胎儿受伤。 胎儿有一个活动的空间，方便胎儿肢体发育。 羊水减少妈妈对胎儿宫内活动时的不适。 。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水的生成 妊娠早期：母体血清经胎膜的透析液。 妊娠中期：胎儿尿液。 妊娠晚期：胎肺分泌600800ml/天。 羊膜、脐带、胎儿皮肤渗出液体少量。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水的吸收 胎膜吸收：约50。 脐带吸收：4050ml/h。 胎儿皮肤角化前可吸收羊水。 胎儿吞咽：500-700ml/24h。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水量 妊娠8周：510ml。 妊娠10周：约30ml。 妊娠20周：约400ml。 妊娠3638周：高峰，1000-1500ml。 妊娠足月：约800ml。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水成份 内含9899水分。 l2无机盐及有机物。 悬浮物：胎儿产物。 含大量激素和酶。 少量白细胞、白蛋白、尿酸盐。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水成份（生物学） 表面活性物质 内皮素 白三烯 白介素-1和TNF- 前列腺素类 花生四烯酸 促凝血酶原激酶 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 羊水成份（悬浮物） 胎毛、胎脂、胎垢 胎儿上皮 胎粪、胎儿肠粘蛋白 （胚胎）滋养层 引起肺血管机械性梗阻（作用较小） Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 兔羊水栓塞试验 18只怀孕24天家兔。 剖宫产取出羊水和胎盘。 实验液体：生理盐水（NS）、羊水（AF)、混有胎 盘提取液的羊水（PAF)。 注射：经耳缘静脉注入血液循环。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 兔羊水栓塞试验 试验液体注入前、注入5min后、45min后从 兔右心室取血。 注入羊水后结果：ET、NO。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. ET 内源性长效血管收缩调节因子强效收缩 血管。 半衰期很短（60 mmHg) - 面罩吸氧、气管插管 维持心排出量和血压 - 快速输入晶体液、使用血管活性药物,收缩 压90mmHg，尿量0.5ml/kg/h。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 防治血容量不足 凝血机能障碍失血输入红细胞。 处理子宫出血：胎盘残留、宫颈口撕裂。 宫缩无力：双侧子宫动脉栓塞、宫腔充填、子宫 切除。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 纠正凝血机能障碍 aPTT延长：FFP 纤维蛋白原1g/L：冷沉淀 Plt 20,000/l：输血小板。 顽固性DIC：重组因子。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 胎 儿 监测胎儿，尽快分娩（产钳）。 复苏反应不好时立即剖宫产 - 抢救胎儿、剖宫产后易于复苏。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 碳酸氢钠（2014年） Evans S：剖宫产病人，胎儿产出后心跳停止， TEE发现急性肺动脉高压、右室负荷过重，左室空 虚。 用碳酸氢钠作肺血管扩张剂，自主循环立即恢复 ，其它心功能指标也迅速恢复。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. BIS 一例孕33周、29岁初产妇，全麻下剖宫产。婴儿 产出后病人BIS突然降至0，1min后病人SpO2降至 85%，PetCO2降至 5mmHg, 峰气道压升至35cmH2O， NIBP测不出来，使用血管活性药物后好转。 作者认为BIS可能预警羊水栓塞。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. TEG指导处理凝血功能 择期剖宫产病人，突然呼吸停止、循环血压测不 出，随后血凝不止，疑为羊水栓塞。TEG示纤溶亢 进、低纤维蛋白血症。立即补充凝血因子和氨甲 环酸，处理成功。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. ECMO 33岁 急性羊水栓塞，心跳停止，立即启用ECMO。 作者认为早期应用，可以避免进一步的脏器损害 。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. NO （nitric oxide） 一产妇急性羊水栓塞，循环虚脱，简单处理后急 剖宫产，产后表现严重低氧血症、大剂量正性肌 力药物、严重出血倾向。 TEE：急性右心负荷过重、肺动脉高压、急性左心 舒张受限（右室扩大） 吸入NO40 ppm，心肺功能迅速改善，母婴平安。 Rapid reversal of critical haemodynamic compromise with nitric oxide in a parturient with amniotic fluid embolism. 也有报告吸入前列环素 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 子宫动脉栓塞 2例，产时突然循环虚脱，第1例心跳停止，第2例 呼吸功能不全、意识改变。疑为AFE 产后病人严重出血，DIC 子宫动脉栓塞，成功止血，避免了子宫切除。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 丝氨酸蛋白酶抑制剂 30岁，多次妊娠，孕38周，产时出血不止，血液 学检查示DIC，怀疑羊水栓塞。 输入全血、使用丝氨酸蛋白酶抑制剂 FOY，约2h 后，出血肿在渐止，生命体征趋于平稳。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 诊 断 临床表现.。 肺组织中：胎儿扁平上平、肠粘蛋白、胎脂、头 发通过免疫组化检查细胞角蛋白、特殊染色等方 法检测。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 生物学标志物 母体血清 - serum sialyl-Tn antigen （STN抗原）。 - zinc-coproporphyrin 锌-粪卟啉。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Asp