羊水栓塞-2011八年制.ppt

AmnioticFluidEmbolismAFE ZhuJiepingShanghaiJiaotongUniversityAffiliatedSixthPeople sHospital DeptofObs Gyn Theentryofamnioticfluidintothematernalcirculationleadstosequelaeofclinicalevents eg suddenonsetofseveredyspnea 呼吸困难 cyanosis 紫绀 anddisseminatedintravascularcoagulation DIC 弥散性血管内凝血 Occursduringlabor deliveryorearlypuerperium ArarebutFATALobstetricemergency leadstoseverematernalmorbidityandmortality Definition Incidence 1 8000to1 80 000deliveries70 occurredduringlabor19 occurredduringcaesareandelivery11 occurredaftervaginaldeliveryRiskfactors HighpressureinamnioticcavityRuptureofthefetalmembranesRuptureofplacentalsinus EpidemiologyandRiskFactors Mechanismisunclear Amnioticfluidcontainsmanyvasoactive 血管活性因子 andprocoagulantsubstances 促凝因子 suchasplateletactivatingfactor cytokines thromboxane 凝血恶烷 leukotrienes 白细胞三烯 andarachidonicacid 花生四烯酸 Entranceofthesesubstancesintothematernalcirculationcouldcausethesyndrome Anaphylactoidsyndromeofpregnancy 妊娠期过敏综合症 Etiology 1 PAH pulmonaryarterialhypertension肺动脉高压 Pathophysiology 1 2 AnaphylacticshockI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 DIC4 MOF multipleorganfailure 急性肝肾功能衰竭 Pathophysiology 2 Clinicalmanifestation MaternalMortalityRateover60 AmJObstetGynecol1995 172 1158 SignsandSymptomsofAFE Lab CoagulantfunctionDIC PLT 100 109 Lordecreasedprogressively Fibrinogen 1 5g L PT prothrombintime 15sec 3Ptest Testtubemethod 30min Bloodsmear血涂片可见破碎的红细胞 Testtubemethod venousblood5ml DiagnosisAclinicaldiagnosis oneofexclusion ECG Electrocardiogram orCDS ColorDopplerSonography OxygensaturationChestX ray enlargedrightatriumandventriclepulmonaryedemaDefinitivediagnosis demonstrationofamnioticfluidmaterialinthematernalcirculation 下腔静脉或右心室 DiagnosisAclinicaldiagnosis oneofexclusion DifferentialDiagnosis Suddenonsetofdyspnea cardiovascularcollapseandDICshouldbesuspectedofAFEandinitiatetreatment Amelioratehypoxemia改善缺氧Oxygenadministrationwithpositivepressure正压给氧TreatmentofPAH1 Papaverine罂粟碱 首选药物torelaxthevascularsmoothmuscle30 90mg 50 GS20 40mliv2 Aminophylline氨茶碱torelaxbronchialsmoothmuscleanddilatecoronaryartery250 500mg 25 GS10mliv Management 1 Antiallergictreatment抗过敏Adrenocorticalhormone肾上腺皮质激素1 Hydrocortisone 氢化可的松 200mgiv300 800mg 5 GS500mlivgtt2 Dexamethasone 地塞米松 20mg 25 GSiv20mg 5 GS500mlivgtt Management 2 Anti shocktreatment抗休克1 SupplementofbloodvolumeFleshblood freezedfreshplasma dextran右旋糖酐2 Vasopressors升压药Dopamine 多巴胺 10 20mg 5 GS250mlivgttAramine 间羟胺 20 80mg 5 GS250mlivgtt3 Treatingheartfailure强心Cedilanid 西地兰 0 2 0 4mg 25 GSiv repeatedevery4 6hours4 Treatingacidosis酸中毒5 NaHco3250mlivgtt Management 3 PreventionandtreatmentofDICHeparinSodium肝素钠Antifibrinolyticdrugsaminocaproicacid 氨基己酸 tranexamicacid 氨甲环酸 PlateletsFresh frozenplasmaCoagulationfactorsCryoprecipitate 冷沉淀物 凝血 因子 Management 4 PreventionofrenalfailureBloodvolumesupplementMannitol 甘露醇 20 250mlivgtt扩张肾小球前小动脉Furosemidum 速尿 呋塞米 20 40mg 5 GSivPreventionofinfection Management 5 Obstetricstreatm