羊水栓塞处理方案

1、AFE（1）Risk factors for amniotic fluid embolismFetalFetal factorsfactorsMaternalMaternal factorsfactorsObstetricalObstetricalfactorsfactorsMale genderAdvancedmaternalage 35Cesarean sectionPlacenta previaMultiparityCervical lacerationPlacenta accretaDiabetesInduction of laborPlacental abruptionInstrum

2、entaldelivery: forceps andvacuum-assistedvaginal deliveriesFetal distressUterine rupturePolyhydramniosEclampsiaFetal macrosomiaOxytocin usePremature rupture ofmembranesIntrauterine death（2 2）PathophysiologyPathophysiology ofof amnioticamniotic fluidfluid embolismembolism（3）Classification of AFE. Amn

3、iotic fluid embolism can beclassified as (1) the mechanical obstruction subtype, (2) theanaphylactic subtype, and (3) the DIC subtype. Thissubclassificationmay be beneficial in the diagnosis and thepersonalized treatment of AFE.(4)Proposed clinical phases of amniotic fluidembolism（5）Clinical manifes

4、tations of amniotic fluid embolism（6 6）diagnosticdiagnostic criteriacriteria（UKUK obstetricobstetric surveillancesurveillance systemsystem）Either - In the absence of any other clear causeAcute maternal collapse with one or more of the followingAcute fetal compromiseCardiac arrestCardiac arrhythmiasH

5、ypotensionMaternal hemorrhageCoagulopathyPremonitory symptomsSeizureShortness of breathExcluding women with maternal hemorrhage as the first presentingfeature in whom there was no evidence of early coagulopathy orcardio-respiratory compromiseOrWomen in whom the diagnosis was made at postmortem exami

6、nation withfetal squames or hair in the lungs（7 7）AdjuvantAdjuvant laboratorylaboratory teststests in in amnioticamniotic fluidfluid embolismembolismComplete blood countsPeripheral smearCoagulation profile - PT, aPTT, D-dimer, fibrin degradation products,fibrinogenThromboelastography/thromboelastome

7、trySerum electrolytesABGECGCardiac enzymesEchocardiography (transthoracic/transesophageal)Chest radiograph（8）Differential diagnoses of AFERespiratoryPulmonary embolismAir embolismAspirationTension pneumothoraxAspirationPulmonary edemaCardiacAcute myocardial infarctionPeripartum cardiomyopathyAortic

8、dissectionCardiac arrhythmiheart failure, tamponadeShockSeptic shockAnaphylactic shock: drug inducedObstetricPostpartum hemorrhageUterine rupturePlacental abruptionEclampsiaAnesthesia related - local anesthetic toxicity, high spinalOther reversible causes - toxins, hypo/hyperkalemia, metabolic,hypot

9、hermia(9)Biomarkers currently utilized for the diagnosis of amnioticfluid embolismCurrent biomarkersZinc coproporphyrinCharacteristic component ofmeconium and fetal urineElevated in AFEDetected via high performance liquidchromatographySialosyl Tn antigenFetal antigen found in meconium andamniotic fl

10、uidDetected via TKH-2 monoclonalantibodyTryptaseMast cell degranulation markerElevated in some AFE patientsComplement factorsDecreased C3 and C4 complementPossible complement activationCytokinesIL-6, IL-8, and tumor necrosis factorElevated in some AFE patientsNonspecific because can be presentin sys

11、temic inflammatory responsesyndromeInsulin-like growth factorbinding protein 1Embryonic development proteinsynthesized in deciduaDetectable in amniotic fluid andmaternal serumNew biomarkersActivin A (transforminggrowth factor)Characteristic of maternal serum, cord blood serum, andamniotic fluidIncre

12、ased with gestational ageProopiomelanocortinCharacteristic of placental membrane10_ more concentrated in amniotic fluid than maternalserumInversely related to human chorionic gonadotropinHigh concentrations at feto-maternal junctionProcollagen type 1N-terminal propeptideAssociated with fetal metabol

13、ism and development400 times more concentrated in amniotic fluid thanmaternal circulationCK13 (Rab); CK10/13(Mab)Strongly expressed in squamous cells from maternalamniotic fluidBrown cytoplasmic granules when immunostainedSummary:AlthoughAFEcannotbeprevented,earlydiagnosisandintervention may lead to

14、 better outcomes for both the mother andthefetus.Clinicalsuspicion,traditionallaboratorydata,orintravascular cellular debris(demonstrated only in 50% of patients)are insufficient to make a definitive diagnosis of AFE. An evolvingarray of novel biomarkers may help differentiate AFE from otherconditio

15、ns, but none of them currently provide sufficient earlywarning ability to make real-time impact on diagnosis and/ortreatment of AFE.(10)Algorithm for management after diagnosis ofamniotic fluid embolism附附1 1：治疗措施：治疗措施1.Promptdelivery（within_5 min of maternal cardiac arrest）2.Aravenous acce

16、ss4.hemodynamic monitoring（include:lactate、ABG、VBG、）5.fluids and vasopressors（early phase of circulatory vasodilation-Phenylephrine andvasopressin、adrenaline、norepinephrine）6.blood and component replacements/( cell salvage、uterine arteryembolization、Bakri balloon)7.pulmonary vasodilation（Milrinone、i

17、nhaled nitric oxide、inhaledepoprostenol）8.Heparin and steroids9.tranexamic acid or aminocaproic（undetermined）10.Sodium bicarbonate（patients unresponsive to advanced lifesupport measures, with right ventricularfailure and acidosis）11.C1INH concentrates(hereditary angioedema)12.hemofiltration or plasma exchange13.nonpneumat