复杂性双胎胎儿诊治规范1课件

Case1Gravida3andParturition1,

41w,laborinducedbypropess,membranerupturednaturally,atthesametime,dyspneaandcyanosisoccurred.Whathappened?Ifyouarethedoctor,whatshouldyoudo?Tracheacannulawasdoneimmediately,andCSwasprepared.Thebabywassurvivalwith9apgarscore.Intheoperation,suddencardiacarrestoccurredandautonomouslyheartbeatrecoveredafter50minutesexternalchestcompression.ButDICemerged,hysterectomywasdone.Finally,thepatient’slifewassaved,

butshebecameavegetable.Oneyearlater,shedied.SeriousintrapartumcomplicationAcomplexdisordercausedbyamnioticfluidenteringmaternalcircurationandclassicallycharacterizedbytheabruptonsetofhypotension,hypoxia,andconsumptivecoagulopathyIncidence:

1:20000Mortality:80%,intermpregnancyAmnioticFluidEmbolism(AFE)RuptureofmembraneHypertoniaofamnioncavityOpenbloodsinusInjuryofcervicalcanaloruterinewallPlacentaprevia,placentaabruption,placentamarginalsinusruptureAdherencesiteofplacentaConditionofAFEOnsetPrematureruptureofmembrane,artificialruptureorstrippingofmembrane,artificialexpansionofcervixToostronguterinecontractionRigiditycontractionandprecipitatelabourcausedbyinappropriateusingofoxytocinandoperationincavityInjuryCervicallaceration,ruptureofuterus,uterineincisionincaesareansection,

forcepcurettagePredisposingfactorsSomepathologicalpregnancyTwin,multiplets,macrosomia,polyhydramnions,prolongedlabour,dystocia,placentaabruption,placentaprevia,retentionofdeadfetus,infectionofamnioncavity,fetaldistressPressabdomananduterusbybruteforceInternalcervicalvein

Amnioticfluidvolumeenteringmaternalcirculationrelatedto:strengthofcontractiondegreeofinjuryUterineplacentabed：BrokenvenuleinadherencesiteofplacentaFissureinadherencesiteofplacentaOpendeciduabloodsinus

placentamarginalvesselAmnioticpermeationpressureofamnioticcavity↑intensityofamnioticmembrane↓PathwayofamnionfluidenteringmaternalbloodcirculationPathyphysiologyPulmonaryhypertensionAllergicshorkDisseminatedintravascularcoagulation(DIC)AcuterenalfailureAmnioticfluid(Epithelialcell,mucus,meconium,vernixcaseosa,lanugo)MaternalcirculationⅠallergicreactionBleedingwithoutcoagulationchillpulmonarycirculationVesselembolismAcutepulmonaryheartdiseaseVesselblock，stenosisPulmonaryhypertentionreturnedbloodvolumetoLAoutputVesselspasmRightheartfailurePeripheralcirculatoryfailure,Bp

dropshorkreflectivelybronchospasmbronchisecretionincreasedbronchiostenosisventilationobstructAcuterespiratoryfailuretoxicosisandanoxiaofthewholebodyRespiratoryacidosiscerebralanoxia,Anxious,seizure,comaHistanoxia(cyanosis)renalanoxiaMetabolicacidosisAcuterenalfailure

Abruptonset,criticaloncomingforceThreestagesappearinsequenceintypicalcasesOnlymassvaginalbleedingandshorkinatypicalcases

——Degreeofsyptomsrelatedtoamountofparticlematterinamnioticfluid,amountandvelocityofamnioticfluidenteringmaternalcirculatinClinicalmanifestationPremonitorysymptom：

Short-perioddysphoria,chillandshiver,coughanddyspnea,cyanosis,vomitatthetimeofruptureofmembraneSymptomsdisappearaftertreatmentinmildAFE,severeAFEarisethreestages:Respiratoryandcirculatoryfailure,shorkBleedingcausedbyDICAcuterenalfailureAcuterespiratoryandcirculatoryfailure

Obviouscyanosis

Dyspnea

Coughingfrothysputum,raisedheartrate,moistralesinlung

Fallofbloodpressure

Coma,seizure

Severecases:scream,respiratoryarrest,cardiopulmonary

arrest，dieClinicalmanifestation

——thefirststageCoagulationdisordershypercoagulablestate→hypocoagulablestageBleedingofskin,mucosa,needleeye,incisionHematuria,hematemesisMassvaginalbleeding

TypicalsymptomofDIC

Clinicalmanifestation

——thesecondstageMultipleorganfailure(MOF)

Acuterenalfailure

Oliguria

urinevolume<400ml/24hor17ml/hAnuria

<100ml/24h，metabolicdisturbance

Azotemia

Obviousjaundice,ascite

Clinicalmanifestation

——thethirdstageAfterruptureofmembrane,afterbirth,orinoperationBreakoutshiver,bucking,dyspnea,dysphoria,scream,cyanosis,seizure,bleeding,shorkunkownreason,AFEshouldbeconsideredRescueimmediately——Thekeytoimproverescuelivabilityiscorrectandpromptdignosis,effectivetherapeuticmeasuresDignosisBloodsmeartofindamnioticvisibleparticleBedsidechestX-layBedsideECGorCDFIRightatriumenlargement,cardiacdamageLaboratoryexaminationrelatedtoDICAssistantexaminationBloodsmeartofindamnioticvisiblematterLeftA(case1)showspinkandwedge-shapedfetalsquamousepithelium,leftB(case2)showspinkfetalsquamousepitheliumsurroundedbyplateletRightA(case1)，rightB(case2)showedfetalsquamousepitheliumfrombronchicasearsefluid（redarrow）

SquamousepitheliuminaperipheralpulmonaryarteryFetalkeratininaperipheralpulmonaryarteryBedsidechestX-lay

70%ofpatientsmayhavemildsymptomsoflungedemaDisseminatedeffusioninpulmonaryalveolusIncreasedheartshadowDissipativehypocoagulabilityProgressivedropofplateletcount（<100×109/L）Prothrombintime（PT>3”）Kaolinactivepartialthromboplastintime(KPTT>10”）Fibrinogen

<1.5/L

Coagulationexamination

SecondaryhyperfibrinolysisPlasmaProtamine

para-coagulationtest(3P

test)OthersD-dimerAntithrombaseⅢ（ATⅢ)FibrinopeptideA（FDA）Fibrindegradationproduction(FDP）CapillaryhemolysisBrokenRBCmorethan10%in20~30%bloodsmearsoflatestageDICTodrawrightventriclebloodforprecipitationtesttofindvisibleparticleofamnioticfluidAutopsyNotablerightventricleexpansionPulmonaryedema,alveolarhemorrhage,emboluscontainingamnioticparticleinkidney,heart,brain,uterine,orbroadligament,emboluscontainingDeciduoussquamousepithelialcellfromfetalskinLanugoFragmentoffetalskinandamnionMucinfromfetalintestinaltractBilefrommeconium

DignosisafterdeathAirembolism：severechestandbackpain,senceofprecordiapressure,occurredinruptureofuterus,placentaprevia,operationincavityPulmonaryembolismbythrombus：varicoseveinandthrombophlebitisoflowerlimb,occurredat9-14daysafterbirth,acutechestpain,bloodysputum,chestfricative,pulmonaryembolisminX-rayEclampsia

：hypertention,proteinuria,shorkappearedlaterRuptureofuterus：cephalopelvicdisproportion,signsofimpendingofruptureofuterus(abdominalpain,hematuria)Differentialdiagnosis

Reasonableusingofoxytocin,tomasterindicationandcontrolldose,watchedbyspecialpersonAvoidinappropriateoperationinuterinecavityandbirthcanalinjuryNoticeinartificialruptureofmembraneAvoidpressingabdomenanduterusstronglyatthetimeofdeliveryofbabyMasterindicationofCSstrictlyUsingsedativetosuppressexcessivecontractionPrevention

TorescuequicklyanddecisivelyTotreatrespiratoryandcirculatoryfailurefirstlyAppropriateobstetricmanagementPrincipleofmanagementStepsofmanagementImprovehypoxemiaSemirecliningpositionOxygenuptakeHighconcentrationoxygen(>50%)bymark，flowvelocity5-10L/minContiniouspositiveairwaypressurebytracheacannulaAntiallergicDexamethasone20mgiv,20mgivgttp.r.nHydrocortisone

1000-2000mg/divgttStep1RelievepulmonaryhypertensionParaverine：Relaxvascularsmoothmuscle30-90mg+5%GS20ml

ivgttAmniophylline：Dilatecoronaryarteryandbronchismoothmuscle250mg+5%GS20mlivgttAtropine：Relievepulmonaryvasospasm,bronchospasm,cardiacdepression1-2mgimorivPhentolamine：Relievepulmonaryvasospasm5-10mg+5%GS100ml

ivgtt，adjustinfusionrateaccordingbloodpressureCorrectshorkCirculatorysupportwithbloodandcomponentreplacement：centralvenouspressure(CVP):8-10cmH2OAdjustvesseltensity：dopamine

10-20mg+5%GS250mlivgttTreatacidosis：5%NaHCO3100-200ml

ivgtt

Step2TreatDICHypercoagulabilityinearlystage——heparin0.5mg-1mg/kg（heparin1mgtobeequivalentto125IU）

First25mg+NS100mlivgttin1h

Then25mg+5%GS500mlivgtt

Clottingtimemaintainat15min

Excessiveheparindetoxifiedusing1%equivalentprotaminesolution