羊水栓塞-2011八年制.ppt

AmnioticFluidEmbolismAFE ZhuJiepingShanghaiJiaotongUniversityAffiliatedSixthPeople sHospital DeptofObs Gyn Theentryofamnioticfluidintothematernalcirculationleadstosequelaeofclinicalevents eg suddenonsetofseveredyspnea 呼吸困難 cyanosis 紫紺 anddisseminatedintravascularcoagulation DIC 彌散性血管內(nèi)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 凝血惡烷 leukotrienes 白細(xì)胞三烯 andarachidonicacid 花生四烯酸 Entranceofthesesubstancesintothematernalcirculationcouldcausethesyndrome Anaphylactoidsyndromeofpregnancy 妊娠期過敏綜合癥 Etiology 1 PAH pulmonaryarterialhypertension肺動(dòng)脈高壓 Pathophysiology 1 2 AnaphylacticshockI型變態(tài)反應(yīng) 平滑肌痙攣 毛細(xì)血管擴(kuò)張 過敏性休克3 DIC羊水中促凝物質(zhì) 激活外源性凝血系統(tǒng) 微血栓形成 消耗大量凝血因子和纖維蛋白原 DIC4 MOF multipleorganfailure 急性肝腎功能衰竭 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血涂片可見破碎的紅細(xì)胞 Testtubemethod venousblood5ml DiagnosisAclinicaldiagnosis oneofexclusion ECG Electrocardiogram orCDS ColorDopplerSonography OxygensaturationChestX ray enlargedrightatriumandventriclepulmonaryedemaDefinitivediagnosis demonstrationofamnioticfluidmaterialinthematernalcirculation 下腔靜脈或右心室 DiagnosisAclinicaldiagnosis oneofexclusion DifferentialDiagnosis Suddenonsetofdyspnea cardiovascularcollapseandDICshouldbesuspectedofAFEandinitiatetreatment Amelioratehypoxemia改善缺氧Oxygenadministrationwithpositivepressure正壓給氧TreatmentofPAH1 Papaverine罌粟堿 首選藥物torelaxthevascularsmoothmuscle30 90mg 50 GS20 40mliv2 Aminophylline氨茶堿torelaxbronchialsmoothmuscleanddilatecoronaryartery250 500mg 25 GS10mliv Management 1 Antiallergictreatment抗過敏Adrenocorticalhormone腎上腺皮質(zhì)激素1 Hydrocortisone 氫化可的松 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升壓藥Dopamine 多巴胺 10 20mg 5 GS250mlivgttAramine 間羥胺 20 80mg 5 GS250mlivgtt3 Treatingheartfailure強(qiáng)心Cedilanid 西地蘭 0 2 0 4mg 25 GSiv repeatedevery4 6hours4 Treatingacidosis酸中毒5 NaHco3250mlivgtt Management 3 PreventionandtreatmentofDICHeparinSodium肝素鈉Antifibrinolyticdrugsaminocaproicacid 氨基己酸 tranexamicacid 氨甲環(huán)酸 PlateletsFresh frozenplasmaCoagulationfactorsCryoprecipitate 冷沉淀物 凝血 因子 Management 4 PreventionofrenalfailureBloodvolumesupplementMannitol 甘露醇 20 250mlivgtt擴(kuò)張腎小球前小動(dòng)脈Furosemidum 速尿 呋塞米 20 40mg 5 GSivPreventionofinfection Management 5 Obstetricstreatm