羊水栓塞-2011八年制

nullnullZhu Jieping Shanghai Jiaotong University Affiliated Sixth People's Hospital, Dept of Obs & Gyn nullThe entry of amniotic fluid into the maternal circulation leads to sequelae of clinical events, eg, sudden onset of severe dyspnea(呼吸困难), cyanosis(紫绀) and disseminated intravascular coagulation (DIC，弥散性血管内凝血). Occurs during labor, delivery or early puerperium. A rare but FATAL obstetric emergency, leads to severe maternal morbidity and mortality.nullIncidence: 1: 8000 to 1: 80,000 deliveries 70% : occurred during labor 19% : occurred during caesarean delivery 11% : occurred after vaginal delivery Risk factors: High pressure in amniotic cavity Rupture of the fetal membranes Rupture of placental sinusnullnull1. PAH: pulmonary arterial hypertension 肺动脉高压null2. Anaphylactic shock I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→DIC 4. MOF (multiple organ failure) 急性肝肾功能衰竭nullMaternal Mortality Rate over 60%nullAm J Obstet Gynecol 1995;172:1158nullLab: Coagulant function DIC :① PLT＜100×109/L or decreased progressively ② Fibrinogen ＜1.5g/L ③ PT(prothrombin time)＞15sec ④ 3P test (+) ⑤ Test tube method ＞30min ⑥ Blood smear 血涂片可见破碎的红细胞。 Test tube method ：venous blood 5mlnullnullSudden onset of dyspnea, cardiovascular collapse and DIC should be suspected of AFE and initiate treatment!nullAmeliorate hypoxemia 改善缺氧 Oxygen administration with positive pressure 正压给氧 Treatment of PAH 1. Papaverine 罂粟碱：首选药物 to relax the vascular smooth muscle 30~90mg+50% GS 20~40ml iv 2. Aminophylline 氨茶碱 to relax bronchial smooth muscle and dilate coronary artery 250~500mg+25%GS 10ml ivnullAntiallergic treatment 抗过敏 Adrenocortical hormone 肾上腺皮质激素 1. Hydrocortisone (氢化可的松) 200mg iv 300~800mg+5%GS 500ml iv gtt 2. Dexamethasone (地塞米松) 20mg+25%GS iv 20mg+5%GS 500ml iv gttnullAnti-shock treatment 抗休克 1. Supplement of blood volume Flesh blood, freezed fresh plasma, dextran 右旋糖酐 2. Vasopressors 升压药 Dopamine(多巴胺) 10~20mg+5%GS 250ml iv gtt Aramine(间羟胺) 20~80mg+5%GS 250ml iv gtt 3. Treating heart failure 强心 Cedilanid(西地兰) 0.2~0.4mg+25%GS iv, repeated every 4~6 hours 4. Treating acidosis 酸中毒 5% NaHco3 250ml iv gttnullPrevention and treatment of DIC Heparin Sodium 肝素钠 Antifibrinolytic drugs aminocaproic acid(氨基己酸) tranexamic acid(氨甲环酸) Platelets Fresh-frozen plasma Coagulation factors Cryoprecipitate(冷沉淀物，凝血Ⅷ因子)nullPrevention of renal failure Blood volume supplement Mannitol (甘露醇) 20% 250ml iv gtt 扩张肾小球前小动脉 Furosemidum (速尿，呋塞米) 20~40mg+5%GS iv Prevention of infection nullObstetrics treatment Delivery: Cesarean section or vaginal delivery Severe PPH: hysterectomy nullArtificial rupture of the membrane? Indications of CS? Oxytocin?null