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1、麻醉及麻醉药对胎儿和新生儿的影响,首都医科大学北京妇产医院 徐铭军,胎盘屏障与胎盘血液循环,一、胎盘与胎盘屏障 胎盘是哺乳动物妊娠期特有的器官，它连接母体与胎儿，通过子宫和滋养层血管化部分的对合，实现提供内分泌激素，选择性交换可溶性非颗粒物质，保证胎儿的正常营养供应和废物排泄。,胎盘屏障与胎盘血液循环,围 产 期 药 理 学,围产期药理学：涉及药物在母亲及胎儿两者体内的吸收、分布、生物转化及排泄。 围产期 ： 胎盘药物转运的决定因素：母体、胎盘、胎儿三方面因素来决定。,围 产 期 药 理 学,母体因素 剂量： 注射部位： 佐剂： 药动学：,围 产 期 药 理 学,胎盘因素 扩散 主动运输 大量
2、运输 吞饮作用 中断,围 产 期 药 理 学,胎盘因素 一、扩散 Fick公式 ：Q/t=KA（Cm-Cf）/D,决定通透性的三个方面,分子量 通透性 脂溶性 离子化,围 产 期 药 理 学,胎儿因素 一旦药物透过胎盘，胎儿对药物的摄取、分布、代谢、排泄决定药物的清除和生理作用。 流向胎盘组织物质交换部位的脐血流是影响胎儿药物摄取的根本因素。 胎儿红细胞和血清蛋白比母体红细胞和血清蛋白与局麻药的结合程度低。 胎儿药物代谢和排泄。,妊娠期麻醉及药物对胎儿的影响,妊娠期间接受外科手术：0.3%2.2% 未知妊娠接受外科手术：0.3% 1-2%的孕妇在孕期需要接受手术 ： 阑尾切除术（1:1500次
3、妊娠） 胆囊切除术（1:2000-10000次妊娠）,妊娠期麻醉及药物对胎儿的影响,妊娠各孕期的孕妇常进行的外科手术,Mazze RL,Kallen B:Reproductive outcome after anesthesia and operation during pregancy. A registry study of 5405 case. Am J Obstet Gynecol 161:1178-1185,1989.,妊娠期麻醉及药物对胎儿的影响,妊娠期麻醉及药物对胎儿的影响,麻醉医师应注意以下几点： 母体安全； 避免应用致畸药物； 避免发生胎儿宫内窘迫； 防止流产和早产。,剖宫产
4、麻醉及药物对新生儿的影响,新生儿状况的评价指标: Apgar评分 碳酸氢根 神经和适应能力评分（ NACS）,剖宫产麻醉及药物对新生儿的影响,Apgar Scoring,FOR IMMEDIATE RELEASE Stamp News Release #94-041 NEW STAMP SCORES A 10 ON THE APGAR SCALE WASHINGTON, DC (AUGUST 15, 1994) A 20-cent definitive stamp honoring Dr.Viriginia Apgar will be issued by the Postal Service
5、on October 24, 1994. A first day of issue ceremony for the new stamp will be held at the American Academy of Pediatrics annual meeting in Dallas on October 24. Millions of babies around the world have already been blessed with Dr.Apgars ownstamp of approval. In 1953, she published the Apgar score, a
6、 simple assessment method that allows doctors and nurses in the delivery room to make an immediate evaluation of a newborn babys general condition, aiding identification of those infants who need immediate medical attention. Dr. Apgar was born on June 7, 1909 in Westfield, New Jersey. She graduated
7、from Mount Holyoke College in 1929 and went on to Columbia for her medical degree, and was the first women selected for a full professorship at Columbia University College of Physicians and Surgeons. She aspired to be a surgeon, and then moved into the then relatively new field of anesthesiology, pl
8、acing special emphasis on the effects of obsteric anesthesia on newborn babies. Dr. Apgar continued her contributions to medicine by serving the National Foundation-March of Dimes, where she directed programs of research in the causes, prevention and treatment of birth defects. The Perinatal Sectiio
9、n of the American Academy of Pediatrics named its annual award to her. The Apgar Award is given annually to the person who has done the most to further the cause to care of newborn babies and their mothers. In addition to her medical achievements, Dr. Apgar was known for her sense of humor and empat
10、hy for humanity. Some of her other interests included chamber music and stamp collecting. As a prelude to the stamp dedication ceremony, a group of physicians/musicians called the Apgar String Quartest will perform some of Dr. Apgars favorite selections on instruments she crafted herself. Dr. Apgar
11、died on August 7, 1974.,剖宫产麻醉及药物对新生儿的影响,Brigham妇产医院,剖宫产麻醉及药物对新生儿的影响,476/510 93.3%,34/510 6.7%,剖宫产麻醉及药物对新生儿的影响,麻醉剂对孕妇及胎儿的影响（全身麻醉） 硫喷妥钠： 氯胺酮： 依托咪酯： 氧化亞氮： 卤化剂：,剖宫产麻醉及药物对新生儿的影响,丙泊酚 丙泊酚是美国FDA确认的对孕妇及胎儿不良影响比较小的一种麻醉药物。 丙泊酚在产妇全身麻醉中的应用以及对母体、胎儿的影响均有研究，认为采用常规剂量时，对胎儿、新生儿没有明显影响。 Hein HAT, Putman JM. Is propofol a
12、 proper proposition for reproductive procedures.J C lin Anesth, 1997, 9: 611-613. 宴馥霞.异丙酚在剖宫产全麻中的应用.国外医学麻醉学与复苏分册,1997, 18: 293-295. Alcaraz AS, Quintana MB, Laguarda M. Placental transfer and neonatal effects of propofol in caesarean sectionJ Clin Phar Therapeut,i 1998, 3: 19-23.,剖宫产麻醉及药物对新生儿的影响,麻醉剂
13、对孕妇及胎儿的影响（全身麻醉） 丙泊酚：UV/MA =0.7 100ug/Kg/min or 2.5 mg/Kg, ,150 ug/Kg/min,99.4529.40min,3.361.87LKg,81.2718.87min,2.660.63L/Kg,39.328.07ml/min/kg,29.408.72ml/min/kg,晏馥霞, 李树人.异丙酚在剖宫产全麻中的应用. 国外医学麻醉学与复苏分册,1997,18(5):293-295.,剖宫产麻醉及药物对新生儿的影响,瑞芬太尼 表 瑞芬太尼血液浓度与胎盘转运,MA.母体动脉；UV，脐带静脉，UA，脐带动脉,Kan RE,Hughes SC,R
14、osen C,en MA,et al.Intravenenous remifentanil:Placental transfer,maternal and neonatal effects. Anesthesiology 1998;88:1467-1474.,剖宫产麻醉及药物对新生儿的影响,肌松药 肌松药由于其分子量大，蛋白结合率高，1025min内经胎盘转运至胎儿的量很小而并不具有临床效应。 Iwama H,Kaneko T,Tobishima S,et al. timedependency of the ratio of umbilical vein/maternalartery conc
15、entrations of vecuronium in cesarean section J. Acta Anesthsiol Scand,1999;43(1):9.,剖宫产麻醉及药物对新生儿的影响,表2两组新生儿NBNA测定结果比较(xs),与硬膜外组相比,P0.05,剖宫产麻醉及药物对新生儿的影响,表 两组新生儿NBNA比较(分,xs),李崇华,朱春仙,贺晶.全身麻醉对剖宫产产妇分娩新生儿的影响.中华妇产科杂志,2006,41(3):162-164.,剖宫产麻醉及药物对新生儿的影响,剖宫产全身麻醉关键点： 时间：10min 时间：3min Kamat SK,Shah MV,Chaudhar
16、y LS,et al. Effect of induction delivery and uterine-delivery on apgar scoring of the newbornJ,J Postgrad Med,1991;37:125.,剖宫产麻醉及药物对新生儿的影响,剖宫产麻醉及药物对新生儿的影响,术后镇痛对新生儿的影响,母乳是婴儿最理想的食品 。 术后镇痛利于泌乳素（PRL）的分泌，利于母乳喂养。 水溶性药物在初乳中浓度高，脂溶性药物在成熟乳汁中浓度较高。,术后镇痛对新生儿的影响,不同镇痛方式对剖宫产术后哺乳的影响 PCEA组：芬太尼0.4 mg+氟哌利多2.5 mg + 0.75%布比卡因25 ml +生理盐水至100 ml持续剂量2 ml/h，PCA剂量05 ml/次。 PCIA组：芬太尼1
