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1、羊水栓塞 AMNIOTIC FLUID EMBOLISM (AFE),时春艳,Case Presentation(1),31y, G2P0 Admitted to L&D with 40+3 Oxytocin induction C/S for the arresting of the active stage,Case Presentation(1),After the baby was delivered Sudden onset: Cough dyspnea mild seizure HR(120), BP (7080/3050) Postpartum heamorrahage :220
2、0ml Coagulopathy: FIB:1.64, PT14.1s, Hb 69,BPC:9.2,Case Presentation(1),Diagnosis: Amniotic fluid embolism Treatment: Prognosis: Recovery,Case Presentation(2),26year G2P0 Admitted because of PROM at 5am At 7:am she had uterus constraction At 7:30am she sudden complained of dyspnea and immediately co
3、ma Summon for help,Case Presentation(3),36 years old,G3P1 Induction for 41weeks After the baby was delivered by spontaneous vaginally Massive vagina hemoarrhage BP Uterus hysterectomy but die from DIC and multi-organ failure,Case Presentation(4),43 years old Termination of pregnancy because of the f
4、etal abnormality at 33 weeks of gestation Dyspnea before the delivery of the baby BP ,Postpartum Hemorrhage,coma Diagnosis: amniotic fluid embolism,DEFINITION,羊水栓塞(amniotic fluid embolism)在分娩过程中(产程中、产后，最迟产后48h内）突然出 现的:急性呼吸困难、休克、循环衰竭、弥散性血管内凝血(DIC)、肾功衰竭或突发死亡的分娩严重并发症。,AFE的认识过程,AFE is thought to occur w
5、hen amniotic fluid , fetal cells, hair, or other debris enter the maternal circulation. Ricardo Meyer (1926); reported the presence of fetal cellular debris in the maternal pulmonary blood vessel. Steiner and Luschbaugh (1941) described the autopsy findings of eight cases of AFE. Until 1950, only 17
6、 cases had been reported. AFE was not listed as a distinct heading in causes of maternal mortality until 1957 when it was labeled as obstetric shock. Since then more than 400 cases have been documented, probably as a result of an increased awareness.,发生率,Overall incidence ranges from 1 in 8,000 to 1
7、 in 80,000 pregnancies. The Incidence in our department:1:8000England:1:56500, American:1:12953美国3百万分娩的统计显示7.7/10万 14% of maternal deaths in USA(第二位的死亡原因) 47:295-8).,Maternal fatality rate:1330%61%86% before 199475 % of survivors are expected to have long-term neurologic deficits.Perinatal mortality
8、:944%If the fetus is alive at the time of the event, nearly 70 % will survive the delivery but 50% of the survived neonates will incur neurologic damage.,AMNIOTIC FLUID EMBOLISM,Time of event: - During labor. - During C/S.- After normal vaginal delivery.- During second trimester TOP. AFE syndrome ha
9、s been reported to occur as late as 48 hours following delivery.,Risk factors of AFE,Advanced maternal age Multiparity Meconium Cervical laceration Very strong frequent or uterine tetanic contractions Sudden foetal expulsion (short labour),Placenta abnormality Polyhydramnios Uterine rupture Maternal
10、 history of allergy or atopy Chorioamnionitis Macrosomia Male fetal sex Oxytocin (controversial) Operative deliveries,Nevertheless, these and other frequently cited risk factors are not consistently observed and at the present time Experts agree that this condition is not preventable.,病理,传统的观点：羊水中的有
11、形物质进入母体循环引起肺毛细血管的物理性的阻塞 循环衰竭研究不支持上述观点：动物实验不能验证；母体循环中都能找到胎儿细胞等；病理学家Steiner 和 Luschbaugh 发现很多死于其他疾病的孕产妇循环中都找到了胎儿细胞（fetal debris）；宫缩过强时子宫血流是停止的。,病理,当前普遍认同的观点：Anaphylactoid Syndrome of Pregnancy对胎儿抗原的异常的母体免疫（Abnormal maternal immune response to the fetal antigen exposure common to virtually all laboring
12、 women 内源性的一系列免疫介质（endogenous-immune mediators)引起一系列的过敏反应,Pathophysiology,To emphasize that the clinical findings are secondary to biochemical mediators rather than pulmonary embolic phenomenon; Clark et al have suggested renaming this clinical syndrome the “anaphylactoid syndrome of pregnancy“,Path
13、ophysiology,呼吸循环衰竭:Amniotic fluid and fetal cells enter the maternalcirculation biochemical mediators pulmonary artery vasospasm pulmonary hypertension elevated rightventricular pressure (右心衰,三尖瓣关闭不全) hypoxia myocardial and pulmonary capillary damage(左心灌注不良并缺氧) left heart failure acute respiratory d
14、istress syndrome凝血功能障碍: biochemical mediators 消耗凝血物质,血小板聚集 DICmassive hemorrhage and uterine atony.,Clinical presentation,发生于分娩过程中、产后即刻，可以发生于正常分娩、引产、死胎等 (1) Respiratory distress (2) Cyanosis (3) Cardiovascular collapse cardiogenic shock (4) Hemorrhage (5) Coma.,Amniotic Fluid Embolism Signs and Symp
15、toms,Clark et al, Amniotic fluid embolism: analysis of a national registry. Am J Obstet Gynecol 1995;172:1158-1169,Clinical presentation,A sudden drop in O2 saturation can be the initial indication of AFE during c/s. some patients die within the first hour. Of the survivors will develop DIC which ma
16、y manifest as persistent bleeding from incision or venipuncture sites. 可以以DIC为首发症状,Clinical presentation,10-15% of patients will develop seizures. CXR may be normal or show effusions, enlarged heart, or pulmonary edema. ECG may show a right strain pattern with ST-T changes and tachycardia. 超声心动：肺动脉高
17、压，急性右心衰竭，1h后出现左心衰竭,Diagnosis,诊断主要依靠临床表现：分娩过程中或产后48小时内出现低血压、呼吸窘迫、DIC、抽搐、昏迷等不能用其他原因解释(排除法) 临床化验：凝血分析、血气、血常规、心肌酶等 胸片、经食道超声心动 非特异性的检验（test）：Findings included mucin, amorphous eosinophilic material , and in some cases squamous cells. The presence of squamous cells in the pulmonary vasculature once considered pathognomonic for AFE is neither sensitive nor specific (only 73% of patients dying from AFE had this finding). The monoclonal antibody TKH-2 （一种胎儿抗原）may eventually prove more useful in the rapid diagnosis of AFE.,
