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1、妊娠和妊娠和产产褥期褥期动动脉瘤性蛛网膜下腔出脉瘤性蛛网膜下腔出血的血的诊疗诊疗广东省中医院神经三科 陈发军一、妊娠和一、妊娠和产产褥期蛛网膜下腔出血褥期蛛网膜下腔出血是指发生在整个妊娠期及产后6周内的SAH。二、流行病学及病因二、流行病学及病因+妊娠和产褥期蛛网膜下腔出血发病率约1/100000-5/100000。成为日本妊娠期妇女的第二大死因。成为美国妊娠期妇女第三大死因。+常见病因是颅内动脉瘤、AVM破裂引起出血，其次是妊娠期高血压、子痫、静脉窦血栓、烟雾病、非动脉瘤性蛛网膜下腔出血等。PERIMESENCEPHALICSUBARACHNOIDPERIMESENCEPHALICSUBAR
2、ACHNOIDEMORRHAGEEMORRHAGE+Case140YHeadachegestationalage(GA)of8weeksand4days32Y,HEADACHE,9THWEEKOFPREGNANCY,SEIZURE,LOSSOF32Y,HEADACHE,9THWEEKOFPREGNANCY,SEIZURE,LOSSOF32Y,HEADACHE,9THWEEKOFPREGNANCY,SEIZURE,LOSSOF32Y,HEADACHE,9THWEEKOFPREGNANCY,SEIZURE,LOSSOFCONSCIOUSNESSCONSCIOUSNESSCONSCIOUSNESSC
3、ONSCIOUSNESSECLAMPTICSUBARACHNOIDHAEMORRHAGEECLAMPTICSUBARACHNOIDHAEMORRHAGEECLAMPTICSUBARACHNOIDHAEMORRHAGEECLAMPTICSUBARACHNOIDHAEMORRHAGE+32YG1P0Fivedaysafterdeliveryseverepoundingpainoverthevertexnausea95/60-130/74妊娠和妊娠和妊娠和妊娠和产产产产褥期褥期褥期褥期动动动动脉瘤性蛛网膜下腔出血的流行病学脉瘤性蛛网膜下腔出血的流行病学脉瘤性蛛网膜下腔出血的流行病学脉瘤性蛛网膜下腔出
4、血的流行病学+妊娠和产褥期动脉瘤性SAH发病率约3/100000。+动脉瘤性SAH的引起的妊娠期妇女死亡率约13%-15%。+妊娠不会增加动脉瘤的破裂机率。+Cerebralaneurysmsintheanteriorcirculationlargerthan7mmaremorelikelytorupture.Rupturemayoccurinsmalleraneurysmsoftheposteriorcirculation.+Theriskforrecurrentbleedingduringtheremainderofpregnancyinpatientswithanuntreatedane
5、urysmis33%to50%,withamaternalmortalityrateof50%to68%.Rebleedingwithin3to8weeksofinitialtreatment.三、三、临临床表床表现现与与诊诊断断+突发剧烈头痛最常见，可伴有恶心、呕吐，时有意识障碍或烦躁，可出现部分性或全面性癫痫发作。+脑膜刺激症（颈强直、Kerning征、Brudzinski征）阳性。辅辅助助检查检查+首选CT检查，在放射吸收剂量50mGY下不会增加胎儿畸形、生长受限和流产的机率。+腰椎穿刺术。+MRI。+CTA、MRA、脑血管造影术明确AN，MRA推荐为未破裂动脉瘤患者的筛选。鉴别诊鉴别诊
6、断断+先兆子痫和子痫的临床表现很相似，难以鉴别。研究显示，30妊娠期SAH可反应性引起血压升高、一过性蛋白尿。而40致命性子痫可同时并发SAH。四、治四、治疗疗+与非妊娠期动脉瘤性SAH处理类似。+积极的手术治疗，文献报道：手术组孕妇死亡率11%，胎儿死亡率5%；非手术组死亡率63%，27%。+不轻易放弃胎儿，妊娠28周后可进行剖腹产，24周-28周视胎儿成熟度选择手术方式。+合并大量脑出血、脑积水等患者可以先进行脑血肿清除及脑室外引流术，但必须要做好胎儿监测，出现胎儿窘迫，需要同时进行剖腹产手术。+麻醉方式选择气管全麻，做好胎儿监测等。+多学科的协作（神经科、产科、麻醉科、新生儿科），以神经
7、科医师为主导。动动脉瘤的手脉瘤的手术术方式方式+动脉瘤夹闭术+动脉瘤栓塞术动动动动脉瘤脉瘤脉瘤脉瘤夹闭术夹闭术夹闭术夹闭术+文献建议对既能够栓塞又能够夹闭的AN，优先选择夹闭术。+文献建议剖腹产手术建议于动脉瘤手术前进行。+并发症：再出血、脑血管痉挛、产后心肌病等。动动动动脉瘤栓塞脉瘤栓塞脉瘤栓塞脉瘤栓塞术术术术+根据动脉瘤类型、形态、大小选择合适栓塞方式。+没有见到使用支架辅助栓塞的病例，有使用球囊辅助栓塞的报道。+对于一些后循环的，难以行夹闭术，优先选择栓塞术。+术后注意充分水化防止胎儿脱水。术术中射中射线线影响及防影响及防护护+Embryogenesis(firsttwoweeksofp
8、regnancy)thedeathoftheembryo.+Duringorganogenesis(weeks2through7ofgestation)congenitalabnormalitiesinthesurvivingfetus.+Thefetalperiod(week8untilbirth)growthretardationwithmicrocephaly,retardationduetoneurondepletion,anddevelopmentofchildhoodcancer. +8to25weeks,thecentralnervoussystem(CNS)isparticul
9、arlysensitivetoradiation.+Accordingtothereference,fetaldosesinexcessofapproximately100mGymayresultinaverifiabledecreaseofintelligencequotientat8to15weeksgestation).+Duringthesameperiod,fetaldosesintherangeof1000mGy(1Gy)resultinahighprobabilityofseverementalretardation. +Shieldingpatientslowerabdomen
10、withdouble-layered0.5mmleadaprons,mayreducethereceiveddosebymorethan97%。+Accordingtothepreviousreports,calculatedexpectedvalueofthefetaldosewasbetween11.5and43.3mGycm.AccordingtotheICRP,atexposurelevelsbelow100mGy,theradiationeffectissosmallthatterminationofpregnancyisnotjustified.21Y,HEADACHE,29THW
11、EEKOFPREGNANCY,CAESARIAN21Y,HEADACHE,29THWEEKOFPREGNANCY,CAESARIAN21Y,HEADACHE,29THWEEKOFPREGNANCY,CAESARIAN21Y,HEADACHE,29THWEEKOFPREGNANCY,CAESARIANSECTIONATTHE38THWEEKOFGESTATIONSECTIONATTHE38THWEEKOFGESTATIONSECTIONATTHE38THWEEKOFGESTATIONSECTIONATTHE38THWEEKOFGESTATION39Y,18THGESTATIONALWEEK,HE
12、ADACHE,DELIVEREDA39Y,18THGESTATIONALWEEK,HEADACHE,DELIVEREDA39Y,18THGESTATIONALWEEK,HEADACHE,DELIVEREDA39Y,18THGESTATIONALWEEK,HEADACHE,DELIVEREDAHEALTHYMALEINFANT4MONTHSHEALTHYMALEINFANT4MONTHSHEALTHYMALEINFANT4MONTHSHEALTHYMALEINFANT4MONTHS34Y16THGESTATIONALWEEKDROWSYLEVELOF34Y16THGESTATIONALWEEKD
13、ROWSYLEVELOF34Y16THGESTATIONALWEEKDROWSYLEVELOF34Y16THGESTATIONALWEEKDROWSYLEVELOFCONSCIOUSNESSAFTEREXPERIENCINGAGENERALSEIZURECONSCIOUSNESSAFTEREXPERIENCINGAGENERALSEIZURECONSCIOUSNESSAFTEREXPERIENCINGAGENERALSEIZURECONSCIOUSNESSAFTEREXPERIENCINGAGENERALSEIZUREFIVECOILS,CESAREANSECTIONATTHE38THWEEK
14、FIVECOILS,CESAREANSECTIONATTHE38THWEEKFIVECOILS,CESAREANSECTIONATTHE38THWEEKFIVECOILS,CESAREANSECTIONATTHE38THWEEK总总结结+妊娠和产褥期动脉瘤性蛛网膜下腔出血是孕妇死亡的一个重要原因。+该阶段以颈内动脉瘤为常见，破裂时期以妊娠第3个3月为常见，妊娠期再破裂机率高，死亡率高。+诊断要结合临床表现及影像学检查。+治疗方面，积极治疗，手术方式可选择夹闭术及栓塞术，可视情况选择手术方式，并做好胎儿监测及相关防护。+妊娠16周进行手术且母子平安的病例是笔者能查到最早的病例。YEAH，这，这家伙讲完了家伙讲完了!1.2.3.
