羊水栓塞的观察及护理

羊水栓塞是产科严重的一种并发症，因其起病急，极为凶险，是造成产妇死亡的重要原因之一。本文总结和分析了羊水栓塞的观察及护理的方法，包括有效观察与预防、诊断准确、及时抢救和护理、肝素的合理使用及身心护理，其中通过及时地发现、诊断、抢救和护理可以有效治疗产妇出现的羊水栓塞。     

羊水栓塞的诊断与急救

羊水栓塞是产科严重的分娩期并发症,目前不可预知,难以预防。羊水栓塞的诊断属于临床诊断,应建立在床边的快速评估和判断的基础上,强调细致全面的排他性诊断。发生羊水栓塞后的抢救重点主要是支持和对症治疗。及时诊断,恰当的支持治疗,可以改善羊水栓塞患者的预后。     

对羊水栓塞的再认识

羊水栓塞是严重而罕见的产科并发症,其发病机制至今尚未阐明。一直以来,诊断羊水栓塞的金标准是在母体中心静脉血或肺动脉血管床组织切片中找到胎儿的有形成分,但目前的研究已使羊水栓塞的诊断受到质疑,母血中找到胎儿有形成分不再是诊断的必须依据。对于羊水栓塞的诊断,国内强调的是发病机制和病理过程,国外强调的是临床表现。目前认为羊水栓塞的发生无法通过对高危因素的识别和干预进行预测和预防。发生羊水栓塞后的抢救重点主要是支持和对症治疗。     

孕产妇羊水栓塞诊断与处理面临的挑战

羊水栓塞发病罕见，大多数医生都缺少直接处理该类案例的临床经验，临床上突然遭遇羊水栓塞时处理常常存在一定不足。文章旨在为临床医师提供帮助，以期提高及早诊断的能力，并为羊水栓塞患者建立适当的高级生命支持治疗，以改善产妇和围产儿结局。     

羊水栓塞的诊治分析

目的:探讨羊水栓塞的诱发因素及其临床诊断和处理方法。方法:选取2007年2月至2010年2月间分娩孕产妇羊水栓塞患者中6例作回顾性分析。结果:羊水栓塞死亡已经成为分娩孕产妇死亡的第二大原因;羊水栓塞发病的诱因主要有催产素的不当使用、胎膜早破、孕产妇宫缩过强或者急产等。结论:及早诊断、尽早治疗、第一时间去除病因是对羊水栓塞实施成功抢救的关键,适当地实施子宫切除手术一定程度上提高了抢救的成活率。     

羊水栓塞的诊治分析

目的：探讨羊水栓塞的诱发因素及其临床诊断和处理方法。方法：选取2007年2月至2010年2月间分娩孕产妇羊水栓塞患者中6例作回顾性分析。结果：羊水栓塞死亡已经成为分娩孕产妇死亡的第二大原因;羊水栓塞发病的诱因主要有催产素的不当使用、胎膜早破、孕产妇宫缩过强或者急产等。结论：及早诊断、尽早治疗、第一时间去除病因是对羊水栓塞实施成功抢救的关键,适当地实施子宫切除手术一定程度上提高了抢救的成活率。     

外周血液沉淀试验对羊水栓塞早期诊断的价值

目的：探讨外周血液沉淀试验对羊水栓塞早期诊断的价值。方法：采用血液沉淀试验对１５例羊水检塞患者（观察组）和１００例健康产妇（对照组）血清中羊水成分进行了检测。结果：观察组血清中均出现脂肪球、上皮细胞和毳毛等有形成分，而对照组孕妇血清中则没有上述成分，两组比较，差异有极显著性（Ｐ＜０．００５）。结论：外周血液沉淀试验对羊水栓塞有早期诊断价值     

剖宫产手术中羊水栓塞的防治

羊水栓塞是产科罕见但却是最为凶险的并发症，不仅是发达国家造成孕产妇死亡的主要原因，也逐步成为我国孕产妇死亡的前三位主要产科因素。文章回顾了近10年剖宫产手术与羊水栓塞的相关文献，对在剖宫产术中羊水栓塞的诊断、预防，尤其是包括产科、麻醉科等科室在内的多学科团队的联合救治进行了总结。     

羊水栓塞的早期诊断

羊水栓塞是产科中极其凶险的并发症之一,长期以来主要依靠典型的临床表现和相应的辅助检查协助诊断,而确诊往往需要尸解。传统的羊水栓塞诊断方法由于缺乏敏感性和操作复杂,临床上未能得到广泛使用。近年来,随着大量的临床和动物实验研究,加上免疫学技术的不断发展,对羊水栓塞的早期诊断有了一些新的、敏感的、无创伤性的检测方法。现对这些诊断方法做一简要综述。     

羊水栓塞致孕产妇死亡29例分析

对１９８９－１９９３年间北京地区因羊水栓塞所致的２９例孕产妇死亡病例进行了回顾性分析。结果发现：北京地区羊水栓塞的平均死亡率为５．９／１０万，占全部孕产妇死亡的１５．５％。其临床经过有１３例以产后出血、血不凝为主要表面；有１２例产程中使用过催产素；有半数以上的病发病后没有得到及时诊断。提示：发生羊水栓塞及死亡者多以凝血功能障碍为主要临床表现，产前催产素使用不当可能与羊水栓塞的发生有关。     

A noninvasive evaluation analysis of amniotic fluid embolism and disseminated intravascular coagulopathy

Objective.?Amniotic fluid embolism (AFE) is a complication of pregnancy with a high mortality rate. The diagnosis of AFE is currently based on clinical findings, acute respiratory distress, cardiovascular collapse during labor and delivery, and immediate massive postpartum hemorrhaging. The serum biological markers are unreliable, and their detection requires a long time intervals for result. An early diagnosis is very important and prompts the clinical management of the condition.

Study design and results.?We present here a noninvasive method (time frequency, entropy) to analyze heart rate variability (HRV). 3D-Spectrogram and entropy were derived from the RR interval of two pregnant subjects with AFE and disseminated intravascular coagulation (DIC) survived after delivering normal babies admitted to the Taiwan Seventh-day Adventists Hospital, and the entropy values were compared with those of 105 healthy pregnant subjects in the same hospital.

Conclusions.?We show that these methods can be successfully applied to the diagnosis of AFE and predict the prognosis of DIC. We also show that CT scans can be applied to the diagnosis of pulmonary embolism, eliminating the need to pathology.     

临床早期诊断羊水栓塞的进一步探讨

目的 :进一步探讨羊水栓塞 (AFE)的临床早期确诊。方法 :前瞻性地对 5例临床拟诊AFE者 ,取中心静脉血或外周血涂片 ,H E滴染 ;取同期 2 2例无心肺功能改变的足月孕妇及同期 4例死亡孕妇作对照组。结果 :5例拟诊羊水栓塞者 ,从作出临床诊断至发病的时间为 4～ 9小时 ,5例细胞学检查均找到角化与不全角化上皮细胞 ;对照组 2 2例孕妇中除 1例HELLP综合征的外周血涂片偶见角化上皮细胞外 ,余 2 1例及 4例死亡孕妇血中均未找到角化或不全角化上皮细胞。结论 :前瞻性地对有典型临床表现或疑诊AFE者进行细胞学检查是一种简单、迅速、可靠的AFE早期诊断方法     

Successful recovery from delayed amniotic fluid embolism with prolonged cardiac resuscitation

Amniotic fluid embolisms (AFE) are one of the most fatal complications of pregnancy. We describe a case of AFE that occurred 2 h after vaginal delivery at 41 weeks of gestation. The diagnosis of AFE was made by symptoms of dyspnea, coagulopathy, and severe hypotension. ZnCP-1, the characteristic component of meconium, was elevated in the serum. Cardiac compressions after repeated cardiac arrests were required during the initial 2 h of resuscitation. Primary resuscitation was performed with airway management and aggressive fluid management, including infusion of 33 units of red cell concentrates and 57 units of fresh frozen plasma. The patient recovered without any aftereffects. This case report warrants that AFE should be considered when coagulopathy and dyspnea are observed during the postpartum period.     

羊水栓塞DIC的处理及肝素使用问题

弥散性血管内凝血（disseminated intravascular coagulation，DIC）是羊水栓塞（amniotic fluid embolism，AFE）病理改变的重要原因之一。DIC造成大量凝血因子消耗和红细胞破坏，并加重肺动脉高压，也是AFE出血的主要原因。早期发现DIC，有助于AFE的诊断。减少促凝物质进入血液循环、抗凝治疗可阻断DIC的进一步发展。肝素应在DIC高凝期或低凝期早期使用，同时需补充凝血因子，监测凝血功能的变化。     

羊水栓塞心脏骤停成功救治一例并文献复习

目的探讨羊水栓塞的临床特征、诊断、治疗策略和母婴预后。 方法根据北京大学深圳医院收治的1例及文献报道的61例羊水栓塞患者的临床资料，对羊水栓塞的诊断、治疗方法及母婴预后进行回顾性分析。 结果本例患者39岁，妊娠39周因胎膜早破入院；分娩过程二次胎膜自破，破膜后出现全身抽搐、意识丧失，随后出现心脏骤停；立即进行紧急床边剖宫产和成功心肺复苏，最终母婴痊愈出院。文献检索61例羊水栓塞患者中的前驱症状包括呼吸困难27例(44.3%)、紫绀14例(21.3%)、血压降低11例(18.0%)、精神状态改变9例(14.8%)、烦躁8例(13.1%)等；临床表现循环功能障碍52例(85.2%)、呼吸功能障碍47例(77.0%)及血液功能障碍39例(63.9%)等；使用体外膜肺氧合治疗8例(13.1%)，预后均良好；死亡16例(26.2%)，存活45例(73.8%)，存活患者中仅3例(4.9%)有后遗症；35例(57.4%)有描述新生儿结局，其中24例(39.3%)健康，4例(6.6%)死亡，7例(11.5%)转入儿科结局未知。 结论羊水栓塞主要表现为循环、呼吸衰竭及凝血功能异常，早期识别、高质量心肺复苏和及时终止妊娠是主要救治方法。     

Amniotic fluid embolism: 10-year retrospective study in a level III maternity hospital

Objective

To provide updated data on amniotic fluid embolism (AFE) based on our population over a 10 year period, and to propose steps for improving current practice.

Study design

Retrospective study carried out in the Department of Gynaecology and Obstetrics at the Strasbourg University Teaching Hospital between 1 January 2000 and 31 December 2010. Dossiers of patients with AFE were identified using medical information system programme (MISP) coding and crosschecked with the pathology reports (hysterectomy, post-mortem examination).

Results

Eleven dossiers were found (0.28/1000). Eight cases (73%) of AFE occurred during labour, two (18%) in the post-partum period and one (9%) outside of parturition. Induction was initiated in four patients (45%) and labour sustained with oxytocin in 9 patients (90%). Acute circulatory collapse with cardio-respiratory arrest (CRA) was the herald symptom of AFE in 2 patients, and secondary cardio-respiratory arrest occurred rapidly in 6 patients (55%) following a relatively non-indicative prodromal phase. Disseminated intravascular coagulopathy (DIC) was observed in 10 cases (91%) and massive transfusion was necessary in all patients. Seven haemostatic hysterectomies (63%) were performed, with secondary arterial embolisation in 2 cases (22%). Although all patients presented a clinical picture of AFE, confirmation through histology or laboratory test results was forthcoming in only 7 cases (63%). Three patients died (27%). When AFE occurred during labour, 8 fetuses (75%) received intensive care support. In all, 11 newborns survived (85%). Their pH was less than 7.00 in 3 cases (27%) and 4 fetuses (36%) had an Apgar score of less than 5 at 5 minutes of life.

Conclusion

AFE is a rare but extremely serious disease. Some risk factors for AFE have been identified but they do not allow its occurrence to be predicted. The diagnosis may be supported by specific laboratory test results but only a post-mortem examination provides a pathognomonic diagnosis: unfortunately it is always retrospective. Obstetrical and intensive care management is complex and must be adapted to the situation bearing in mind the significant risk of haemorrhage and DIC. Hysterectomy must be performed if there is the least doubt.