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剖宫产术中心脏骤停——一例可能的羊水栓塞病例

Sudden cardiac arrest during cesarean section -- a possible case of amniotic fluid embolism.

作者信息

Mahshid Nikooseresht, Ahmad Sadegian, Nahid Manochehrian, Afshin Farhanchi

机构信息

Department of Anesthesiology and Intensive Care, Hamadan University of Medical Sciences, Fatemieh Hospital, Hamadan, Iran.

出版信息

Middle East J Anaesthesiol. 2009 Jun;20(2):315-7.

Abstract

Amniotic Fluid Embolism (AFE) is a rare obstetric catastrophe that occurs in approximately 1/50,000 pregnancies and has a mortality rate in excess of 80%. AFE is a condition that is poorly understood and often difficult to diagnose. We report a case of a healthy 27-yr-old gravid two, 35 wk gestation parturient with a previous Cesarean section two years previously, and presently admitted for emergent Cesarean section due to premature uterine contractions. Induction of general anesthesias was performed with no problem and a male preterm infant with Apgar 8 at 1 min was delivered. Amniotic fluid was bloody and 40% placental abruption existed. Following delivery of the placenta, patient suddenly became plethoric and O2 saturation began to decrease and no pulse could be palpated! Immediate CPR was successful but she was hemodynamically unstable and signs of right heart strain was obvious. Right jugular venous catheterization was performed, vasopressors were administered. After a two hours period of relatively stable vital signs, patient's reflexes returned to normal, however, profound coagulopathy on lab data was reported and she was treated with 10 unit Packed Red Blood Cells (PRBCs), 10 unit FFP and 8 unit platelets, Sodium bicarbonate, oxytocin and Methergine. The patient remained hemodynamically unstable while laparotomy-hysterectomy was performed to stop the bleeding. Unfortunately attempts were unsuccessful and patient died four hours later in ICU. Post-mortem findings showed signs of Disseminated Intravascular Coagulation (DIC), no fetal squamous cells in pulmonary vasculature were found and special staining of Cytokeratin marker shows no positive cells in lumen of vessels. The post-mortem diagnosis of AFE is challenging to forensic investigators and pathologists and can be confirmed by histological confirmation of amniotic fluid contents in the pulmonary vasculature, although they may be difficult to identify. In recent years it has been suggested that AFE is an anaphylactoid reaction to fetal antigens and an elevated serum tryptase level is increasingly being used to support the diagnosis. Sudden onset of cardiovascular collapse and early signs of right heart strain and fulminant DIC supports the diagnosis of AFE in this case, although no fetal debri could be find in pathologic staining.

摘要

羊水栓塞(AFE)是一种罕见的产科灾难,发生率约为1/50000次妊娠,死亡率超过80%。AFE是一种人们了解甚少且常常难以诊断的病症。我们报告一例病例,患者为一名27岁、孕2产、妊娠35周的健康产妇,两年前曾行剖宫产,此次因先兆子宫收缩入院行急诊剖宫产。全身麻醉诱导过程顺利,娩出一名1分钟Apgar评分8分的早产男婴。羊水呈血性,存在40%的胎盘早剥。胎盘娩出后,患者突然面色潮红,血氧饱和度开始下降,触不到脉搏!立即进行心肺复苏成功,但患者血流动力学不稳定,右心劳损体征明显。行右颈内静脉置管,给予血管升压药。经过两小时生命体征相对稳定期后,患者反射恢复正常,但实验室检查报告显示存在严重凝血功能障碍,遂给予10单位浓缩红细胞(PRBC)、10单位新鲜冰冻血浆(FFP)和8单位血小板、碳酸氢钠、缩宫素和麦角新碱治疗。患者血流动力学仍不稳定,同时行剖腹子宫切除术以止血。遗憾地是,手术未成功,患者4小时后在重症监护病房死亡。尸检结果显示有弥散性血管内凝血(DIC)迹象,肺血管内未发现胎儿鳞状细胞,细胞角蛋白标记物的特殊染色显示血管腔内无阳性细胞。AFE的尸检诊断对法医和病理学家来说具有挑战性,尽管可能难以识别,但可通过肺血管内羊水成分的组织学证实来确诊。近年来,有人提出AFE是对胎儿抗原的类过敏反应,血清类胰蛋白酶水平升高越来越多地被用于支持诊断。心血管崩溃的突然发作、右心劳损的早期体征和暴发性DIC支持本例AFE的诊断,尽管病理染色未发现胎儿碎片。

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