1、Amniotic Fluid Embolism,1,Serious intrapartum complicationA complex disorder caused by amniotic fluid entering maternal circuration and classically characterized by the abrupt onset of hypotension, hypoxia, and consumptive coagulopathyIncidence: 1:20000Mortality: 80% in term pregnancy,Amniotic Fluid
2、 Embolism(AFE),Rupture of membraneHypertonia of amnion cavityOpen blood sinusInjury of cervical canal or uterine wallPlacenta previa, placenta abruption, placenta marginal sinus ruptureAdherence site of placenta,Condition of AFE Onset,Premature rupture of membrane, artificial rupture or stripping of
3、 membrane, artificial expansion of cervixToo strong uterine contractionRigidity contraction and precipitate labour caused by inappropriate using of oxytocin and operation in cavityInjuryCervical laceration, rupture of uterus, uterine incision in caesarean section, forcep curettage,Predisposing facto
4、rs,Some pathological pregnancyTwin, multiplets, macrosomia, polyhydramnions, prolonged labour, dystocia, placenta abruption, placenta previa, retention of dead fetus, infection of amnion cavity, fetal distress Press abdoman and uterus by brute force,Internal cervical vein Amniotic fluid volume enter
5、ing maternal circulation related to : strength of contraction degree of injuryUterine placenta bed ：Broken venule in adherence site of placentaFissure in adherence site of placentaOpen decidua blood sinus placenta marginal vesselAmniotic permeationpressure of amniotic cavityintensity of amniotic mem
6、brane ,Pathway of amnion fluid entering maternal blood circulation,Pathyphysiology,Pulmonary hypertensionAllergic shorkDisseminated intravascular coagulation(DIC)Acute renal failure,Amniotic fluid(Epithelial cell, mucus,meconium, vernix caseosa, lanugo),Maternal circulation,allergic reaction,Bleedin
7、g without coagulation,chill,pulmonary circulation,Vessel embolism,Acute pulmonary heart disease,Vessel block ，stenosis,Pulmonary hypertention,returned blood volume to LA output,Vessel spasm,Right heart failure,Peripheral circulatory failure, Bp drop,shork,reflectively,bronchospasm,bronchi secretion
8、increased,bronchiostenosis,ventilation obstruct,Acute respiratory failure,toxicosis and anoxia of the whole body,Respiratory acidosis,cerebral anoxia,Anxious, seizure, coma,Histanoxia (cyanosis),renal anoxia,Metabolic acidosis,Acute renal failure,Abrupt onset , critical oncoming forceThree stages ap
9、pear in sequence in typical casesOnly mass vaginal bleeding and shork in atypical cases Degree of syptoms related to amount of particle matter in amniotic fluid, amount and velocity of amniotic fluid entering maternal circulatin,Clinical manifestation,Premonitory symptom： Short-period dysphoria, chi
10、ll and shiver, cough and dyspnea, cyanosis, vomit at the time of rupture of membrane Symptoms disappear after treatment in mild AFE, severe AFE arise three stages :Respiratory and circulatory failure, shorkBleeding caused by DICAcute renal failure,Acute respiratory and circulatory failure Obvious cy
11、anosis Dyspnea Coughing frothy sputum, raised heart rate, moist rales in lung Fall of blood pressure Coma, seizure Severe cases: scream, respiratory arrest, cardiopulmonary arrest ，die,Clinical manifestation the first stage,Coagulation disorders hypercoagulable statehypocoagulable stage Bleeding of
12、skin, mucosa, needle eye, incisionHematuria, hematemesisMass vaginal bleeding Typical symptom of DIC,Clinical manifestation the second stage,Multiple organ failure (MOF) Acute renal failure Oliguria urine volume 400ml/24h or 17ml/h Anuria 10”）Fibrinogen 50%) by mark，flow velocity 5-10L/minContinious
13、 positive airway pressure by trachea cannulaAntiallergic Dexamethasone 20mg iv, 20mg ivgtt p.r.nHydrocortisone 1000- 2000mg/d ivgtt,Step 1,Relieve pulmonary hypertensionParaverine ：Relax vascular smooth muscle30-90mg+5%GS20ml ivgttAmniophylline ：Dilate coronary artery and bronchi smooth muscle250mg+
14、5%GS 20ml ivgttAtropine ：Relieve pulmonary vasospasm, bronchospasm, cardiac depression1-2mg im or ivPhentolamine ：Relieve pulmonary vasospasm5-10mg+5%GS100ml ivgtt，adjust infusion rate according blood pressure,Correct shork Circulatory support with blood and component replacement ： central venous pr
15、essure(CVP): 8-10cmH2OAdjust vessel tensity：dopamine 10-20mg+5%GS 250ml ivgttTreat acidosis：5%NaHCO3 100-200ml ivgtt,Step 2,Treat DICHypercoagulability in early stageheparin 0.5mg-1mg/kg（heparin 1mg to be equivalent to 125IU） First 25mg+NS100ml ivgtt in 1h Then 25mg+5%GS500ml ivgtt Clotting time mai
16、ntain at 15min Excessive heparin detoxified using 1% equivalent protamine solution To plan CS is a contraindication of using heparin,Step 3,Hyperfibrinolysis Antifibrinolysis 6-aminoacetic acid (EACA）ivgttP-aminiomethyl beozonic acid(Pamba)200-300mg/d ivgttBlood coagulation factors supplyFresh blood
17、 Fresh frozen blood plasma, condensation sedimentPlatelet suspension , fibrinogenVitK 20-40mg to promote liver to synthesis coagulation factors,Prevent heart failure：Lanatoside 0.4mg+5%GS 20ml ivgtt slowly Energy mixturePrevent renal failure：Furosemide 40mg iv，repeated p.r.nPrevent infection：To select broad-spectrum antibiotic with less renal toxicity,Step 4,Obstetric management Onset in first stage of labor termination of pregnancy by CSOnset in second stage of labor termination of labor by vaginal midwiferyPPH occurred and not stopping bleeding hysterectomy,Thanks for your attention！,
