糖尿病對母兒的影響

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 consum

2、ptive coagulopathyIncidence: 1:20000Mortality: 80% in term pregnancy,Amniotic Fluid Embolism(AFE),Rupture of membraneHypertonia of amnion cavityOpen blood sinusInjury of cervical canal or uterine wallPlacenta prev

3、ia, placenta abruption, placenta marginal sinus ruptureAdherence site of placenta,Condition of AFE Onset,Premature rupture of membrane, artificial rupture or stripping of membrane, artificial expansion of cervixToo str

4、ong 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,

5、forcep curettage,Predisposing factors,,Some pathological pregnancyTwin, multiplets, macrosomia, polyhydramnions, prolonged labour, dystocia, placenta abruption, placenta previa, retention of dead fetus, infection of amn

6、ion cavity, fetal distress Press abdoman and uterus by brute force,Internal cervical vein Amniotic fluid volume entering maternal circulation related to : strength of contraction

7、degree of injuryUterine placenta bed ：Broken venule in adherence site of placentaFissure in adherence site of placentaOpen decidua blood sinus placenta marginal vesselAmniotic permeation?pressure o

8、f amniotic cavity↑?intensity of amniotic membrane ↓,Pathway of amnion fluid entering maternal blood circulation,Pathyphysiology,Pulmonary hypertensionAllergic shorkDisseminated intravascular coagulation(DIC)Acute ren

9、al failure,Amniotic fluid(Epithelial cell, mucus,meconium, vernix caseosa, lanugo),Maternal circulation,Ⅰallergic reaction,Bleeding without coagulation,chill,pulmonary circulation,Vessel embolism,Acute pulmonary heart

10、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 incr

11、eased,bronchiostenosis,ventilation obstruct,Acute respiratory failure,toxicosis and anoxia of the whole body,Respiratory acidosis,cerebral anoxia,Anxious, seizure, coma,Histanoxia (cyanosis),renal anoxia,Met

12、abolic acidosis,Acute renal failure,,Abrupt onset , critical oncoming forceThree stages appear in sequence in typical casesOnly mass vaginal bleeding and shork in atypical cases ——Degree of syptoms re

13、lated to amount of particle matter in amniotic fluid, amount and velocity of amniotic fluid entering maternal circulatin,Clinical manifestation,Premonitory symptom： Short-period dysphoria, chill and shiver, cough a

14、nd 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 rena

15、l failure,,Acute respiratory and circulatory failure Obvious cyanosis Dyspnea Coughing frothy sputum, raised heart rate, moist rales in lung Fall of blood pressure Coma, seizure Severe cases: scre

16、am, respiratory arrest, cardiopulmonary arrest ，die,Clinical manifestation ——the first stage,Coagulation disorders hypercoagulable state→hypocoagulable stage Bleeding of skin, mucosa, needle eye, inc

17、isionHematuria, hematemesisMass vaginal bleeding Typical symptom of DIC,Clinical manifestation ——the second stage,Multiple organ failure (MOF) Acute renal failure Oliguria urine volume < 400ml/24

18、h or 17ml/h Anuria <100ml/24h ，metabolic disturbance Azotemia Obvious jaundice, ascite,Clinical manifestation ——the third stage,,After rupture of membrane , after birth, or in operation Break

19、out shiver, bucking, dyspnea, dysphoria, scream, dyspnea, cyanosis, seizure, bleeding, shork unkown reason, AFE should be considered Rescue immediately ——The key to improve rescue livability is correct and prompt

20、 dignosis, effective therapeutic measures,Dignosis,Blood smear to find amniotic visible particleBedside chest X-lay Bedside ECG or CDFI Right atrium enlargement, cardiac damageLaboratory examination related to DIC,As

21、sistant examination,Blood smear to find amniotic visible matter,,Blood sample from pulmonary artery by Papanicolaou's staining Left A (case1)shows pink and wedge-shaped fetal squamous epithelium , left B(case2)

22、 shows pink fetal squamous epithelium surrounded by platelet Right A(case1)，right B(case2) showed fetal squamous epithelium from bronchic asearse fluid （red arrow）Cite from ：Pluymakersa C, Weerdta A D, Jacquemynb Y, et

23、 al. Amniotic fluid embolism after surgical trauma:Two case reports and review of the literature. Resuscitation. 2007;72(2):324-32.,,Squamous epithelium in a peripheral pulmonary artery,Fetal keratin in a peripheral pul

24、monary artery,Bedside chest X-lay,Disseminated effusion in pulmonary alveolusCite from：Pluymakersa C, Weerdta A D, Jacquemynb Y, et al. Amniotic fluid embolism after surgical trauma:Two case reports and review of the li

25、terature. Resuscitation. 2007;72(2):324-32.,Dissipative hypocoagulability Progressive drop of platelet count （3”）Kaolin active partial thromboplastin time( KPTT ? > 10”）Fibrinogen < 1.5/L,Coagulation examinat

26、ion,Secondary hyperfibrinolysisPlasma Protamine para-coagulation test (3P test)OthersD-dimerAntithrombase Ⅲ（AT Ⅲ)Fibrinopeptide A（FDA）Fibrin degradation production (FDP）Capillary hemolysisBroken RBC more than 10

27、% in 20~30% blood smears of late stage DIC,To draw right ventricle blood for precipitation test to find visible particle of amniotic fluidAutopsy Notable right ventricle expansionPulmonary edema, alveolar hemorrhage

28、, embolus containing amniotic particle in kidney, heart, brain, uterine, or broad ligament , embolus containingDeciduous squamous epithelial cell from fetal skinLanugo Fragment of fetal skin and amnion Mucin from f

29、etal intestinal tractBile from meconium,Dignosis after death,Air embolism：severe chest and back pain, sence of precordia pressure, occurred in rupture of uterus, placenta previa, operation in cavityPulmonary embolism

30、by thrombus：varicose vein and thrombophlebitis of lower limb, occurred at 9-14 days after birth, acute chest pain, bloody sputum, chest fricative, pulmonary embolism in X-rayEclampsia ：hypertention, proteinuria, shork a

31、ppeared laterRupture of uterus：cephalopelvic disproportion, signs of impending of rupture of uterus ( abdominal pain, hematuria),Differential diagnosis,Reasonable using of oxytocin, to master indication and controll dos

32、e, watched by special personAvoid inappropriate operation in uterine cavity and birth canal injuryNotice in artificial rupture of membraneAvoid pressing abdomen and uterus strongly at the time of delivery of babyMast

33、er indication of CS strictlyUsing sedative to suppress excessive contraction,Prevention,To rescue quickly and decisivelyTo treat respiratory and circulatory failure firstlyAppropriate obstetric management,Principle

34、of management,Steps of management,Improve hypoxemiaSemireclining positionOxygen uptakeHigh concentration oxygen(>50%) by mark，flow velocity 5-10L/minContinious positive airway pressure by trachea cannulaAntiall

35、ergic 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 coro

36、nary artery and bronchi smooth muscle250mg+5%GS 20ml ivgttAtropine ：Relieve pulmonary vasospasm, bronchospasm, cardiac depression1-2mg im or ivPhentolamine ：Relieve pulmonary vasospasm5-10mg+5%GS100ml ivgtt，adj

37、ust infusion rate according blood pressure,Correct shork Circulatory support with blood and component replacement ： central venous pressure(CVP): 8-10cmH2OAdjust vessel tensity：dopamine 10-20mg+5%GS 250ml i

38、vgttTreat acidosis：5%NaHCO3 100-200ml ivgtt,Step 2,Treat DICHypercoagulability in early stage——heparin 0.5mg-1mg/kg（heparin 1mg to be equivalent to 125IU） First 25mg+NS100ml ivgtt in 1h Then 25mg+5%GS500ml ivg

39、tt Clotting time maintain 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 ac

40、id (EACA）ivgttP-aminiomethyl beozonic acid(Pamba)200-300mg/d ivgttBlood coagulation factors supplyFresh blood Fresh frozen blood plasma, condensation sedimentPlatelet suspension , fibrinogenVitK 20-40mg to promot

41、e 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-spec

42、trum 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 ——termi