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中华产科急救电子杂志 ›› 2020, Vol. 09 ›› Issue (01) : 36 -43. doi: 10.3877/cma.j.issn.2095-3259.2020.01.009

所属专题： 经典病例； 文献；

论著

羊水栓塞心脏骤停成功救治一例并文献复习
程宁宁1, 梁轶珩2, 樊尚荣2,†(), 严少梅2   
  1. 1. 518036　深圳，安徽医科大学北大深圳医院临床学院
    2. 北京大学深圳医院妇产科
  • 收稿日期:2019-01-19 出版日期:2020-02-18
  • 通信作者: 樊尚荣

Amniotic fluid embolism followed by cardiac arrest- A case report and review of the literature

Ningning Cheng1, Yiheng Liang2, Shangrong Fan2,†(), Shaomei Yan2   

  1. 1. Peking University Shenzhen Hospital, Clinical College of Peking University Shenzhen Hospital, Anhui Medical University, Guangdong 518036, China
  • Received:2019-01-19 Published:2020-02-18
  • Corresponding author: Shangrong Fan
  • About author:
    Corresponding author: Fan Shangrong, Email:
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引用本文：

程宁宁, 梁轶珩, 樊尚荣, 严少梅. 羊水栓塞心脏骤停成功救治一例并文献复习[J]. 中华产科急救电子杂志, 2020, 09(01): 36-43.

Ningning Cheng, Yiheng Liang, Shangrong Fan, Shaomei Yan. Amniotic fluid embolism followed by cardiac arrest- A case report and review of the literature[J]. Chinese Journal of Obstetric Emergency(Electronic Edition), 2020, 09(01): 36-43.

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。

关键词: 羊水栓塞, 妊娠并发症, 心脏骤停
Objective

To explore the clinical features, diagnosis, treatment and the outcome of amniotic fluid embolism (AFE).

Methods

We retrospectivly studied the clinical manifestation, diagnosis, treatment and the outcome of 1 case of AFE in Peking University Shenzhen Hospital and previous 61 literature reports.

Results

We reported a case of AFE followed by cardiac arrest in a 39 years old woman who was admitted to the hospital with premature rupture of membranes at 39 weeks of gestation. Cardiopulmonary resuscitation and cesarean were performed immediately. The patient and the infant were healthy. The common aura symptoms of patients with AFE included polypnea (27 cases, 44.3%), cyanosis (14 cases, 21.3%), drop of blood pressure (11 cases, 18.0%), altered mental status (9 cases, 14.8%) and dysphoria (8 cases, 13.1%). The common clinical manifestations were circulatory dysfunction (52 cases, 85.2%), respiratory dysfunction (47 cases, 77.0%) and blood dysfunction (39 cases, 63.9%). Eight cases (13.1%) used extracorporeal membrane oxygenation (ECMO), and the prognosis was excellent. Of the 61 patients with AFE, 16 cases (26.2%) died and 45 cases (73.8%) survived. There are 35 cases described neonatal outcome, 24 cases(57.4%)were healthy, 4 cases (6.6%) were dead, 7 cases (11.5%) were transferred to the neonatal intensive care unit (NICU) and the outcome was unknown.

Conclusions

The main manifestations of AFE are circulatory failure, respiratory failure and coagulation failure. Early identification, high quality cardiopulmonary resuscitation and opportune termination of pregnancy are the main treatment methods.

Key words: Amniotic fluid embolism, Pregnancy complications, Cardiac arrest
图1 患者在AFE发生后胎心监护图。胎心监护提示胎心率减慢
图2 AFE患者生命体征及抢救措施。(1)正压面罩通气给氧及建立双静脉通道；(2)持续胸外心脏按压、静脉注射肾上腺素、气管插管、呼吸机机械通气和床边剖宫产；(3)剖宫产分娩一个活女婴；(4)间断静脉注射肾上腺素和多巴胺；(5)去甲肾上腺素8 mg＋生理盐水100 ml静脉滴注，肾上腺素1 mg静注；(6)建立右颈内静脉通路，持续静脉泵入去甲肾上腺素(24 μg/h)，然后间断静脉注射肾上腺素，同时快速输注晶体溶液、红细胞、新鲜冰冻血浆、冷沉淀和血小板；(7)去甲肾上腺素52.5 μg/h持续静脉泵入，浓缩红细胞11 U、新鲜冰冻血浆750 ml、冷沉淀26 U静脉输注；(8)5%碳酸氢钠溶液250 ml静滴；(9)第7凝血因子1.2 mg静注；(10)去甲肾上腺素0.017 5 μg/(kg·min)持续泵入转入ICU
表1 本例患者主要的实验室结果和处理*
项目 参考范围 入院 手术中** 转入ICU 术后第1天 术后第2天 术后第3天
白细胞(×109/L) 3.5～9.5 7.9 19.11 15.85 15.82 13.57 12.94
红细胞(×1012/L) 3.8～5.1 4.3 2.53 3.72 2.94 2.56 2.89
血红蛋白(g/L) 115～150 132 80 109 91 79 87
红细胞比积(%) 35～45 38.8 23.2 31.7 24.7 22.3 25.9
血小板(×109/L) 125～350 182 47 140 49 57 104
纤维蛋白原(g/L) 4～6 4.54 1.36 1.61 3.42 － 3.42
纤维蛋白(原)降解产物(mg/L) 0～5 － >159 42.44 >150 － －
D-二聚体(mg/L) 0～0.5 － >20 >20 >20 － 10.28
C反应蛋白(mg/L) <10 12.2 － 23.72 － － －
降钙素原(ng/mL) <0.05 － － 16.33 19.54 9.16 5.96
血肌酐(umol/L) 46～92 55 － 83 87 － －
总胆红素(umol/L) 8.5～29.2 0.9 － 69.3 22.5 14.5 16.4
丙氨酸氨基转移酶(U/L) 9～66 10 － 218 138 102 83
乳酸脱氢酶(U/L) 313～618 － － 3272 － － －
肌酸激酶(U/L) 30～170 － － 564 － － －
肌红蛋白(ng/ml) 0～61.5 － － － 267.4 116.1 84.9
乳酸(mmol/L) 0.7～2.1 － － 4.7 2.98 1.22 0.93
血清补体3(g/L) 0.7～1.4 － － 0.63 － － －
血清补体4(g/L) 0.1～0.4 － － 0.04 － － －
肌钙蛋白(ng/ml) 0～0.034 － － 14.000 － － －
高灵敏度肌钙蛋白(ng/ml) <0.014 － － 2.270 － － －
表2 61例AFE患者常见临床特征
临床表现 例(%)
循环功能障碍 52(85.2%)
呼吸功能障碍 47(77.0%)
血液功能障碍 39(63.9%)
神经功能障碍 28(45.9%)
肾功能障碍 5(8.2%)
肝功能障碍 1(1.6%)
表3 8例使用ECMO的AFE患者临床资料
文献 年代(年) 年龄(岁) 孕周(周) 孕产次 发生时间 临床特征 超声心动图 孕产妇结局 后遗症 住院天数(d) 新生儿情况
Seong等[22] 2018 32 39＋1 G2P1 阴道产时 血压下降，抽搐，呼吸心跳骤停，DIC 左心室严重收缩功能障碍 存活 无 13 －
Tincrès等[23] 2017 35 39 G1P0 分娩前 意识丧失，DIC，心脏骤停，ARDS， 急性肺心病 存活 无 39 －
Mita等[25] 2017 29 37 G4P1 剖宫产时 粉红色泡沫痰，室颤，持续低血压 前间隔运动减退，右心房和右心室增大 存活 无 142 －
Fang等[28] 2016 35 36 － 剖宫产时 反应迟钝，发绀，心脏停搏，室颤 右心室严重扩张和运动减退 存活 无 13 －
Wise等[29] 2016 34 39＋4 G1P0 阴道产时 疲倦，低血压，出血，DIC，粉红色泡沫痰，休克，ARDS 右心室轻度扩张运动减退，三尖瓣反流伴重度肺动脉高压 存活 无 18 健康
Hession等[30] 2016 33 41 G1P0 阴道产时 心脏骤停，DIC － 存活 无 26 健康
Sanghavi等[31] 2015 35 － G1P0 剖宫产后 呼吸衰竭，ARDS 右心室功能异常，平均肺动脉压54 mmHg 存活 无 － －
Ecker等[37] 2012 43 36＋4 G4P1 剖宫产后 血压血氧降低，呼吸暂停，心脏骤停 － 存活 无 13 健康
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