Amniotic Fluid Embolism
Page 251
You should rember!
? It is axiomatic that when a choice must be
made,maternal considerations take
perference over those of the fetus
Prognosis
? Perinatal outcomes are dismal with amniotic
fluid embolism,Few conditions in medicine
have potential for such sudden devastation,
We are aware of one case during labor in
which mother and baby not only died,but
the visiting grandmother also suffered a
fatal myocardial infarction during
resuscitation efforts on her daughter!
Defition
? Amniotic Fluid Embolism is a complex
condition characterized by the abrupt onset
of pulmonary embolism,shock and DIC.
? Incidence varies greatly.
Etiology
? Pressure increasing:
? uterinehypertonus,tetanic,oxytocin
? open vessles:traumatic,laceration
? membrane changing:fetal death,dystocia
pathophysiology
? Emblus(amniotic fluid component+fibrin)-----
allergic reaction
? --mechanic block+vagus nerve(spasm)----blood
return decreasing---peripheral circulation faiture
? --hypertetion of pulmonary artery---pulmonary
edema---left heart faiure+respiratory failure
? --coagulopathy---DIC
? --general ischemia—renal failure
Clinical manifestation
? A,time of onset
? B,circulation and respiratory failure
? C,shock,DIC----bleeding
? D,renal failure
diagnosis
? Emergent, typical clinical manifestation
? Pulmonary edema
? Definitive diagnosis,aspiration:debris +DIC
? autopsy
treatment
? 1.correct R&C failure
? 2.correct coagulopathy,DIC,renal
dysfunction
? 3.Anti-allergic reaction
? 4.obstetric management
Chapter 20
genetic counseling,genetic
screening,prenatal diagnosispage202
Genetic counseling
? 1.significance of genetic counseling
? 2.steps
? A.make the definitive diagnosis
? genetic disease/congenital disease/familial
disease/
? B.predict the effects on their offspring
? Autosomal dominant disease:expressed even when
only one chromosome of a pair carries an abnormal allele
? Autosomal recessive disease,expressed
only when both chromosomes of a pair
carry an abnormal allele.
? X-linked dominant
? X-linked recessive
? Multiple-gene disorders
? Chromosomal disorders
3.risk assessment
? Appreciation of disk for a genetic condition
is directly related to the degree of assurance
that a diagnosis truly exists without an exact
diagnosis,a risk assessment is difficult or
impossible,Four questions present
themselves each time a patient is seen by a
geneticist or genetic counselor:
? 1,What diagnostic entity is being
considered?
? 2.what is the cause?
? 3.might it happen again?
? 4.what diagnostic or management options
are available?
? An accurate diagnosis or possible diagnosis
helps address the first two questions,Risk
assessment and calculations aim to answer
the third question,Finally,patients’
perception of risk is directly tied to their
understanding of the diagnostic tests and
avaible treatments,
Genetic counseling
? A.premarriage counseling
? B.counseling contents
? (1) comprehend the medical facts,including the
diagnosis,probable course of the disorder and the
available management
? (2)appreciate the may heredity contributes to the
disorder and the risk of recurrence in specified
relatives
? (3)understand the options for dealing with
the risk of recurrence
? (4)choose the course of action that seems
appropriate to them in view of their risk and
the family goals and act in accordance with
that decision
? (5)make the best possible adjustment to the
disorder in an effected member and to the
risk of recurrence of that disorder.
notes
? It must be provided in the atmosphere of
reproductive choice and
options.Sophisticated prenatal diagnostic
testing requires coordinated educational and
psychosocial support,Patients referred for
prenatal diagnosis should be provided some
information before their arrival regarding
the tests for which they are being referred.
words
? Genotype Phenotype
? Alleles Polymorphisms
? Homozygous Heterozygous
? Pedigree sibship
? Risk of recurrence
Genetic screening
? Carrier screening
? Methods for genetic screening
? 1.amniocentesis( traditional---,early----)
? 2.chorionic villus sampling
? 3.fetograthy 4.fetoscopy
? 5.B-ultrasound
? 6.percutaneous umbilical blood sampling
? 7.fetocardiogram 8.MRI
Fetal Distress
Page 143
Definition
? Fetal distress is a kind of syndrome
presenting signs of fetal hypoxia which will
threaten the health and life of fetus
Etiology
? Fetal oxygen supplied from:
– maternal circulation-----placenta------umbilical
cord------fetus
? maternal factors
– cardiovescular diseases
– acute bleeding
– uterus placental blood supplied
Etiology
? Fetal factors
– cardiovescular dysfunction
– deformity
? umbilical cord and placental factors
– abnormal cord (page 211):entanglement,nuchal
umbilical cord
pathophysiology
? Hypoxia!
– Acidosis----sympathetic nerve excited----
? hypertension,
? tachycardia(initial signs)
– profound acidosis-----vagus nerve----
? hypotension,
? bradycardia,
? hyperperistalsis----meconium discharge
– chronic condition,
? nutritional deficiency----IUGR
Clinical manifestation
? Chronic fetal distress
– IUGR (FGR)
– dysfunction of maternal-placental-fetal unit
– fetal heart monitoring
– fetal movement calculation
– amnioscopy
产前的监护
? 产前监护包括检查胎动, 胎心率, 生物物理相评分,
宫内 Apgar评分, 胎儿生长速度, 胎盘, 脐带, 胎儿血
流以及一些生化检查 。
? 1,胎动：母亲感知胎动的记录：胎动是胎儿情况良
好的一种表现, 从孕 18-20周起, 孕妇可以自觉胎动,
正常情况下, 12小时内胎动不得少于 10次, 若少于 10
次或逐日下降超过 50%,表示胎儿有缺氧的可能；如
果胎儿突然剧烈活动, 接着胎动停止, 往往提示胎儿
宫内急性缺氧, 它的危险性更大 。 国外有文献报道,
分娩前 7天孕妇感到胎动减少预示, 不良围生期结局,,
包括分娩时胎心异常, 低 Apgar评分甚至胎死宫内或死
胎等 。
羊水检查
? 羊水检查：尽管羊水减少与胎儿宫内窘
迫关系的机制目前还不清楚, 但临床观
察确实证实了这一现象, 但关于羊水过
少的诊断标准也不完全一致, 有研究表
明, 羊水最深处 <3cm比羊水指数 <8cm预
测缺氧的价值更大 。
Clinical manifestation
? Acute fetal distress
– fetal heart rate
– characteristics of fluid
– fetal movement
– acidosis
分娩时的监测
? 1,羊水胎粪污染：宫内有胎粪排入羊
水可能是一种正常的生理现象, 是随着
胎儿成熟过程中不断增强的迷走神经的
张力而引起的 。 足月儿中羊水胎粪污染
占 10-15%,过期儿中占 25-50%。 因而关
于分娩过程中羊水胎粪污染的重要意义
尚有争议, 羊水有胎粪污染时应将胎粪
排出分为早期与晚期
continuous
? 早期胎粪排出是指在活跃期或其前破膜的时候就发现
羊水胎粪污染，又进一步分为轻或重度，轻重程度的
区分是以胎粪排出量（羊水的颜色）为基础；晚期胎
54%，分
娩后与对照组相比无明显差异；早期重度占 25%，这
种情况下的新生儿结局不良甚至胎死宫内或新生儿死
亡的比例大大增加, 与胎心异常及其他导致新生儿异
常的产科因素相关； 而晚期羊水胎粪污染大约占 21%，
其 1分钟及 5分钟 Apgar评分 <7分者是对照组的 2-3倍以
上，但无统计学差异，与某些宫内胎心异常联合出现
使 Apgar评分大大降低。
continuous
? 因此，有羊水胎粪污染的胎儿是否异常，最关键的是
判断胎粪排出的时间及量的多少, 临床上估计胎粪排
出的时间可以通过检查胎盘胎膜及新生儿来加以判断，
如下表 1-1：
? 表 1-1 出生前胎粪排出时间的判断
? 临床 /病理特点 距出生的大致时间
? 羊膜见载满色素的巨噬细胞 >1小时
? 绒毛见载满色素的巨噬细胞 >3小时
? 胎儿指甲有胎粪污染 >4-6小时
Premature rupture of membranes
(PROM) page163
definition
? The diagnosis of PROM is made whenever
the bag of water ruptures before the onset of
true labor.
incidence
? Varied greatly 2.7%--17%
? PROM is causally related to about 10%
perinatal deaths regardless of gestation age,
Its occurrence before term adds the risk of
neonatal respiratory distress syndrome
(RDS)from hyaline membrane disease to
the risk of chorioamnionitis neonatal sepsis
associated with ascending infection.
etiology
? The exact etiology of PROM remains unknown,
there have been many postulated causes,but a
single common denominator has not yet been
found.
? Such as,trauma/cervical incompetence/cervical
lacerations/cervical
operations/polyhydramnios/multiple
gestations/smokers/infection:subclinical infection,
chorioamnionitis,patients who had coitus within 7
days before delivery,
diagnosis
? Fern pattern detection
? PH determination
? accuracy rate:93-96%
? False-positive:
? cervicitis/vaginitis/presence of
semen,alkaline urine/blood in vagina
management
? Gestational age
? immature:<28w----- induction
? preterm:28—35w---controversial
? tocolytics----controversial?1)labor can be
one of the signs of chorioamnionitis---infection
problem may worsen2)less effective:only 24 hours
can be gained by using tocolytics in these patients,
all of these patients should be kept at bed rest and
evaluated for first signs of infection.
? >36w---inducible cervix---induction
? not favorable---24-48hs,90%labor
Page 251
You should rember!
? It is axiomatic that when a choice must be
made,maternal considerations take
perference over those of the fetus
Prognosis
? Perinatal outcomes are dismal with amniotic
fluid embolism,Few conditions in medicine
have potential for such sudden devastation,
We are aware of one case during labor in
which mother and baby not only died,but
the visiting grandmother also suffered a
fatal myocardial infarction during
resuscitation efforts on her daughter!
Defition
? Amniotic Fluid Embolism is a complex
condition characterized by the abrupt onset
of pulmonary embolism,shock and DIC.
? Incidence varies greatly.
Etiology
? Pressure increasing:
? uterinehypertonus,tetanic,oxytocin
? open vessles:traumatic,laceration
? membrane changing:fetal death,dystocia
pathophysiology
? Emblus(amniotic fluid component+fibrin)-----
allergic reaction
? --mechanic block+vagus nerve(spasm)----blood
return decreasing---peripheral circulation faiture
? --hypertetion of pulmonary artery---pulmonary
edema---left heart faiure+respiratory failure
? --coagulopathy---DIC
? --general ischemia—renal failure
Clinical manifestation
? A,time of onset
? B,circulation and respiratory failure
? C,shock,DIC----bleeding
? D,renal failure
diagnosis
? Emergent, typical clinical manifestation
? Pulmonary edema
? Definitive diagnosis,aspiration:debris +DIC
? autopsy
treatment
? 1.correct R&C failure
? 2.correct coagulopathy,DIC,renal
dysfunction
? 3.Anti-allergic reaction
? 4.obstetric management
Chapter 20
genetic counseling,genetic
screening,prenatal diagnosispage202
Genetic counseling
? 1.significance of genetic counseling
? 2.steps
? A.make the definitive diagnosis
? genetic disease/congenital disease/familial
disease/
? B.predict the effects on their offspring
? Autosomal dominant disease:expressed even when
only one chromosome of a pair carries an abnormal allele
? Autosomal recessive disease,expressed
only when both chromosomes of a pair
carry an abnormal allele.
? X-linked dominant
? X-linked recessive
? Multiple-gene disorders
? Chromosomal disorders
3.risk assessment
? Appreciation of disk for a genetic condition
is directly related to the degree of assurance
that a diagnosis truly exists without an exact
diagnosis,a risk assessment is difficult or
impossible,Four questions present
themselves each time a patient is seen by a
geneticist or genetic counselor:
? 1,What diagnostic entity is being
considered?
? 2.what is the cause?
? 3.might it happen again?
? 4.what diagnostic or management options
are available?
? An accurate diagnosis or possible diagnosis
helps address the first two questions,Risk
assessment and calculations aim to answer
the third question,Finally,patients’
perception of risk is directly tied to their
understanding of the diagnostic tests and
avaible treatments,
Genetic counseling
? A.premarriage counseling
? B.counseling contents
? (1) comprehend the medical facts,including the
diagnosis,probable course of the disorder and the
available management
? (2)appreciate the may heredity contributes to the
disorder and the risk of recurrence in specified
relatives
? (3)understand the options for dealing with
the risk of recurrence
? (4)choose the course of action that seems
appropriate to them in view of their risk and
the family goals and act in accordance with
that decision
? (5)make the best possible adjustment to the
disorder in an effected member and to the
risk of recurrence of that disorder.
notes
? It must be provided in the atmosphere of
reproductive choice and
options.Sophisticated prenatal diagnostic
testing requires coordinated educational and
psychosocial support,Patients referred for
prenatal diagnosis should be provided some
information before their arrival regarding
the tests for which they are being referred.
words
? Genotype Phenotype
? Alleles Polymorphisms
? Homozygous Heterozygous
? Pedigree sibship
? Risk of recurrence
Genetic screening
? Carrier screening
? Methods for genetic screening
? 1.amniocentesis( traditional---,early----)
? 2.chorionic villus sampling
? 3.fetograthy 4.fetoscopy
? 5.B-ultrasound
? 6.percutaneous umbilical blood sampling
? 7.fetocardiogram 8.MRI
Fetal Distress
Page 143
Definition
? Fetal distress is a kind of syndrome
presenting signs of fetal hypoxia which will
threaten the health and life of fetus
Etiology
? Fetal oxygen supplied from:
– maternal circulation-----placenta------umbilical
cord------fetus
? maternal factors
– cardiovescular diseases
– acute bleeding
– uterus placental blood supplied
Etiology
? Fetal factors
– cardiovescular dysfunction
– deformity
? umbilical cord and placental factors
– abnormal cord (page 211):entanglement,nuchal
umbilical cord
pathophysiology
? Hypoxia!
– Acidosis----sympathetic nerve excited----
? hypertension,
? tachycardia(initial signs)
– profound acidosis-----vagus nerve----
? hypotension,
? bradycardia,
? hyperperistalsis----meconium discharge
– chronic condition,
? nutritional deficiency----IUGR
Clinical manifestation
? Chronic fetal distress
– IUGR (FGR)
– dysfunction of maternal-placental-fetal unit
– fetal heart monitoring
– fetal movement calculation
– amnioscopy
产前的监护
? 产前监护包括检查胎动, 胎心率, 生物物理相评分,
宫内 Apgar评分, 胎儿生长速度, 胎盘, 脐带, 胎儿血
流以及一些生化检查 。
? 1,胎动：母亲感知胎动的记录：胎动是胎儿情况良
好的一种表现, 从孕 18-20周起, 孕妇可以自觉胎动,
正常情况下, 12小时内胎动不得少于 10次, 若少于 10
次或逐日下降超过 50%,表示胎儿有缺氧的可能；如
果胎儿突然剧烈活动, 接着胎动停止, 往往提示胎儿
宫内急性缺氧, 它的危险性更大 。 国外有文献报道,
分娩前 7天孕妇感到胎动减少预示, 不良围生期结局,,
包括分娩时胎心异常, 低 Apgar评分甚至胎死宫内或死
胎等 。
羊水检查
? 羊水检查：尽管羊水减少与胎儿宫内窘
迫关系的机制目前还不清楚, 但临床观
察确实证实了这一现象, 但关于羊水过
少的诊断标准也不完全一致, 有研究表
明, 羊水最深处 <3cm比羊水指数 <8cm预
测缺氧的价值更大 。
Clinical manifestation
? Acute fetal distress
– fetal heart rate
– characteristics of fluid
– fetal movement
– acidosis
分娩时的监测
? 1,羊水胎粪污染：宫内有胎粪排入羊
水可能是一种正常的生理现象, 是随着
胎儿成熟过程中不断增强的迷走神经的
张力而引起的 。 足月儿中羊水胎粪污染
占 10-15%,过期儿中占 25-50%。 因而关
于分娩过程中羊水胎粪污染的重要意义
尚有争议, 羊水有胎粪污染时应将胎粪
排出分为早期与晚期
continuous
? 早期胎粪排出是指在活跃期或其前破膜的时候就发现
羊水胎粪污染，又进一步分为轻或重度，轻重程度的
区分是以胎粪排出量（羊水的颜色）为基础；晚期胎
54%，分
娩后与对照组相比无明显差异；早期重度占 25%，这
种情况下的新生儿结局不良甚至胎死宫内或新生儿死
亡的比例大大增加, 与胎心异常及其他导致新生儿异
常的产科因素相关； 而晚期羊水胎粪污染大约占 21%，
其 1分钟及 5分钟 Apgar评分 <7分者是对照组的 2-3倍以
上，但无统计学差异，与某些宫内胎心异常联合出现
使 Apgar评分大大降低。
continuous
? 因此，有羊水胎粪污染的胎儿是否异常，最关键的是
判断胎粪排出的时间及量的多少, 临床上估计胎粪排
出的时间可以通过检查胎盘胎膜及新生儿来加以判断，
如下表 1-1：
? 表 1-1 出生前胎粪排出时间的判断
? 临床 /病理特点 距出生的大致时间
? 羊膜见载满色素的巨噬细胞 >1小时
? 绒毛见载满色素的巨噬细胞 >3小时
? 胎儿指甲有胎粪污染 >4-6小时
Premature rupture of membranes
(PROM) page163
definition
? The diagnosis of PROM is made whenever
the bag of water ruptures before the onset of
true labor.
incidence
? Varied greatly 2.7%--17%
? PROM is causally related to about 10%
perinatal deaths regardless of gestation age,
Its occurrence before term adds the risk of
neonatal respiratory distress syndrome
(RDS)from hyaline membrane disease to
the risk of chorioamnionitis neonatal sepsis
associated with ascending infection.
etiology
? The exact etiology of PROM remains unknown,
there have been many postulated causes,but a
single common denominator has not yet been
found.
? Such as,trauma/cervical incompetence/cervical
lacerations/cervical
operations/polyhydramnios/multiple
gestations/smokers/infection:subclinical infection,
chorioamnionitis,patients who had coitus within 7
days before delivery,
diagnosis
? Fern pattern detection
? PH determination
? accuracy rate:93-96%
? False-positive:
? cervicitis/vaginitis/presence of
semen,alkaline urine/blood in vagina
management
? Gestational age
? immature:<28w----- induction
? preterm:28—35w---controversial
? tocolytics----controversial?1)labor can be
one of the signs of chorioamnionitis---infection
problem may worsen2)less effective:only 24 hours
can be gained by using tocolytics in these patients,
all of these patients should be kept at bed rest and
evaluated for first signs of infection.
? >36w---inducible cervix---induction
? not favorable---24-48hs,90%labor
