产科危重症合并多系统器官功能障碍综合征与母婴结局

目的 :探讨产科危重症合并多系统器官功能障碍综合征 (MODS)与母婴结局的关系 ,以提高产科危重症合并MODS的救治水平。方法 :对 4 8例产科危重症按 1995年重修MODS疾病评分标准进行诊断分析 ,并行多学科综合监护和救治。结果 :4 8例产科危重症 ,产妇死亡 12例 (2 5 .0 % ) ,围生儿死亡 14例 (2 9.17% ) ,母、婴病死率随脏器衰竭数目的增加而增加 (P <0 .0 0 5 ,P <0 .0 5 ) ,与终止妊娠的方式无关 ;围生儿死亡与终止妊娠的时机有关 ,孕周越小病死率越高(P <0 .0 0 5 )。结论 :产科危重症合并MODS的母婴死亡率高 ,抢救难度大 ,采用MODS评分进行产科危重症监护 ,结合产科处理与多学科综合救治方法 ,有利于提高临床监护效果 ,从而提高抢救成功率     

妊娠合并多器官功能障碍综合征患者原发病因及其死亡原因分析

目的 探讨妊娠合并多器官功能障碍综合征（MODS）患者的原发病因及其死亡原因。方法 对2000年1月至2006年12月广州医学院第三附属医院收治的206例妊娠合并MODS患者的原发病因及其死亡原因进行回顾性分析。结果 （1）原发病因：206例妊娠合并MODS患者主要原发病因依次为产后出血63例（30．6％），重度子痫前期及子痫60例（29．1％），妊娠合并肝炎23例（11．2％），妊娠合并心脏病11例（5．3％），异位妊娠12例（5．8％）。（2）死亡原因：206例妊娠合并MODS患者中死亡44例，死亡的主要原发病因为产后出血11例（17．5％，11／63），重度子痫前期及子痫7例（11．7％，7／60），妊娠合并心脏病7例（63．6％，7／11），妊娠合并肝炎6例（22．7％，6／23），异位妊娠5例（41．7％，5／12）。结论 妊娠合并MODS原发病因中以产科因素为主；不同原发病器官功能障碍的死亡率有明显差异，其中原发病器官为心脏、脑的死亡率较高。提示临床工作中可根据不同原发病器官采取相应的预防和治疗措施。     

产科休克合并多器官功能障碍综合征的诊断及处理

产科休克是指在妊娠与分娩期由各种不同原因所导致的休克，是产科紧急情况，患者常因有效循环血量不足，使组织灌注急剧减少，引起细胞缺氧和代谢障碍，可同时或序贯发生2个或更多的重要脏器的功能障碍而产生多器官功能障碍综合征（MODS），如心、脑、肾、肺、肝等受到严重损害、严重时可导致患者死亡。所以，及时诊断与处理、防止产科休克患者合并多器官功能障碍综合征的发生是降低孕产妇死亡率的关键。     

改良产科危重症评分在危重孕产妇病情评估中的意义

目的评价改良产科危重症评分系统在危重孕产妇病情评估中的意义。方法收集2004年1月至2010年12月转入福建医科大学附属第一医院ICU161例产科危重症临床病例。应用新建立的产科危重症病情评估系统对患者进行病情严重程度量化评分。比较死亡组与存活组之间各评分分值的差异。将APACHEⅡ评分系统和改良产科危重患者评分系统对危重症患者的诊断率做ROC曲线,找出截断值。分析患者评分分值与患者各器官功能障碍及预后的关系。结果改良产科危重症评分中存活组评分为8.33±5.74,死亡组为17.93±5.00,死亡组的评分明显高于存活组,差异有统计学意义(P<0.05)。随分值增加,病死率增加。改良产科危重症评分ROC曲线下面积(0.914)大于APACHEⅡ评分ROC曲线下面积(0.859)。随着评分的升高,母亲的器官功能障碍的阳性率增加,且与器官功能障碍发生数目增多呈显著正相相关关系(Kendall相关系数b=0.651,spearman相关系数b=0.784,均为P=0.000)。结论改良产科危重症评分比APACHEⅡ评分对危重孕产妇预后的预测性优越,评分分值越高,病情越重。改良产科危重症评分分值升高,母亲器官功能障碍发生的阳性率增加。     

重度子痫前期并发急性肾损伤临床分析

目的了解重度子痫前期并发急性肾损伤(acute kidney injury,AKI)患者的临床发病特点。 方法对广州医科大学附属第三医院产科2005年8月至2011年7月收治的90例重度子痫前期并发AKI的病例资料进行回顾性分析,包括患者的一般资料、发病特点和临床结局等。 结果(1)重度子痫前期并发AKI的主要病因依次为严重产后出血、胎盘早剥、HELLP综合征以及合并基础肾脏疾病;(2)多器官功能障碍的发生率为63.3%(57/90),重症监护病房入住率64.4%(58/90),病死率15.6%(14/90);(3)AKI 1期治愈率71.9%(23/32),2期治愈率62.5%(5/8),3期治愈率28.0%(14/50),即随着急性肾损伤分期的增加,重度子痫前期并发AKI患者的治愈率逐渐下降,而病死率有所增加;(4)重度子痫前期合并AKI死亡的14例患者中,主要死因分别为多器官功能障碍7例,脑血管意外4例,严重产后出血2例,呼吸衰竭1例。 结论重度子痫前期并发AKI的主要病因为严重产后出血、胎盘早剥、HELLP综合征以及合并基础肾脏疾病;并发多器官功能障碍、脑血管意外和严重产后出血是患者死亡的主要原因。     

APACHE Ⅱ评分在综合ICU产科危重患者中的应用

目的评估急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)在预测综合ICU产科危重患者的病情预后中的应用效果。方法连续观察2000年1月~2004年4月转入GICU资料完整产科危重患者81例,应用APECHEⅡ评分预测死亡风险率,并进行验证。结果81例产科危重患者APACHEⅡ评分范围6~56分,平均为(20.02±9.55)分;64例生存者评分为(18.24±6.95)分;17例死亡者评分为(30.39±10.54)分,两者差异有显著性P<0.001;随着APACHEⅡ评分的增高,预测死亡风险的阳性率逐渐升高;APACHEⅡ评分对以非产科医学指征转入GICU患者的死亡风险预测的阳性率可高达93.03%,而对以产科指征转入者其阳性率仅为30.91%。结论APACHEⅡ评分系统能在一定程度上评价产科危重患者疾病的严重程度和预测预后,尤其对妊娠合并内外科危重疾病患者的预后评估有较好的价值。但产科危重患者是一独特的群体,APACHEⅡ评分系统的应用有一定的局限性,有必要开发一种产科危重患者专用的病情严重程度及预后的评估系统。     

妊娠期急性脂肪肝21例临床分析

目的:探讨妊娠期急性脂肪肝(AFLP)的临床特点。方法:对我院21例AFLP患者的临床表现、治疗及预后进行回顾性分析。结果:AFLP的临床表现以肝损害为主伴多器官功能受损。轻型组10例,无死亡。重型组11例,死亡2例。结论:早诊断、及时终止妊娠,积极支持治疗,多学科合作抢救多器官功能障碍综合征(MODS)是降低AFLP死亡率的关键。     

妊娠期高血压疾病并发多器官功能障碍综合征的诊治

多器官功能障碍综合征（MODS）为急性疾病过程中同时或序贯2个或更多的重要脏器的功能障碍或衰竭。严重的妊娠期高血压疾病及其并发症是导致产科MODS的常见诱因，是导致孕产妇病死的重要原因。目前MODS在产科危重患者抢救中仍是一个难题。     

晚期妊娠分娩前休克37例处理及围生期结局

目的:探讨晚期妊娠分娩前发生休克患者的积极治疗方法以改善围生期母耍的结局.方法:对2000年1月至2008年6月在我院产科分娩的、资料齐全的37例晚期妊娠分娩前发生休克患者的临床资料进行回顾性分析.结果:晚期妊娠分娩前发生休克以低血容量性休克为主,占62.2%(23/37),除1例外,休克或入院至胎儿娩出的平均时间55.6分钟.终止妊娠的方式,剖宫产占86.5%(32/37),阴道分娩占13.5%(5/37).共分娩39个新生儿,其中早产儿51.3%(20/39)、围生儿死亡率12.8%(5/39).行子宫切除3例.发生多器官功能障碍综合征(MODS)3例,无孕产妇死亡.结论:晚期妊娠分娩前发生休克,通过及时诊断、积极抗休克治疗,适时终止妊娠,大多数患者可以取得良好的围生期结局.     

125例妊娠并发弥散性血管内凝血原发病因与预后分析

目的:探讨妊娠并发弥散性血管内凝血(DIC)患者的原发病因及其预后.方法:对2004年1月至2009年12月我院收治的125例妊娠并发DIC患者的病因及其死亡原因进行回顾性分析.结果:①125例妊娠并发DIC患者主要病因为产后出血49例(39.2％)、胎盘早剥25例(20.0％)、妊娠期急性肝病15例(12.0％)、重度子痫前期或子痫10例(8.0％)、羊水栓塞10例(8.0％).②26例死亡患者引起死亡的主要病因为羊水栓塞(50.0％,5/10)、妊娠期急性肝病(40.0％,6/15),产后出血(16.3％,8/49),胎盘早剥(16.0％,4/25).③不同病因的DIC死亡患者出现功能障碍的器官不一样.结论:妊娠并发DIC原发病因中以产科因素为主;不同原发病因DIC患者死亡率有明显差异,累及的系统或器官不同.提示临床工作中可根据不同原发病因采取相应的预防和治疗措施.     

机械通气在危重症孕产妇中的应用

目的分析危重症孕产妇行机械通气治疗的特点和围产结局。 方法对广州医科大学附属第三医院妇产科重症孕产妇救治中心ICU 1999年1月至2008年1月收治的114例需机械通气治疗的危重症孕产妇临床相关资料进行回顾性分析,包括一般资料、行机械通气治疗的病种和指征、未分娩者行机械通气情况、呼吸机模式的选择与通气指标以及脱机情况等。 结果114例需机械通气治疗的危重症孕产妇中,未分娩者10例,其中8例合并有基础疾病,6例胎儿在行机械通气治疗前已发生胎死宫内。需机械通气的产科病因主要为重度子痫前期或子痫及相关并发症(34.21%)、失血性休克(27.19%),非产科病因主要为妊娠合并风湿性心脏病并心力衰竭(6.14%)和妊娠合并重症肝炎(6.14%)。危重症孕产妇行机械通气治疗的主要指征是低氧血症(62.28%)和低通气量(37.72%)。孕产妇死亡26例,占22.81%。 结论危重症孕产妇机械通气的产科病因主要为重度子痫前期或子痫及相关并发症和失血性休克等;容量控制下的同步间歇指令通气(SIMV)＋压力支持通气(PSV)＋呼气未正压(PEEP)模式是机械通气呼吸机的常用模式,可减少孕产妇肺水肿的发生;在危重症孕产妇救治过程中机械通气的特点值得产科及ICU科医生重视。     

Anesthesia for the high-risk parturient

High-risk pregnancies require specialized obstetric and anesthetic care. A basic understanding of how specific pathophysiology and pharmacologic therapy interact with anesthetic care is essential for both obstetrician and anesthesiologist. This paper selectively focuses on preeclampsia/eclampsia, diabetes mellitus, prematurity, multiple gestations, infectious disease, preexisting neurologic disease, and preexisting cardiac disease, reviewing anesthesia for labor and vaginal and cesarean delivery for each high-risk problem, as practiced at a Level III perinatal unit. Emphasis will be placed, when appropriate, on recent experience with monitoring and aggressive pharmacologic therapy of the critically ill parturient.     

Study of serum levels of superoxide dismutase in preeclampsia and eclampsia: role of the test as a predictive tool

AIM: To report serum levels of superoxide dismutase in women with preeclampsia and eclampsia. To document the use of the value as a predictive tool for deciding the time of onset of subsequent convulsions with fulminating eclampsia and use of the value as a marker for obstetric intervention in clinical severe preeclampsia and eclampsia. METHODS: Superoxide dismutase concentration was measured in a consecutive study in sera of women admitted in obstetric ward for preeclampsia and eclampsia, and compared with sera of normotensive, healthy pregnant women in third trimester. Three mL venous blood was subjected to superoxide dismutase estimation by pyrogallol autoxidation method. RESULTS: We found statistically significant difference (P < 0.05) in mean superoxide dismutase levels of normotensive pregnant women; and preeclamptic and eclamptic subjects, no statistically significant difference was found in between value of enzyme in preeclampsia and eclampsia (P > 0.05). Superoxide dismutase levels in two pregnancy outcomes; live births and still births, shows significant difference (P < 0.05), being 1.03 U/mL and 0.52 U/mL, respectively. The comparison of values before delivery and after delivery showed highly statistically significant difference (P < 0.001) in both groups separately. The cut-off value of serum superoxide dismutase 0.52 U/mL has sensitivity 68.5%, specificity 59.5% and negative predictive value of 78.6%, for predicting the fetal death as outcome of pregnancy with severe grade of disease. CONCLUSION: We found low levels of serum superoxide dismutase, less than 0.52 U/mL, being the predecessor of fulminating eclampsia. Our results support this predictive value of serum superoxide dismutase level as important in deciding the time of intervention as termination of pregnancy.     

Characteristics and outcome of severe preeclampsia/eclampsia concurrent with or complicated by acute pancreatitis: a report of five cases and literature review

Objective: The objective of this study is to determine the rate of acute pancreatitis in preeclampsia/eclampsia patients and describe the clinical manifestations, treatment characteristics and outcome of five cases of severe preeclampsia concurrent with or complicated by acute pancreatitis.

Methods: The clinical data of pregnant women with preexisting or gestational hypertension who sought medical care between January 2002 and December 2015 at the Pregnant Women Critical Care Unit of Chaoyang Hospital, Capital Medical University, Beijing, China were retrieved. The rate of acute pancreatitis in preeclampsia/eclampsia patients was calculated and patients with preeclampsia/eclampsia and acute pancreatitis were included for further analysis.

Results: Totally 1703 pregnant women who received medical care at our institution during the review period were diagnosed with hypertension. Four hundred and seven (23.9%) of them had severe preeclampsia. Five (1.2%, 5/407) women with severe preeclampsia developed acute pancreatitis. Their median age was 32 (range 25–35) years and the median duration of gestation was 32 (range 28–40) weeks. Mild acute pancreatitis occurred in three cases, and moderately severe and severe acute pancreatitis in one case each. Four patients underwent cesarean resection and one patient underwent vaginal delivery. Conservative therapy was undertaken. No patient received surgical intervention and cure was achieved in all patients.

Conclusion: Acute pancreatitis may complicate severe preeclampsia/eclampsia or may be concurrent with severe preeclampsia/eclampsia, complicating and compromising the management of preeclampsia/eclampsia. Physicians should be alert for the presence of acute pancreatitis as prompt diagnosis and treatment, rapid termination of pregnancy and subsequent conservative management of pancreatitis could lead to a general favorable outcome.     

Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials

In the US, the routine use of magnesium sulfate for seizure prophylaxis in women with preeclampsia is an ingrained obstetric practice. During the past decade, several observational studies and randomized trials have described the use of various regimens of magnesium sulfate to prevent or reduce the rate of seizures and complications in women with preeclampsia. There are only 2 double-blind, placebo-controlled trials evaluating the use of magnesium sulfate in mild preeclampsia. There were no instances of eclampsia among 181 women assigned to placebo, and there were no differences in the percentage of women who progressed to severe preeclampsia (12.5% in magnesium group vs 13.8% in the placebo group, relative risk [RR] 0.90; 95% CI 0.52-1.54). However, the number of women enrolled in these trials is too limited to draw any valid conclusions. There are 4 randomized controlled trials that compare the use of no magnesium sulfate, or a placebo vs magnesium sulfate, to prevent convulsions in patients with severe preeclampsia. The rate of eclampsia was 0.6% among 6343 patients assigned to magnesium sulfate vs 2.0 % among 6330 patients assigned to a placebo or control (RR 0.39; 95% CI 0.28-0.55). However, the reduction in the rate of eclampsia was not associated with a significant benefit in either maternal or perinatal outcome. In addition, there was a higher rate of maternal respiratory depression among those assigned magnesium sulfate (RR 2.06; 95% CI 1.33-3.18). The evidence to date confirms the efficacy of magnesium sulfate in reduction of seizures in women with eclampsia and severe preeclampsia; however, this benefit does not affect overall maternal and perinatal mortality and morbidities. The evidence regarding the benefit-to-risk ratio of magnesium sulfate prophylaxis in mild preeclampsia remains uncertain, and does not justify its routine use for that purpose.     

Examining the Use of Magnesium Sulfate to Treat Pregnant Women with Preeclampsia and Eclampsia: Results of a Program Assessment of Emergency Obstetric Care (EmOC) Training in India

Background

The aim of this study is to examine rates of magnesium sulfate utilization by emergency obstetric care trainees to treat preeclampsia–eclampsia in India. Secondarily, structural barriers are identified which limit the use of magnesium sulfate, highlighting limitations of emergency obstetric care training, which is a commonly implemented intervention in resource-poor settings.

Methods

Trainees’ curriculum specified magnesium sulfate treatment for eclampsia and severe preeclampsia. Case records were analyzed for preeclampsia–eclampsia diagnosis, magnesium sulfate utilization, delivery route, and maternal and neonatal outcomes from 13,238 reported deliveries between 2006 and 2012 across 75 district hospitals in 12 Indian states.

Results

Of 1320 cases of preeclampsia–eclampsia, 322 (24.4%) had eclampsia. Magnesium sulfate was given to 12.9% of preeclamptic and 54.3% of eclamptic women, with lower usage rates in rural communities. Among the 1308 women with preeclampsia–eclampsia, only 24 deaths occurred (1.8%). In contrast, among the 17,179 women without preeclampsia–eclampsia, there were 95 reported deaths (0.6%). Both maternal mortality ratios were found to be much higher than the Millennium Development Goal target of 0.15%. Magnesium sulfate administration was associated with a higher death rate in preeclamptic but not eclamptic women, representing possible confounding by severity.

Conclusion

To optimize resources spent on emergency obstetric care training, the consistent availability of magnesium sulfate should be improved in India. Increasing drug availability, implementing clinical guidelines around its administration, and training health-care providers on the identification and treatment of preeclampsia–eclampsia could lead to notable improvements in maternal and infant mortality.

     

The safety and utility of pulmonary artery catheterization in severe preeclampsia and eclampsia

OBJECTIVE: The objective of this research was to study the safety and utility of pulmonary artery catheterization in the management of severe preeclampsia and eclampsia.Study Design: In a retrospective chart review from January 1, 1995, through December 31, 1997, a total of 115 patients admitted to the obstetric intensive care unit at Groote Schuur Hospital were found to have required placement of a pulmonary artery catheter. From this population 100 maternal charts were examined for medical and pregnancy history, including indication for pulmonary artery catheter placement, hemodynamic readings, complications, and subsequent management. RESULTS: The initial indications for pulmonary artery catheter placement in cases of severe preeclampsia or eclampsia were renal failure in 53 cases (53%), pulmonary edema in 30 (30%), and eclampsia in 17 (17%). Subjective evaluation demonstrated that the pulmonary artery catheter was helpful in determining management in 93 cases (93%). There was a 4.0% complication rate, which included three venous thromboses and one case of cellulitis. Eleven patients required dialysis, and 3 women died. The mean (+/-SE) duration of catheter placement was 2.1 +/- 0.1 days and the mean (+/-SE) intensive care unit and hospital stays were 3.4 +/- 0.2 days and 11.4 +/- 0.8 days, respectively. The pulmonary artery catheter measurements of pulmonary artery wedge pressure and central venous pressure were increased in the cases of pulmonary edema (21.0 +/- 2.0 mm Hg and 9. 6 +/- 1.2 mm Hg, respectively) but were normal in the cases of renal failure and eclampsia. CONCLUSION: Despite significant maternal morbidity and mortality, pulmonary artery catheter use in cases of severe preeclampsia or eclampsia was subjectively beneficial in 93 of 100 cases (93%), with an acceptable complication rate (4.0%).