产科多器官功能障碍综合征的诊治进展

孕产妇合并多脏器功能障碍综合征(MODS)罕见,与妊娠生理的高容量、高代谢改变及病理产科如产科出血、子痫和先兆子痫、羊水栓塞、妊娠期急性脂肪肝和感染等相关,出血、高血压和感染等可以启动瀑布式的病理生理反应——全身炎症反应综合征(SIRS),导致低血氧或低灌注,从而走向生命末路MODS和死亡。产科MODS诊断标准未统一,治疗提倡整体干预,明确病因和病理生理变化,评估母胎血液动力学的继发改变状况,尽早提供治疗窗纠正低容量、低血供和低灌注,维持血流动力学稳定;预防和治疗MODS的三大环节:启动因子的控制,限制炎症因子形成和器官支持。     

妊娠期高血压疾病严重并发症的诊治

<正>妊娠期高血压疾病是产科特发性疾病,对母儿危害较大,其中重度子痫前期病情严重时由于全身小动脉痉挛,内皮细胞功能障碍,全身各系统靶器官血流灌注减少可造成全身多器官系统损害,极端的情况下可导致肾脏、肝脏、心脏等功能衰竭,中枢神经系统病变以及发生弥散性血管内凝血(DIC),是孕产妇死亡的主要原因之一。妊娠期高血压疾病严重并发症的及时诊断和处理有利于改善母儿预后。     

产科并发症与DIC—附九例分析

弥散性血管内凝血(简称DIC)是由许多疾病引起的血管内广泛凝血的病理过程,促发因素很多,其中以产科并发症(羊水栓塞、胎盘早期剥离、重度妊娠高血压综合征、产后失血、产后感染等)引起者最常见,并且起病急骤,发展迅速,来势凶险,极易危及孕产妇的生命。为提高对本病的认识,做到早期诊断、合理治疗,我们就我院近年来由产科并发症所致DIC9例,结合文献复习,作如下分析, 一、诊断依据 (一)有能诱发DIC的产科并发症。 (二)有DIC的临床表现,如:出血倾向、循环障碍、栓塞症状等。     

肝素在某些产科并发症方面的应用

肝素是具有抗凝作用和多种生物活性的一族天然糖胺聚糖。 1916年由Mcleen发现 ,1935年因其抗凝作用而开始应用于临床 ,是预防手术后血栓形成、治疗急性静脉血栓和弥散性血管内凝血(DIC)早期的首选药物。近年来 ,肝素在产科方面的临床应用有明显增加的趋势。主要原因有 :(1)妊娠期特别是妊娠晚期血液呈高凝状态 ,血液动力学、凝血及纤溶系统均发生改变 ,孕产妇易发生血栓及 DIC;(2 )围产医学的发展认识到胎盘局部梗塞与孕产妇患病及围产儿死亡息息相关 ;(3)低分子量肝素 (low-molecular- weight heparin,L MWH)的发现 ,提高了用药的安全…     

妊娠高血压综合征时的血液凝固和纤溶系统

妊娠高血压综合征(妊高血压征),在产科临床占很重要位置,其发病原因不清楚,近年来,关于妊高血征与凝血和纤溶系统关系的研究,发现虽不能断言DIC状态就是妊高血征的病因,但认为本病确与DIC状态有关。特别是重症妊高血压征从血凝和纤溶系统来看,妊高血压征常呈慢性DIC过程。在妊娠期,血液凝固第一阶段凝血激酶的存在是本病的焦点。1953年,Mckay在重度妊高血压征和胎盘早剥尸解中见到,各脏器(肝、心、肾上腺、垂体)的血管和毛细血管中有纤维蛋白血栓形成。其结果组织出血坏死及一系列全身反应,认为子痫的发生和DIC有关。以后相继报导妊高血压征时血液呈高凝状态。胎盘的各种病理改变都容易使胎盘组织的凝血活酶进入血管内引来DIC。1972年Page     

围产期急性肺损伤四例报告及文献复习

机体遭受严重的感染、创伤、休克、手术打击以及再灌注损伤等均可导致急性肺损伤发生.孕产妇发生急性肺损伤多与产后失血性休克、DIC、全身炎症反应综合征(SIRS)、官内感染、重度子痫前期等因素相关,其临床特点是起病急、治疗困难,且死亡率高.本文报道首都医科大学附属北京妇产医院2009年1-6月收治的4例急性肺损伤,并结合国内外文献复习,探讨围产期发生急性肺损伤的诊治与预防.     

产科DIC合并急性肾功能衰竭的治疗

弥散性血管内凝血(DIC)是许多疾病中一个严重复杂的病理过程。诱发因素很多,其中以产科并发症(羊水栓寒、胎盘早期剥离、前置胎盘、重度妊娠高血压综合征。产后流血及产后感染等)引起者最常见。病情急骤、发展迅速。其典型的病理改变是毛细血管内纤维蛋白的沉积、微血栓形成,组织局灶性出血及梗死性坏死。由于DIC对肾脏损伤严重,可引起肾微血管阻塞,肾小管缺血、缺氧,甚至肾皮质急性坏死,因此如不及时治疗极易导致急性肾功能衰竭(简称肾     

妊娠期高血压疾病并发产后出血的防治

妊娠期高血压疾病是产科最常见的并发症,能引发全身重要脏器的病理改变,出现一系列并发症。产后出血仍然是威胁孕产妇生命的重要因素,妊娠期高血压疾病由于本身的病理生理特点,具备了发生产后出血的高危因素,尽早识别该类患者,并积极正确的处理能改善孕产妇预后,降低孕产妇病死率。     

羊水栓塞合并产后出血的手术处理

羊水栓塞 (amnioticfluidembolism ,AFE)是指在分娩过程中羊水进入母体血循环后引起的肺栓塞、休克、弥散性血管内凝血 (disseminatedintravascularcoagulation ,DIC)、肾功能衰竭或骤然死亡等一系列严重症状的综合征 ,是造成孕产妇死亡的主要原因之一 ,发生在孕足月分娩者病死率可高达 70 %～ 80 %[1 ] 。羊水中含有丰富的凝血物质 ,进入母体后易引起DIC ,而且因促凝物质对子宫壁的刺激和发生在子宫壁内微血管的栓塞与出血 ,可减低子宫的收缩力 ,加重子宫出血。临床上各种原因所致的产后出血 ,以羊水栓塞最为严重、最急骤、最难控制 ,…     

播散性血管内凝血

作者结合最近1例播散性血管内凝血(DIC)的治疗经验,对DIC的一般治疗作了讨论。一、DIC的诊断: 患有可能引起DIC的妇产科并发病,如发生全身出血倾向及受累器官的功能障碍时,即应考虑有DIC的可能,并需迅速作下述的化验检查。 1.血沉:是一种重要而简单的检查,DIC时由于纤维蛋白原减少,血沉常减慢。 2.出血时间:DIC多延长。 3.全血凝固时间和血栓弹力图(TEG):重症患者全血凝固时间延长甚至不凝或虽有凝血块也很脆弱,较快地出现全部或部分溶解,表明有低纤维蛋白原血症,纤维蛋白溶解活性亢进。TEG实验有助于全面了解凝血和纤溶的过程。 4.纤维蛋白(原)降解产物(FDP):纤溶亢进时,纤维蛋白(原)经纤溶酶作用使FDP显     

The specific characteristics of DIC syndrome vary with different clinical settings in the newborn

Abstract

Two hundred fourteen newborns with serious perinatal pathology (posthypoxic syndrome, sepsis, surgical intervention, etc.) were examined in progress, according to 27 parameters including coagulative, trombocitic, anti-coagulative and fibrinolitic parts of hemostasis system. It was proved, that neonatal disseminated intravascular coagulation (DIC) syndrome had different hemostasiological patterns, which were connected with the genesis: sepsis, surgical intervention or posthypoxic syndrome. Precise periods of DIC syndrome are not always presented in newborns. DIC syndrome with neonatal sepsis has two different patterns (overcompensated and decompensated). The manifestation of trombo-hemorrhagic disorders and their characteristics depend on the genesis of DIC syndrome (e.g. an infection process and hyperbilirubinemia can provide the appearance of hemorrhagic syndrome).     

The development of disseminated intravascular coagulation in hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP) at very early gestational age

Hemolysis, elevated liver enzymes, and low platelet count syndrome(HELLP) is a severe pregnancy complication since it is life-threatening for both mother and fetus. When HELLP syndrome associates with disseminated intravascular coagulation (DIC) or with other complications it is necessary to terminate the pregnancy; however, due to fetal prematurity, it may be advisable to wait for the effectiveness of the corticosteroid prophylaxis of neonatal respiratory distress syndrome when such complications are not present. This article reports an initially mild HELLP syndrome case, with onset at week 26 and two days of pregnancy, where it was necessary to wait for the effectiveness of respiratory distress prophylaxis and, consequently, to carry out a close monitoring of the onset and worsening of DIC. Tests for blood cell distribution width, D-dimer, plasmatic electrolytes and urinary sediment, which undergo precocious and rapid variations in DIC, are quickly processed, and useful for the conservative management of HELLP.     

Disseminated intravascular coagulation in the HELLP syndrome: how much do we really know?

The rate of disseminated intravascular coagulation (DIC) during pregnancy varies among nations from 0.03% to 0.35%. The existing reports suggest dissimilarity in the underlying mechanisms leading to DIC during gestation. While in developing countries preeclampsia and the HELLP syndrome are prevalent causes of DIC, the leading causes in the developed countries are placental abruption and postpartum hemorrhage. In different cohort studies, DIC is reported in about 12–14% of women with preeclampsia. Nevertheless, it has been suggested that in most cases these women also had a HELLP syndrome and that the occurrence of DIC in women who had only preeclampsia without manifestations of the HELLP syndrome is rare. The aims of this review are to: (1) highlight the mechanisms leading to DIC; (2) describe the changes in the coagulation system during this complication; and; (3) discuss the diagnostic tool and treatment modalities of DIC, in women who develop a HELLP syndrome.     

Chronic diffuse intravascular coagulation (DIC) in nonmetastatic ovarian cancer: Report of a case and review of the literature

A patient with a dramatic clinical picture of cerebral artery occlusion, peripheral artery occlusion, and pulmonary embolism was diagnosed as suffering from disseminated intravascular coagulation (DIC) according to the typical laboratory findings of hypofibrinogenemia, hypoprothrombinemia, relative thrombocytopenia, and reduction of other clotting factors. Increased fibrinogen split products (FSP) were found on several occasions later in the disease. Heparin was effective in controlling the syndrome which recurred when treatment was stopped. The cause of the syndrome was an ovarian tumor. The patient died of acute myocardial infarction. The postmortem examination confirmed the diagnosis of DIC, the primary disease being a mucinous cystadenocarcinoma of the right ovary, and revealed that the terminal myocardial infarction was also the result of DIC. The surprise was that the tumor was solitary and without metastases. The literature dealing with chronic DIC in cancer is reviewed, and its diagnosis, frequency, and association with metastases is assessed.     

Coagulation studies in the syndrome of haemolysis, elevated liver enzymes and low platelets

Summary. The presence of disseminated intravascular coagulation (DIC) in the syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP) is debated. We assessed the occurrence of decompensated and compensated DIC (using predefined criteria) in 15 consecutive nulliparous pregnant patients with gestastional hypertension combined with the HELLP syndrome and in 12 consecutive nulliparous controls with pregnancy induced hypertension (PIH) but without the HELLP syndrome. A combination of routine coagulation assays revealed the absence of decompensated DIC in all studied patients. However, using more specific and sensitive coagulation assays, compensated DIC was observed in all HELLP patients and in three patients in the control group. The mean values of antithrombin III, thrombin-antithrombin III complexes and protein C in the HELLP and the control group were 66 vs 87% (  P=0.0004  ), 21 vs 8 ng/ml (  P=0.0008  ) and 57 vs 90% (  P=0.0018  ) respectively. We conclude that HELLP patients show evidence of compensated DIC which may have pathophysiological significance for the observed organ damage.     

Coagulation studies in the syndrome of haemolysis, elevated liver enzymes and low platelets

The presence of disseminated intravascular coagulation (DIC) in the syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP) is debated. We assessed the occurrence of decompensated and compensated DIC (using predefined criteria) in 15 consecutive nulliparous pregnant patients with gestational hypertension combined with the HELLP syndrome and in 12 consecutive nulliparous controls with pregnancy induced hypertension (PIH) but without the HELLP syndrome. A combination of routine coagulation assays revealed the absence of decompensated DIC in all studied patients. However, using more specific and sensitive coagulation assays, compensated DIC was observed in all HELLP patients and in three patients in the control group. The mean values of antithrombin III, thrombin-antithrombin III complexes and protein C in the HELLP and the control group were 66 vs 87% (P = 0.0004), 21 vs 8 ng/ml (P = 0.0008) and 57 vs 90% (P = 0.0018) respectively. We conclude that HELLP patients show evidence of compensated DIC which may have pathophysiological significance for the observed organ damage.     

Disseminated intravascular coagulation associated with intratumoral hemorrhage of ovarian cancer.

BACKGROUND: Ovarian carcinoma usually presents in an indolent manner. A patient with ovarian cancer rarely shows acute clinical features which require immediate medical intervention. CASE: We present a 36-year-old Japanese woman with an ovarian tumor, who suffered general fatigue and increased abdominal girth on admission. Her hemoglobin, platelet count and fibrinogen were decreased, and fibrin/fibrinogen degradation products were elevated, which determined the diagnosis of disseminated intravascular coagulation (DIC). Since computed tomography scan and magnetic resonance imaging revealed an intratumoral hemorrhage, an emergency laparotomy was performed. The patient was found to have ovarian cancer with a massive intratumoral hemorrhage, and DIC improved immediately after the operation. CONCLUSION: The clinician should be alert to the possibility that intratumoral bleeding of ovarian cancer might be associated with DIC.     

Disseminated intravascular coagulation and the syndrome of hemolysis, elevated liver enzymes, and low platelets in severe preeclampsia

To clarify the role of disseminated intravascular coagulation (DIC) in women with the hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, serial coagulation studies were performed prospectively in 18 patients. A semiquantitative DIC scoring system was used retrospectively to augment the diagnostic confidence of coagulopathy. At the time of admission to the hospital, three patients showed no evidence of DIC, eight had suspected DIC, and seven had manifest DIC. The intravascular coagulation process was progressive in all patients; upon delivery, eight patients proved to have suspected DIC and ten had manifest DIC. The laboratory criteria of DIC were found to agree with the degree of organ dysfunction. Patients with manifest DIC at delivery developed significantly more life-threatening maternal complications than did patients with suspected DIC (P less than .02). Conservative management was not possible in any patients who were admitted with overt DIC because of deterioration of maternal and fetal status. Application of a sensitive DIC scoring system may be valuable in managing patients with the HELLP syndrome and selecting patients who may be treated expectantly.     

Aggressive Therapie des HELLP-Syndroms

The HELLP syndrome is a severe and life-threatening complication of pre-eclampsia. Its management has been controversial, some authors recommending a conservative approach for induction of pulmonary maturity in the fetus when the pregnancy has not reached the 32nd (34th) week while the majority recommend immediate delivery by caesarean section in the case of an unfavourable cervix, regardless of gestational age. Aggressive management means early recognition of the condition by laboratory screening methods on admission and immediate delivery once the diagnosis has been confirmed. Patients with the HELLP syndrome should be treated in a perinatal centre. The high maternal mortality (3%) and morbidity (12.5–65%) and also the high perinatal mortality (22%) are due to unpredictable complications and the development of disseminated intravascular coagulation (DIC). It has been shown that the frequency of DIC increases significantly with lengthening time interval between diagnosis and delivery. As there are no reliable clinical or laboratory parameters that can be used to predict the course and prognosis of the disease, the outcome of the HELLP syndrome is not calculable. A review of the literature published since 1990 clearly shows that aggressive management of the HELLP syndrome is associated with a significant reduction in maternal and fetal mortality.     

Evaluation of obstetrical patients with disseminated intravascular coagulopathy – tertiary center experience

Objective: The purpose of the present study is twofold: (a) to investigate the etiology of disseminated intravascular coagulopathy (DIC) caused by obstetrical conditions and (b) to present parameters that can be used in predicting DIC-related mortality in obstetrical patients.

Material and method: Obstetrical patients who had a delivery at or were referred (after delivery) to Obstetrics and Gynecology Clinic of Dicle University between July 2006 and December 2013 were retrospectively analyzed in this study. Those patients diagnosed with DIC were included in the study.

Results: Fifty-six obstetrical patients carrying the diagnosis of DIC were included in this study. The overall mortality rate was 25% among these patients. More specifically, the mortality rate was 10.7% among patients with a DIC score?≤5 and 40.7% among those with a DIC score?>?5. Multiple logistic regression analysis resulted in the finding that international normalized ratio (INR) and urea were among those factors affecting mortality in obstetrical DIC [OR: 8.44 (CI: 1.9–36.8), OR: 1.05 (CI: 1.0–1.1), respectively].

Conclusion: DIC is a syndrome that might be caused by obstetrical conditions. It is associated with high mortality and morbidity rates. In obstetrical DIC, urea is the most important factor affecting mortality. In addition, we are of the opinion that DIC score might guide mortality predictions as a determinant of prognosis.