产科休克

休克是以低血压为主要特征,伴有末梢循环障碍和多脏器功能不全的状态。孕产妇比非孕妇易发生休克。与妊娠、分娩异常有关的,如产科出血引起的休克,感染性流产或产褥感染引起的败血症性休克和羊水栓塞等称产科休克,但广义的还应包括由于麻醉和偶发合并症引起的休克。一、产科休克的特点妊娠晚期循环血量比非孕期约增加50%,有抗失血性休克的作用,但妊娠子宫的血流量维持在600ml/分左右,以致胎盘剥离面和产道损伤处又可在短时间内发生大量出血。另外,妊娠期心排出量增加加重心脏负荷,常可导致有心血管疾病且心功能储备能力不足者发生心源性休克。妊娠期毛细血管和静脉系统扩张,易引起盆腔与下肢静脉血液淤滞,是腰麻性休克和仰卧位低血压综合征的原因。妊娠期凝血功能亢进,由于纤维蛋白原     

妊娠合并感染性休克

感染性休克是导致孕产妇死亡的重要原因之一,产科感染性休克的原因主要是绒毛膜羊膜炎、无菌操作不严格致产后感染、妊娠合并阑尾炎、血栓性静脉炎等。治疗包括积极的抗感染治疗、有效的容量复苏、血管活性药物的应用及器官功能支持。     

第六届全国妊娠合并心血管疾病诊治学习班通知

妊娠合并心血管疾病是导致孕产妇死亡的重要原因之一。为提高产科医师心血管疾病的理论知识和诊治水平，上海市产科心脏病监护中心、上海第二医科大学附属仁济医院妇产科将于2005年11月下旬联合举办第六届全国妊娠合并心血管疾病诊治学习班。授课题目包括妊娠合并先天性心脏病、风湿性心脏病及围产期心肌病等的诊治；妊娠期心力衰竭的处理；妊娠期心脏手术；妊娠期心脏超声检查；     

202例妊娠期肝内胆汁淤积症的妊娠结局分析

妊娠期肝内胆汁淤积症(intrahepatic cholestasisof pregnancy,ICP)是以妊娠中、晚期出现的皮肤搔痒、黄疸为特发症状的妊娠期特有疾病,可导致早产、羊水胎粪污染及围生儿死亡,是围生儿预后不良的重要原因。其不良妊娠结局已引起产科医师的广泛重视。通过对病例的回顾性分析,我     

孕产妇感染性休克61例临床分析

目的:探讨孕产妇感染性休克发生的常见临床因素及其预防措施。方法:回顾性分析2012年1月—2017年12月郑州大学第一附属医院产科收治的61例感染性休克的病例资料。根据结局分为生存组(45例)和死亡组(16例),分析2组患者的临床特征。结果:61例感染性休克的患者死亡16例(26.23%),产褥期患者37例(60.66%)。2组患者急性生理功能和慢性健康状态评分系统Ⅱ(APACHEⅡ)评分比较,差异有统计学意义(t=4.170,P=0.001)。2组患者比较,死亡组患者未足月胎膜早破和多器官功能衰竭(MODS)的发生率增高,差异有统计学意义(均P0.05)。确诊感染性休克时,死亡组患者较生存组血小板(PLT)下降、凝血酶原时间(PT)增高、纤维蛋白原(FIB)下降、降钙素原(PCT)增高,差异有统计学意义(均P0.05)。Logistic回归分析提示APACHEⅡ评分高、并存未足月胎膜早破、并发MODS为影响感染性休克孕产妇预后的危险因素。结论:孕产妇发生感染性休克后病死率高;确诊感染性休克后注意监测PLT、PT、FIB、PCT等临床指标变化,加强对其预后的评估;对APACHEⅡ评分高、并存未足月胎膜早破、并发MODS的感染性休克患者,加强临床管理,减少不良预后。     

孕产妇感染性休克61例临床分析

目的：探讨孕产妇感染性休克发生的常见临床因素及其预防措施。方法：回顾性分析2012年1月—2017年12月郑州大学第一附属医院产科收治的61例感染性休克的病例资料。根据结局分为生存组（45例）和死亡组（16例），分析2组患者的临床特征。结果：61例感染性休克的患者死亡16例（26.23%），产褥期患者37例（60.66%）。2组患者急性生理功能和慢性健康状态评分系统Ⅱ（APACHEⅡ）评分比较，差异有统计学意义（t=4.170，P=0.001）。2组患者比较，死亡组患者未足月胎膜早破和多器官功能衰竭（MODS）的发生率增高，差异有统计学意义（均P＜0.05）。确诊感染性休克时，死亡组患者较生存组血小板（PLT）下降、凝血酶原时间（PT）增高、纤维蛋白原（FIB）下降、降钙素原（PCT）增高，差异有统计学意义（均P＜0.05）。Logistic 回归分析提示APACHEⅡ评分高、并存未足月胎膜早破、并发MODS为影响感染性休克孕产妇预后的危险因素。结论：孕产妇发生感染性休克后病死率高；确诊感染性休克后注意监测PLT、PT、FIB、PCT等临床指标变化，加强对其预后的评估；对APACHEⅡ评分高、并存未足月胎膜早破、并发MODS的感染性休克患者，加强临床管理，减少不良预后。     

产科休克时麻醉方面的几个问题

产科休克是产科中最突出的急症。本文从麻醉方面讨论产科休克的几个问题。 1.麻醉加于休克病人的危险因素:麻醉可使病人进一步趋向危险状态(包括胎儿),导致此危险的原因称为危险因素。 1)妊娠期发生休克,选用麻醉剂、麻醉方法受到一定限制,如:①腰麻、硬膜外麻醉可引起周围血管阻力增加、心博量减     

肝移植治疗妊娠期急性肝功能衰竭

妊娠期急性肝功能衰竭(acute liver failure, ALF)处理非常棘手,对孕妇和婴儿的生命是一种严重的威胁。早期的诊断和治疗是预后的关键,而这需要肝脏外科医师、产科医师和重症监护医师的多学科协作。目前,尽管在急性肝功能衰竭的治疗上已取得长足进步,肝移植仍只是部分患者的最终选择。本文通过系统回顾妊娠期行肝移植的文献报道,结合本移植中心的经验,对妊娠期ALF治疗的标准流程、终止妊娠的时机及哪些患者需要肝移植等问题进行探讨。     

消息

第六届全国妊娠合并心血管疾病诊治学习班通知妊娠合并心血管疾病是导致孕产妇死亡的重要原因之一。为提高产科医师心血管疾病的理论知识和诊治水平,上海市产科心脏病监护中心、上海第二医科大学附属仁济医院妇产科将于2005年11月下旬联合举办第六届全国妊娠合并心血管疾病诊治学习班。授课内容包括妊娠合并先天性心脏病、风湿性心脏病及围产期心肌病等的诊治;妊娠期心力衰竭的处理;妊娠期心脏手术;妊娠期心脏超声检查;妊娠期心肺复苏;胎儿心血管疾病的诊治等。学习班由妇产科专家林其德、狄文、林建华,麻醉科专家王祥瑞,心内科专家何奔等教…     

围产期自发性肝破裂诊治进展

围产期自发性肝破裂是产科临床罕见的急腹症,发病率低,短时间内可导致母体严重休克,甚至母胎死亡。早期诊断并针对病因治疗,可显著降低母婴不良结局。本文复习了近年围产期自发性肝破裂的文献报告,就该病发病的年龄、时间、临床表现、治疗方法及预后等进行回顾,以期为临床早期识别及诊断治疗提供参考。     

Severe sepsis and septic shock in pregnancy

Pregnancies complicated by severe sepsis and septic shock are associated with increased rates of preterm labor, fetal infection, and preterm delivery. Sepsis onset in pregnancy can be insidious, and patients may appear deceptively well before rapidly deteriorating with the development of septic shock, multiple organ dysfunction syndrome, or death. The outcome and survivability in severe sepsis and septic shock in pregnancy are improved with early detection, prompt recognition of the source of infection, and targeted therapy. This improvement can be achieved by formulating a stepwise approach that consists of early provision of time-sensitive interventions such as: aggressive hydration (20 mL/kg of normal saline over the first hour), initiation of appropriate empiric intravenous antibiotics (gentamicin, clindamycin, and penicillin) within 1 hour of diagnosis, central hemodynamic monitoring, and the involvement of infectious disease specialists and critical care specialists familiar with the physiologic changes in pregnancy. Thorough physical examination and imaging techniques or empiric exploratory laparotomy are suggested to identify the septic source. Even with appropriate antibiotic therapy, patients may continue to deteriorate unless septic foci (ie, abscess, necrotic tissue) are surgically excised. The decision for delivery in the setting of antepartum severe sepsis or septic shock can be challenging but must be based on gestational age, maternal status, and fetal status. The natural inclination is to proceed with emergent delivery for a concerning fetal status, but it is imperative to stabilize the mother first, because in doing so the fetal status will likewise improve. Prevention Aggressive treatment of sepsis can be expected to reduce the progression to severe sepsis and septic shock and prevention strategies can include preoperative skin preparations and prophylactic antibiotic therapy as well as appropriate immunizations.     

Severe sepsis and septic shock in pregnancy: indications for delivery and maternal and perinatal outcomes

Objective: To report maternal and perinatal outcomes in obstetric patients with severe sepsis and septic shock. Methods: We performed a retrospective study of obstetric patients admitted to an intensive care unit (ICU) for severe sepsis/septic shock. Maternal clinical characteristics, hemodynamic profiles, laboratory findings, and perinatal outcomes were evaluated. Patients with severe sepsis (N = 20) and septic shock (N = 10) were compared using Fisher’s Exact and Mann–Whitney U tests. Results: Pyelonephritis was the most common etiology overall (37%) and acute respiratory distress syndrome (ARDS) was the most common organ injury in both severe sepsis (50%) and septic shock (80%). Liver dysfunction was present in cases with increased morbidity as a late finding and was the least frequent organ injury. Patients with septic shock had significantly higher rates of disseminated intravascular coagulation (DIC) (p = 0.01), altered mental status (p ≤ 0.001), total bilirubin >4?mg/dl (p = 0.04), failure in ≥3 organ systems (70% vs. 15%, p = 0.005), and maternal death (30% vs. 0%, p = 0.03). All patients with septic shock were delivered during hospitalization vs. 40% with severe sepsis. 71% of viable pregnancies required emergent cesarean delivery, and 50% of these for worsening respiratory function. Conclusions: ARDS is frequently found in critically ill obstetric patients with severe sepsis/septic shock and is associated with a high risk of emergent cesarean delivery.     

98例脓毒性休克患者的临床分析

目的了解孕产妇患脓毒性休克的病因、临床特点及结局。 方法回顾性分析广州医科大学附属第三医院2005年5月至2019年12月发生脓毒性休克的孕产妇临床资料。 结果共纳入98例产科脓毒性休克孕产妇,其中孕产妇存活73例(74.5%),死亡25例(25.5%);75例(76.5%)脓毒性休克发生在孕期,52例(69.3%)因脓毒性休克终止妊娠。肺部感染30例(30.6%),生殖道感染25例(25.5%),泌尿道感染27例(27.6%),腹腔内感染7例(7.1%),其他感染9例(9.2%)。98例脓毒性休克孕产妇的外科干预性感染(46例,46.9%)较非外科干预性感染(52例,53.1%)的存活率高[42例(91.3%) vs 21例(40.4%),P<0.001],平均住院时间长(11 vs 6 d,P<0.001),功能障碍器官数目≥3个者比例低(17.4% vs 55.8%,P<0.001)。75例孕期感染者的83例胎儿中死胎/死产为56.6%(47例),活产30.1%(25例),继续妊娠至足月分娩胎儿为13.3%(11例)。 结论孕产妇脓毒性休克主要为肺部、生殖道以及泌尿道感染;具有手术干预指征的外科干预性感染患者存活率高。孕期严重感染容易导致不良妊娠结局,但脓毒性休克并非终止妊娠的绝对指征,胎儿结局有赖于母亲病情的转归。     

Non-haemorrhagic obstetric shock.

The causes of non-haemorrhagic obstetric shock (pulmonary thromboembolism, amniotic fluid embolism, acute uterine inversion and sepsis) are uncommon but responsible for the majority of maternal deaths in the developed world. Clinically suspected pulmonary thromboembolism should be treated initially with heparin and objective testing should be performed. If the diagnosis is confirmed, heparin is usually continued until delivery, following which anticoagulation in the puerperium is achieved with either warfarin or heparin. Amniotic fluid embolism is a rare complication of pregnancy, occurring most commonly during labour. The management of amniotic fluid embolism involves maternal oxygenation, the maintenance of cardiac output and blood pressure, and the management of any associated coagulopathy. Acute uterine inversion arises most commonly following mismanagement of the third stage of labour. The shock in uterine inversion is neurogenic in origin, although there may also be profound haemorrhage. The management of this condition includes maternal resuscitation and replacement of the uterus either manually, surgically or by hydrostatic pressure. Genital tract sepsis remains a significant cause of maternal death, the most common predisposing factor being prolonged rupture of the fetal membranes. The management of septic shock in pregnancy includes resuscitation, identification of the source of infection and alteration of the systemic inflammatory response.     

Life-threatening septic shock in a pregnant woman with ileus

Septic shock during pregnancy is very rare but has high mortality. We report a case of septic shock in a pregnant woman with ileus, showing that severe ileus in a pregnant woman could be attributed to life-threatening septic shock and that we should give special attention to a nosocomial infection.     

Life-threatening septic shock in a pregnant woman with ileus.

Septic shock during pregnancy is very rare but has high mortality. We report a case of septic shock in a pregnant woman with ileus, showing that severe ileus in a pregnant woman could be attributed to life-threatening septic shock and that we should give special attention to a nosocomial infection.     

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。     

Brucella septicemia in pregnancy

A case of Brucella melitensis septicemia in a second-trimester pregnancy causing intrauterine fetal death and Gram-negative septic shock with diffuse intravascular coagulation is reported. The literature is reviewed.This is the first reported case of human brucellosis in association with Gram-negative sepsis and DIC during pregnancy. The importance of blood cultures and agglutinins for Brucella in febrile pregnant patients is re-emphasized.     

Early goal directed therapy for sepsis during pregnancy

Sepsis is a leading cause of death in pregnancy and results in significant perinatal mortality. These deaths occur despite the younger age of pregnant patients, the low rate of comorbid conditions and the potential for effective interventions that should result in rapid resolution of illness. To date, no "evidence-based" recommendations are specific to the pregnant patient who is critically ill or septic. Optimal care for the septic patient requires a multidisciplinary team with expertise in obstetrics, maternal-fetal medicine, critical care, infectious disease, anesthesia, and pharmacy. Coordination of care and good communication amongst team members is essential. Incorporation of early goal directed therapy for suspected sepsis into obstetric practice is needed to optimize maternal and neonatal outcomes.     

Maternal mortality due to the hepatorenal syndrome of pre-eclampsia. A case report.

A maternal death in the 23rd wk of pregnancy is described. The patient was gravida 8, with 6 previous abortions and one growth-retarded term infant. The clinical symptoms and biochemical findings strongly suggest that the mode of death was septic shock, with the hepatorenal syndrome due to pre-eclampsia as the underlying cause.