摘要

BACKGROUND:Amniotic fluid embolism (AFE) remains one of the principal reported causes of direct maternal mortality in high-income countries. However, obtaining robust information about the condition is challenging because of its rarity and its difficulty to diagnose. This study aimed to pool data from multiple countries in order to describe risk factors, management, and outcomes of AFE and to explore the impact on the findings of considering United Kingdom, international, and United States AFE case definitions. METHODS AND FINDINGS:A population-based cohort and nested case-control study was conducted using the International Network of Obstetric Survey Systems (INOSS). Secondary data on women with AFE (n = 99-218, depending on case definition) collected prospectively in population-based studies conducted in Australia, France, the Netherlands, Slovakia, and the UK were pooled along with secondary data on a sample of control women (n = 4,938) collected in Australia and the UK. Risk factors for AFE were investigated by comparing the women with AFE in Australia and the UK with the control women identified in these countries using logistic regression. Factors associated with poor maternal outcomes (fatality and composite of fatality or permanent neurological injury) amongst women with AFE from each of the countries were investigated using logistic regression or Wilcoxon rank-sum test. The estimated incidence of AFE ranged from 0.8-1.8 per 100,000 maternities, and the proportion of women with AFE who died or had permanent neurological injury ranged from 30%-41%, depending on the case definition. However, applying different case definitions did not materially alter findings regarding risk factors for AFE and factors associated with poor maternal outcomes amongst women with AFE. Using the most liberal case definition (UK) and adjusting for the severity of presentation when appropriate, women who died were more likely than those who survived to present with cardiac arrest (89% versus 40%, adjusted odds ratio [aOR] 10.58, 95% confidence interval [CI] 3.93-28.48, p < 0.001) and less likely to have a source of concentrated fibrinogen (40% versus 56%, aOR 0.44, 95% CI 0.21-0.92, p = 0.029) or platelets given (24% versus 49%, aOR 0.23, 95% CI 0.10-0.52, p < 0.001). They also had a lower dose of tranexamic acid (median dose 0.7 g versus 2 g, p = 0.035) and were less likely to have had an obstetrician and/or anaesthetist present at the time of the AFE (61% versus 75%, aOR 0.38, 95% CI 0.16-0.90, p = 0.027). Limitations of the study include limited statistical power to examine factors associated with poor maternal outcome and the potential for residual confounding or confounding by indication. CONCLUSIONS:The findings of our study suggest that when an AFE is suspected, initial supportive obstetric care is important, but having an obstetrician and/or anaesthetist present at the time of the AFE event and use of interventions to correct coagulopathy, including the administration of an adequate dose of tranexamic acid, may be important to improve maternal outcome. Future research should focus on early detection of the coagulation deficiencies seen in AFE alongside the role of tranexamic acid and other coagulopathy management strategies.

译文

背景: 羊水栓塞 (AFE) 仍然是高收入国家报告的直接产妇死亡的主要原因之一。然而,由于该疾病的罕见性和诊断的困难,获得关于该疾病的可靠信息具有挑战性。本研究旨在汇集来自多个国家的数据,以描述 AFE 的风险因素、管理和结果,并探讨考虑英国、国际、和美国 AFE 案例定义。方法和结果: 使用国际产科调查系统网络 (INOSS) 进行了一项基于人群的队列和嵌套病例对照研究。在澳大利亚、法国、荷兰、斯洛伐克进行的基于人口的前瞻性研究中收集的 AFE 女性的二级数据 (n = 99-218,取决于病例定义), 英国和在澳大利亚和英国收集的对照女性样本 (n = 4,938) 的次要数据一起被合并。通过使用逻辑回归分析比较澳大利亚和英国的 AFE 女性和这些国家的对照女性,调查了 AFE 的危险因素。使用逻辑回归或 Wilcoxon 秩和检验对来自每个国家的 AFE 妇女中与不良母亲结局 (死亡和死亡或永久性神经损伤的复合) 相关的因素进行调查。根据病例定义,AFE 的估计发病率为每 0.8 个母亲 1.8-100,000,死亡或有永久性神经损伤的 AFE 女性比例为 30%-41%。然而,应用不同的病例定义并没有实质性地改变关于 AFE 风险因素和 AFE 妇女不良产妇结局相关因素的发现。使用最自由的案例定义 (英国),并在适当的时候根据表现的严重程度进行调整,死亡的女性比幸存下来的女性更有可能出现心脏骤停 (89% 对 40%, 调整后的比值比 [aOR] 10.58,95% 置信区间 [CI] 3.93-28.48,p <0.001)并且不太可能有浓缩纤维蛋白原的来源 (40% 对 56%,aOR 0.44,95% CI 0.21-0.92,p = 0.029) 或给予血小板 (24% 对 49%,aOR 0.23, 95% CI 0.10-0.52,p <0.001)。他们也有较低剂量的氨甲环酸 (中位剂量 0.7 克对 2 克,p = 0.035) 并且在 AFE 时不太可能有产科医生和/或麻醉师在场 (61% 对 75%,aOR 0.38,95% CI 0.16-0.90,p = 0.027)。该研究的局限性包括有限的统计能力来检查与不良产妇结局相关的因素,以及残余混淆或由适应症混淆的可能性。结论: 我们的研究结果表明,当怀疑 AFE 时,初始支持性产科护理很重要, 但是在 AFE 事件发生时,有产科医生和/或麻醉师在场,并使用干预措施来纠正凝血病,包括服用足够剂量的氨甲环酸, 可能对改善产妇预后很重要。未来的研究应侧重于早期发现 AFE 中出现的凝血缺陷,以及氨甲环酸和其他凝血病管理策略的作用。

amniotic fluid embolism

妇产 分娩并发症 疾病
概述  :  

羊水栓塞(amniotic fluid embolism , AFE)是指羊水进人母体血液循环,引起肺动脉高压、低血症、循环衰竭、弥散性血管内凝血以及多器官功能衰竭等一系列病理生理变化的过程。其临床特点是起病急骤、病情凶险、难以预测、病死率高,是一种极其严重的分娩并发症。近年来,由于各医学学科的发展及支持治疗能力的提高,AFE孕产妇的死亡率已有明显的下降。 病因高龄初产、经产妇、宫颈裂伤、子宫破裂、羊水过多、多胎娃振、子宫收缩过强、急产、胎膜早破、前置胎盘、子宫破裂,剖宫产和刮宫术

amniotic 英 [æmnɪ'ɒtɪk] 美 [,æmnɪ'otɪk]

释    义   adj. [昆]羊膜的

例    句   Perhaps we are really talking about amniotic fluid, which surrounds the foetus in the birth sac.也许我们真正在谈论的是羊水,也就是包围着胎儿的那些液体。

 

fluid 英 [ˈflu:ɪd] 美 [ˈfluːɪd]

释    义   n. 流体,液体

adj. 流动的;不固定的,易变的;流畅的 [复数 fluids ]

例    句   And what is one own fluid element?什么是一个自己的流体元素?

 

embolism 英 [ˈembəlɪzəm] 美 [ˈembəlɪzəm]

释    义   n. 栓塞;闰日 [复数 embolisms ]

例    句   Treatment of embolism depends on which type it is, how big it is and where it is.栓塞的治疗取决于栓塞的类型、大小和位置。

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