Embolism amniotic waters
The Embolism Amniotic Waters (EAW) – pathology which development is connected with hit of amniotic liquid in the blood circulatory system of mother with the subsequent anafilaktoidny reaction to components of this liquid. Clinical manifestations are mainly caused by kardiopulmonalny shock and violation of system of coagulation. Diagnostics at an embolism is performed by amniotic waters by complex assessment of fizikalny, laboratory and tool data. Treatment of EOV consists in elimination of anafilaktoidny reaction, normalization of work of cardiovascular and respiratory systems, restoration of OTsK and system of a hemostasis.
Embolism amniotic waters
The embolism amniotic waters or an anafilaktoidny syndrome of pregnancy is a pathological state in obstetrics which is characterized by hit of amniotic liquid in a system blood-groove of mother. For the first time clinical picture EOV was described in 1926 by the Brazilian doctor J. Meyer. In 1941 set of signs of this state was united by Americans P. Steiner and K. Lashbou in a special obstetric syndrome. The general prevalence of an embolism amniotic waters makes from 1 to 8 cases on 10 000 childbirth. At the same time the indicator of maternal and perinatal mortality at this complication fluctuates within 84-87%. In the general structure of a maternal lethality the embolism amniotic waters makes about 15-17% of all cases.
Embolism reasons amniotic waters
Allocate several mechanisms of development of an embolism by amniotic waters: increase in intrauterine pressure, falling of blood pressure in uterus veins, direct contact between an amniotic bag and the injured blood vessels. Include all factors capable to excessively increase pressure in an amniotic bag which in the course of patrimonial activity normal makes up to 20 mm w.g. in the first group. Amniotic waters in such cases polycarpous pregnancy, body weight of the child over 4500 g ("a large fruit"), abundance of water, pelvic prelying, loss of elasticity of a neck of a uterus, the wrong carrying out stimulation of sokratitelny activity of a uterus, too bystry birth of the child, presence of mekonialny masses in amniotic liquid, anatomo-physiological features of a fruit and/or patrimonial ways of mother can be the cause of an embolism.
Development of an embolism by amniotic waters against the background of falling of venous pressure is, as a rule, caused by an absolute or relative gipovolemiya and pressure decrease in uterus veins at childbirth lower than 40 mm w.g. Such state can arise against the background of a preeklampsiya, diabetes, various heart diseases, loss of a tone of vessels at the multigiving birth women, reception of diuretic medicines, irrational use of antigipertenzivny or vasodilating means. The high risk of an embolism is always connected by amniotic waters with a direct trauma of an amniotic bag and violation of integrity of blood vessels of a uterus. In most cases this mechanism of development of EOV is caused by premature peeling of normally located placenta or its prelying, a rupture of a uterus, performing Cesarean section or plodorazrushayushchy operations, manual inspection of a cavity of a uterus, the pathological preliminary period.
Classification and symptoms of an embolism amniotic waters
Depending on a prevalence of these or those symptoms of an embolism allocate with amniotic waters the following forms of pathology:
- Kollaptoidny. It is characterized by pronounced kardialny shock. Leading symptoms: "collapse" HELL, the threadlike accelerated pulse, the pallor of skin of hands and legs which is followed by their cold snap, consciousness loss.
- Convulsive. The main manifestation of this form of an embolism amniotic waters – a generalized convulsive syndrome.
- Hemorrhagic. It is caused by the shift of system of a hemostasis towards hypocoagulation. Main signs: profuzny bleedings from a nose, a mouth, a vagina, places of a puncture and statement of catheters.
- Edematous. The clinical option of an embolism amniotic waters which is shown hypostasis of pulmonary fabric which, in turn, causes sharp respiratory insufficiency.
- Lightning. The most dangerous form of an embolism amniotic waters which is characterized by rapid development and polyorgan insufficiency.
The pathogenesis of clinical symptoms at an embolism amniotic waters is based on hit in the blood circulatory system of mother together with amniotic liquid of prostaglandins, tsitokin, a histamine and other eykozanoid. They cause anafilaktoidny reaction with development of a spasm of pulmonary vessels, violation of system of coagulability of blood and the mechanical block in the microcirculator course of lungs. These reactions at an embolism amniotic waters are shown by sudden emergence of the general excitement and fear, a fever and temperature increase of a body, the expressed short wind of the inspiratory or mixed character, cough, "collapse" HELL, increases in ChSS and ChD. Also pains in heart, nausea, vomiting, toniko-clonic spasms, swelling and a pulsation of cervical veins, generalized cyanosis and a pobledneniye ("a skin mramornost"), profuzny bleedings of various localization are observed. Depending on a clinical form of an embolism amniotic waters these or those its manifestations can prevail.
Diagnosis of an embolism amniotic waters
Diagnostics at an embolism amniotic waters includes collecting anamnestichesky data and complaints at the time of delivery, fizikalny survey, laboratory and tool researches. Higher risk of development of EOV is observed at the women having in the anamnesis of operation on genitals, frequent gynecologic pathologies, a large number of childbirth, in particular – with complications. Complaints which are shown by the pregnant woman in many respects depend on a clinical form of an embolism amniotic waters. Fizikalny inspection includes assessment of ChSS, ChD and AD, and also identification of symptoms of EOV after which if necessary inspection of a neck of a uterus and its palpation can be performed.
The program of laboratory tests at women with symptoms of an embolism amniotic waters includes OAK (level of platelets, erythrocytes, indicators of hemoglobin and a gematokrit), a koagulogramm (D-dimer, the fibrinogen level, coagulability of blood and AChTV), a biochemical research ( blood, electrolytes). From tool methods of a research at an embolism amniotic waters use the ECG on which symptoms of ischemia of a myocardium and sinusovy tachycardia, and also the X-ray analysis of OGK allowing to define existence of interstitsialny hypostasis of lungs of drain character in the form of "butterfly" and increase in the right departments of heart come to light. In the presence of the central venous access monitoring of TsVD is carried out.
Treatment of an embolism amniotic waters
Therapeutic measures at an embolism are directed by amniotic waters to knocking over of anafilaktoidny reaction, kardiopulmonalny shock and prevention of development of critical violations of system of a hemostasis. First of all the woman is provided with supply of the moistened oxygen or transferred to IVL. Further high doses of glucocorticosteroids (Prednisolonum or a hydrocortisone) are entered, OTsK by means of the large volume of krovozameshchayushchy liquids (the balanced colloids and crystallites) is filled. For correction of acidosis sodium bicarbonate is used. At the expressed hypotension against the background of an embolism amniotic waters medicines of the choice are simpatomimetik (ephedrine), if necessary can be applied a dopamine or . For elimination of a hemorrhagic syndrome inhibitors of a fibrinoliz (traneksamovy acid), concentrates of anti-thrombin, a prothrombin and blood medicines are entered.
Obstetric aid tactics at an embolism amniotic waters depends on results of treatment. If therapeutic measures were effective, and the condition of the woman managed to be stabilized – the rodorazresheniye is carried out in patrimonial ways. At development of complications of an embolism by amniotic waters or lack of effect of conservative treatment immediate performing Cesarean section is shown. At massive uterine bleedings which do not manage to be stopped the uterus extirpation is carried out.
Forecast and prevention of an embolism amniotic waters
The outcome at an embolism amniotic waters depends on the general weight of a condition of the woman, speed of development of symptoms and efficiency of the held therapeutic events. In most cases the forecast adverse both for mother, and for the child. Prevention of an embolism amniotic waters means early diagnostics and treatment of states which can potentially lead to EOV: preeklampsiya and eklampsiya, fetoplatsentarny insufficiency. Knocking over of a hyper tone of a uterus on pregnancy time, observance of the doses appointed by the treating obstetrician-gynecologist of medicines, the rational choice of a method of a rodorazresheniye is necessary. Also to preventive measures pregnancy planning, timely registration in antenatal clinic and its regular visit treat with passing of all diagnostic testings, performance of special LFK for pregnant women, an exception of intensive psychoemotional loadings.