РЦРЗ (Республиканский центр развития здравоохранения МЗ РК)
Версия: Клинические протоколы МЗ РК — 2013
Общая информация
Краткое описание
Эмболия околоплодными водами (ЭОВ) – критическое состояние, связанное с попаданием амниотической жидкости в легочные сосуды с развитием симптомокомплекса шока смешанного генеза, вплоть до остановки сердечной деятельности, острой дыхательной недостаточности и острого синдрома ДВС. ЭОВ рассматривается как анафилактическая реакция на биологически активные вещества, входящие в состав амниотической жидкости.
I. ВВОДНАЯ ЧАСТЬ
Название протокола: Эмболия околоплодными водами
Код протокола:
Код(ы) МКБ-10:
O88 Акушерская эмболия
Включено: легочная эмболия во время беременности, родов или в послеродовом периоде
O88.0 Акушерская воздушная эмболия
O88.1 Эмболия амниотической жидкостью
O88.2 Акушерская эмболия сгустками крови
O88.3 Акушерская пиемическая и септическая эмболия
O88.8 Другая акушерская эмболия
Сокращения, используемые в протоколе:
ЭОВ – эмболия околоплодными водами
ДВС – диссеминированное внутрисосудистое свертывание
КОС – кислотно-основное состояние
ЦВД – центральное венозное давление
Дата разработки протокола: май 2013 года.
Категория пациентов: беременные, роженицы, родильницы.
Пользователи протокола: акушеры-гинекологи. При подозрении на эмболию околоплодными водами необходимо вызвать анестезиолога-реаниматолога.
Диагностика
II. МЕТОДЫ, ПОДХОДЫ И ПРОЦЕДУРЫ ДИАГНОСТИКИ И ЛЕЧЕНИЯ
Перечень основных диагностических мероприятий:
1. R-графия легких
2. Эритроциты, гемоглобин, гематокрит
3. Тромбоциты
4. Фибриноген
5. Время свертывания
6. Паракоагуляционные тесты
7. ЭКГ
8. КОС и газы крови
9. ЦВД
Диагностические критерии:
Необходимые условия для попадания околоплодных вод в кровоток:
— превышение амниотического давления над венозным;
— зияние сосудов матки.
Факторы, повышающие риск ЭОВ:
— Многорожавшая
— Околоплодные воды, загрязненные меконием
— Разрывы шейки матки
— Внутриутробная гибель плода
— Очень сильные тетанические схватки
— Стремительные или затяжные роды
— Амниоцентез
— Приращение плаценты
— Преждевременная отслойка нормально расположенной плаценты
— Многоводие
— Разрыв матки
— Хориоамнионит
— Макросомия
— Плод мужского пола
— Операция кесарева сечения
Причины амниотической эмболии при кесаревом сечении:
— избыточное давление на матку извне;
— попытки извлечь плод через разрез несоответствующий размерам головки плода;
— выраженная гиповолемия.
Возможные пути проникновения околоплодных вод в кровоток матери:
1. Трансплацентарный путь (через дефект плаценты).
2. Через сосуды шейки матки.
3. Через межворсинчатое пространство – при преждевременной отслойке нормально расположенной плаценты.
4. Через сосуды любого участка матки – при кесаревом сечении, нарушении, нарушении целостности плодных оболочек, разрывах матки.
Клиника ЭОВ представлена двумя основными синдромами:
— кардиопульмональным шоком
— и коагулопатией (синдромом ДВС).
Клиническая картина амниотической эмболии во время родов и после родов:
внезапное начало
— бледность кожных покровов
— беспокойство и страх, иногда боли в грудной клетке
— нарушение дыхания
— возникает потрясающий озноб
— гипертермия до 39 градусов и более
— нарастает цианоз кожи лица и конечностей
— резко затруднено дыхание, может развиться возбуждение с тонико – клоническими судорогами, и затем, почти сразу, может наступить кома.
— после вышеуказанной клинической симптоматики, возможно, ожидать профузное кровотечение из половых путей.
Клинические проявления амниотической эмболии при кесаревом сечении в условиях общей анестезии:
— внезапное трудно объяснимое снижение насыщения крови кислородом (SpO2) до 85%, а в тяжелых случаях до 70%, во время или сразу после извлечения плода;
— при ИВЛ повышение давления в дыхательном контуре до 35 – 40 и более см вод.ст.;
— при аускультации возможны хрипы в легких;
— развивается развернутый ДВС синдром.
Клинические проявления амниотической эмболии при кесаревом сечении в условиях регионарной анестезии:
— внезапное возбуждение пациентки во время или сразу после извлечения плода;
— снижение насыщения крови кислородом (SpO2) до 85%, а в тяжелых случаях до 70%, во время или сразу после извлечения плода;
— затрудненное дыхание;
— при аускультации возможны хрипы в легких;
— развивается развернутый ДВС синдром.
Дифференциальный диагноз
Симптомы | Эмболия околоплодными водами | Тромбоэмболия легочной артерии |
Тахикардия |
Повышение давления в дыхательных путях
Увеличения ЦВД
Кратковременно
Длительно
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Лечение
Цели лечения: оказание экстренной помощи.
Тактика лечения
При появлении первых симптомов амниотической эмболии (озноб, повышение температуры тела) или при подозрении амниотической эмболии:
Мероприятия первой очереди:
1. Оксигенотерапия (обеспечить подачу увлажненного кислорода со скоростью 6-8 литров в минуту).
2. Катетеризация двух – трех вен (центральной вены — после коррекции гипокоагуляции, желательно яремной).
3. Катетеризация мочевого пузыря.
4. Развернуть операционную.
5. Одномоментно ввести 420 – 480 мг преднизолона в/в.
6. Перевести больную в операционную для наблюдения!
7. Через 20 минут после введения первой дозы – 180 – 240 мг преднизолона в/в.
Своевременно проведенные мероприятия первой очереди купируют анафилактическую реакцию и предотвращают развитие коагулопатического осложнения.
Акушерская тактика при купировании признаков ЭОВ и стабилизации состояния беременной – роды вести через естественные родовые пути под непрерывным мониторным наблюдением за состоянием роженицы и плода.
Акушерская тактика при коагулопатическом осложнении эмболии околоплодными водами заключается в немедленном оперативном родоразрешении и тщательном хирургическом гемостазе, не исключается расширение операции и перевязка подвздошных артерий.
На следующие сутки после родоразрешения – 30 мг преднизолона 4 раза в сутки в/в. В последующие сутки 30 мг преднизолона в/в однократно.
Анестезиологическая тактика при коагулопатическом осложнении:
— анестезия только общая;
— массивная инфузионная, трансфузионная терапия;
— медикаментозная коррекция коагулопатических расстройств;
— антибактериальная терапия;
— кардиальная терапия;
— продленная ИВЛ;
— контроль диуреза;
— контроль ЦВД;
— профилактика полиорганной недостаточности.
Медикаментозная терапия осложнений эмболии околоплодными водами:
— Экстренная трансфузия свежезамороженной плазмы – до 20 — 25 мл/кг, но не менее 800 мл.
— Кристаллоиды (р-р Рингера, физиологический раствор) инфузионная терапия до 300% от предполагаемого объема кровопотери при 100% замещении эритроцитсодержащими средствами.
— Плазмозаменители (6% гидроксиэтилированный крахмал), сукцинилированный желатин.
— Эритроцитарная масса 100% от объема кровопотери.
— При отсутствии подъема ад на фоне инфузии подключать вазопрессоры: допамин 5 – 10 мг/кг в мин микроструйно (дозатором) эфедрин, фенилэфрин. АД удерживать на уровне 100 – 110/70 мм.рт.ст.
— Ингибиторы протеаз: препараты апротинина (под контролем фибринолитической активности).
— Транексамовая кислота (250 – 500 мг в/в).
— Антигистаминные препараты
— Наиболее современным, эффективным и радикальным средством коррекции коагулопатических расстройств является одномоментное введение эптаког альфа (активированный)(рекомбинантный фактор свертывания крови VIIa) в дозе 90 мкг/кг.
Дальнейшая тактика лечения:
— антибактериальная терапия – цефалоспорины IV поколения, бета-лактамные антибактериальные препараты;
— кардиальная терапия проводится в соответствии с клинической ситуацией;
— пролонгированная ИВЛ до восстановления гемоглобина до уровня 65 – 70 г/л, количества тромбоцитов не менее 100 * 10 9/л , до стабильного восстановления показателей гемодинамики;
— профилактика полиорганной недостаточности до исчезновения симптомов гипокоагуляции; дезагреганты только после устранения коагулопатического кровотечения.
Индикаторы эффективности лечения: не допустить материнской смертности.
Эмболия околоплодными водами — это осложнение, возникающее в период вынашивания ребенка или в процессе родов из-за попадания околоплодных вод в кровоток женщины. Чаще всего отмечается на первом и втором триместрах беременности, у только родивших девушек.
Причины
Данное опасное для жизни осложнение возникает, если давление в полости матки больше, чем в венозных сосудах. Причины могут быть различными. Важным условием является нарушение целостности кровеносных сосудов матери.
Во время родов повышается риск при кесаревом сечении, несвоевременном проколе плодного пузыря, предлежании плаценты или ее преждевременной отслойке (при этом в околоплодных водах присутствуют примеси крови), разрыве матки или шейки.
Повышения давления внутри матки
Нередко амниотическая жидкость попадает в кровеносную систему женщины, если объемы ее слишком велики, плод чрезмерно крупный. Часто патологию регистрируют при многоплодной беременности. Фактором риска является тазовое предлежание.
Во время родов вызвать эмболию могут аномалии родовой деятельности: чрезмерная активность, несоответствие силы схваток раскрытию шейки матки, продвижению плода по родовым путям. Опасна ригидность шейки матки: если она плохо растягивается, риск развития эмболии увеличивается. Кроме того, привести к патологии может неадекватная стимуляция.
Гиповолемия
Возможны причины и со стороны матери. В случаях, когда у женщины пониженное венозное давление из-за гестоза, имеются пороки сердца или сахарный диабет, наблюдается сильное обезвоживание, амниотическая жидкость может попасть в кровоток роженицы.
Разновидности и симптоматика
Распознать эмболию возможно по ряду симптомов. Цвет кожи становится бледным, наблюдается холодный пот. Возникает озноб. Появляется кашель, быстро из сухого переходящий во влажный. Дыхание учащенное, поверхностное. Возникают болевые ощущения за грудиной, в верхних отделах живота. Болезненность отмечается в конечностях. Часто наблюдаются головные боли.
Отмечается синюшность губ, лица, конечностей. Часто женщина испытывает сильную тревожность, иррациональное чувство страха. Артериальное давление сильно снижается, пульс становится частым, плохо прощупывается. Отмечаются судороги, сильные кровотечения. Возможна потеря сознания.
Симптоматика часто проявляется частично. Особенности зависят от того, какое количество околоплодной жидкости проникло в кровеносную систему.
Коллаптоидная форма
Коллаптоидная эмболия околоплодными жидкостями характеризуется отклонениями в функционировании сердечно-сосудистой системы. Артериальное давление сильно понижается, пульс учащается. Конечности бледнеют, при прикосновении холодные. Часто отмечаются обмороки. Сильно проявляется кардиальный шок.
Судорожная форма
Характерными симптомами такой разновидности являются неконтролируемые мышечные сокращения. Во время приступов наблюдается нарушение дыхания, отмечаются слабость, головокружения, тошнота.
Геморрагическая форма
Характеризуется обильными кровотечениями. Биологическая жидкость быстро вытекает из организма через нос, глаза, влагалище. При взятии пункций, установке катетеров кровь начинает течь из мест проколов.
Отечная форма
При данной разновидности тромбоэмболии амниотической жидкостью отмечается отек ткани легких, приводящий к острой дыхательной недостаточности. Дыхание шумное, сопровождается отхождением пенистой мокроты. Возникает одышка, кашель, сильное удушье. Характерно чувство страха. Отмечаются интенсивные болевые ощущения в области грудины. При несвоевременной медицинской помощи наблюдается остановка дыхания.
Молниеносная форма
Является самой тяжелой разновидностью патологии, при которой летальные исходы регистрируются чаще, чем при прочих. Развивается стремительно. Возникает недостаточность большей части внутренних органов. В 80% случаев спасти женщину и ребенка не удается, гибель обоих наступает в течение 1 часа по причине необратимого шокового состояния. Быстро поднимается температура тела, женщина теряет сознание. Вскоре останавливается сердце.
Диагностика
Поскольку эмболия начинается внезапно, отследить предпосылки к ее возникновению заранее затруднительно. Диагностика и лечение возможны лишь тогда, когда появились первые симптомы.
Первичную диагностику врач проводит по наблюдающейся симптоматике. Сначала оценивают дыхание: если оно сбивается, появляется одышка, прослеживаются быстро исчезающие единичные сухие хрипы, можно заподозрить эмболию. Доктор должен проверить пульс, измерить артериальное давление.
После этого матери придется сдать на анализ образцы крови. Необходимо оценить количество тромбоцитов, фибриногена. Затем исследуют скорость свертывания цельной крови и АЧТВ, представляющий собой показатель свертываемости биологической жидкости.
Третьим этапом являются обследования с помощью медицинского оборудования. Проводится электрокардиограмма, рентген легких.
После этого специалист оценивает состояние плода и подбирает подходящие методы терапии.
Лечение
Начинать терапию необходимо сразу после обнаружения первых признаков. Действовать нужно быстро, в противном случае и женщина, и плод погибнут.
Эффективность лечения оценивают по восстановлению сердечной деятельности, нормализации гемодинамики, отсутствию кровотечения, прекращению использования аппарата для искусственной вентиляции легких.
Неотложная помощь
Требуется незамедлительно вызвать врачей. Понадобится помощь акушерок, неонатологов, анестезиологов. Затем следует изменить положение тела женщины таким образом, чтобы полая вена не подвергалась сдавливанию маткой. Для этого правое бедро нужно сместить влево. После этого обеспечивают подачу кислорода женщине. Требуется срочная сердечно-легочная реанимация. Если реанимировать беременную не удается, доктора принимают меры по спасению жизни ребенка.
Терапевтический метод
Терапевтические меры применяются, чтобы купировать анафилактоидную реакцию, для предотвращения развития необратимых, опасных для жизни нарушений системы гемостаза. Женщину нужно обеспечить подачей увлажненного кислорода. Может быть подключена искусственная вентиляция легких. Проходимость легочных путей обеспечивают с помощью интубации трахеи. Объем циркулирующей крови восполняют с помощью кровозамещающих жидкостей, вводить которые приходится в больших объемах.
Медикаментозный способ
Внутривенно вводят глюкокортикостероидные препараты в большом количестве. Используются Преднизолон, Гидрокортизон. Бикарбонат натрия применяется, чтобы откорректировать ацидоз. Если артериальное давление сильно понижается, потребуется введение симпатомиметиков. Иногда применяют Допамин, Добутамин. Легочную нагрузку снижают внутривенным введением Простациклина или ингаляциями оксида азота.
Операция
Метод родоразрешения зависит от состояния женщины, особенностей протекания эмболии. Возможны роды естественным способом или использование экстренного кесарева сечения. Срочно проведенная операция увеличивает шанс на выживание матери, поскольку матка перестает давить на полую вену, препятствуя нормальному кровоснабжению сердечной мышцы. Кроме того, быстрые роды предотвращают попадание в кровоток большего количества жидкости.
Операцию проводят при стабилизации состояния матери.
Профилактика заболевания
Снизить риск развития патологии поможет планирование беременности, предварительная подготовка. Женщине следует излечить имеющиеся патологии до зачатия, чтобы избежать развития нежелательных реакций в период вынашивания.
Необходимо своевременно начать наблюдаться у гинеколога. Посещать доктора нужно регулярно: врач сможет своевременно обнаружить отклонения, примет меры, чтобы избежать гибели женщины и ребенка.
Все диагностические исследования должны быть своевременно пройдены.
Рекомендована регулярная физическая активность. Упражнения специальной лечебной физкультуры для беременных следует выполнять каждый день не меньше, чем по полчаса. Можно заниматься на фитболе, выполнять дыхательные упражнения, прогуливаться. Если гинеколог разрешит, допускается плаванье, аквааэробика и другие виды спорта.
Необходимо соблюдать специальную диету. Следует отказаться от острой пищи, жаренных на масле блюд. Лучше отдавать предпочтение натуральным продуктам. Из термической обработки предпочтительнее варка, готовка на пару, тушение, запекание в духовке.
Уровень нервного напряжения нужно снизить. Для этого следует сократить общение с неприятными людьми, избегать недосыпания. Если работа связана с постоянными стрессами, лучше сменить ее, уйти в декретный отпуск, уволиться. Важно достаточно отдыхать. Спать нужно не меньше 8-9 часов ежедневно.
Следует предотвращать состояния, приводящие к эмболии. Необходимо своевременно диагностировать повышенный тонус матки и купировать его. Кроме того, важно предотвращение развития гестоза, плацентарной недостаточности, преэклампсии, эклампсии и прочих патологий.
Требуется обильное питье. Обезвоживание недопустимо.
Осложнения и прогнозы
Вероятность развития эмболии составляет всего 5-8 случаев на 100000 родов. Соблюдение рекомендаций врача помогает снизить вероятность появления опасного осложнения.
Исход зависит от того, насколько тяжелым было состояние беременной, как быстро приняты меры. Чаще всего патология заканчивается летальным исходом как для женщины, так и для ребенка. При молниеносной форме эмболия околоплодными жидкостями с вероятностью до 80% завершается смертью у матери и плода. Другие разновидности отклонения имеют большее количество благоприятных исходов, риск гибели снижается. Положительное завершение патологии возможно лишь при быстром начале медицинских манипуляций.
Если мать и ребенок выжили, нередко развиваются осложнения. У женщины часто возникает почечная недостаточность, нарушается кровоснабжение головного мозга. После родов возможно появление воспалительных процессов, гнойные образования.
Появление на свет малыша — чарующий и крайне сложный процесс, во время которого могут случиться серьёзные осложнения. Например, эмболия околоплодными водами.
Эмболия околоплодными водами
Эмболия околоплодными водами — очень опасное осложнение в процессе родовой деятельности, связанное с излиянием околоплодных вод в кровоток женщины. Эмболия ОВ (околоплодными водами) может произойти как на стадии вынашивания плода, так и в процессе родовой деятельности. Бывали случаи развития патологии в первые 30 минут послеродового периода.
Разновидности эмболии ОВ
Акушер-геникологи и анестезиологи-реаниматологи выделяют пять разновидностей этой аномалии:
- коллаптоидная;
- судорожная;
- отёчная;
- геморрагическая;
- молниеносная.
Коллаптоидная форма
Эта форма характеризуется ярко выраженным падением сосудистого тонуса (особенно венозного) и резким снижением артериального давления.
Симптоматика:
- резкое ухудшение общего состояния;
- появление головокружения;
- ощущение сильной слабости, озноба;
- цвет кожи становится мраморно-белый;
- отстранённость пациентки от окружающего мира;
- выступает холодный пот;
- пульс практически не прослушивается;
- дыхание становится учащённым, но поверхностным;
- снижается АД (систолическое до 70–60, диастолическое до 40 мм рт. ст. и даже ниже);
- потеря сознания.
Судорожная форма
Появление генерализированного судорожного синдрома.
Симптоматика:
- головокружение;
- тошнота;
- слабость;
- резкое, частое и сильное сокращение мышц с последующим краткосрочным расслаблением;
- нарушение ритма дыхания во время приступов судороги.
Геморрагическая форма
Выражается обильными кровотечениями.
Происходит быстрая и сильная кровопотеря из носа, глаз, рта, влагалища, участков взятия пункции и установки катетеров.
Отёчная форма
Проявляется отёком лёгочной ткани, который, вызывает острую дыхательную недостаточность.
Симптоматика:
- дыхание шумное, клокочущее, с отхождением пенистой мокроты;
- развитие одышки;
- появление чувства страха, удушья;
- острые боли за грудиной;
- появления сильного кашля;
- головокружение, слабость;
- выраженный цианоз верхней части груди и лица;
- потеря сознания;
- остановка дыхания.
Молниеносная форма
Самая страшная и тяжёлая форма патологии. Развивается стремительно и характеризуется полиорганной недостаточностью. В 80% случаев пациентка и плод умирают в течение часа от необратимого шока.
Помимо всего прочего, наблюдается быстрое повышение температуры тела, потеря сознания, остановка сердца.
Болезнь протекает стремительно, при этом сбивается работа всех внутренних органов.
Нужно сказать, что симптомы эмболии ОВ могут быть весьма вариабельными. Всё зависит от количества попадания вещества в систему кровотока, от скорости распространения и реактивности материнского организма.
Причины
Эмболия всегда начинается внезапно. Предпосылки для развития патологии выявить практически невозможно. Неправильное излияние амниотической жидкости может начаться в процессе бурной родовой деятельности и даже во время кесарева сечения.
Проникновение амниотической жидкости в кровеносную систему женщины может быть обусловлено следующими причинами:
- повышение давления в матке при многоводии, многоплодной беременности, дискоординации, бурной родовой деятельности;
- ранняя отслойка плаценты, которой предшествуют околоплодные воды с кровью;
- разрыва шейки матки при родах или самой матки в случае травматизации при беременности;
- операции кесарева сечения;
- аномалии развития оболочек;
- нарушение сообщения между сосудистым и амнионом руслом матери;
- предлежание плаценты;
- недоброкачественное исследование околоплодных вод.
Итак, чтобы околоплодные воды попали в кровоток матери, должны быть соблюдены два фактора: нарушение цельность сосудов и увеличение внутриматочного давления (давление в амнионе должно быть выше, чем в венах матки).
Диагностика
Диагностика основана прежде всего на клинической картине. При внезапном появлении симптомов тяжёлого шока необходимо соблюдать следующий алгоритм действий:
- Тщательный учёт клинических симптомов
- Оценка функций дыхания
- учащённое дыхание (до 20–25 вдохов в минуту);
- возможна отдышка;
- аускультативно дыхание жёсткое, единичные рассеянные сухие хрипы, которые быстро исчезают.
- Оценка гемодинамики
- артериальное давление;
- пульс.
- ЭКГ (электрокардиограмма)
- признаки перегрузки правых отделов (отклонение электрической оси вправо, увеличение размеров зубца P во II, III и AVE отведениях сегмента ST и инверсия зубца Т в правых грудных отведениях).
- R — лёгких (рентгенография лёгких)
- увеличенное правое предсердие и желудочек, картина интерстициального сливного отёка, что проявляется в виде «бабочки» с уплотнением в прикорневой зоне и просветлением рисунка по периферии.
Оценить состояние плода.Выбор тактики лечения.
Лечение
Дважды мне приходилось слышать мнение родственников, чьи близкие ушли из жизни от эмболии ОВ. Разумеется, все обвиняют врачей. Говорят, что специалисты не квалифицированные, помощь оказали несвоевременно и вообще просто просмотрели, не подошли к роженице вовремя. Хочется отметить, что эмболия развивается настолько стремительно, счёт идёт даже не на минуты — на секунды. Женщина может идеально чувствовать себя во время беременности, но это не исключает развития патологии. В большинстве случаев при излиянии околоплодных вод в кровоток матери удаётся спасти только малыша. И это уже считается заслугой врачей. Если всё-таки женщина выживает, она в последующем должна уделять своему здоровью повышенное внимание.
При появлении первых признаков развития эмболии необходимо немедленно:
- Позвать на помощь акушерок, анестезиологов, неонатологов.
- Помочь женщине принять такое положение, чтобы предотвратить передавливание нижней полой вены беременной маткой (бедро роженицы смещается влево).
- Провести подачу кислорода матери.
- Незамедлительно начать сердечно-лёгочную реанимацию.
- Родоразрешение. Если реанимация матери бесполезна, делается незамедлительно для сохранения жизни ребёнка.
После стабилизации состояния больная переводится в отделение интенсивной терапии.
Подробное описание лечения эмболии околоплодными водами
- Обеспечить проходимость дыхательных путей путём интубации трахеи.
- Обеспечение искусственной вентиляции лёгких с высоким вдохом кислорода (менее 60%) и положительного в конце выдоха. Как правило. положительный конец выдоха начинается в 5 см H2O и увеличивается на 2 до 3 см H2O до удовлетворительного уровня Pa 02.
- Целью кислородной терапии является поддержание артериального давления выше 60 мм. рт. ст. и насыщения артериальной крови кислородом на 90%.
- Далее, следует применение Гидрокортизона 500 мг внутривенно, затем каждые 6 часов (до 2 г/24 ч). Или Преднизолон 360–420 мг, через 10–15 минут 280–360 мг внутривенно из расчёта суммарной дозы 700–800, в последующие 2 суток назначают по 30 мг Преднизолона 4 раза и по 30 мг 2 раза во второй день.
Во время ранней фазы развивается правожелудочковая недостаточность.
- Необходимо электрокардиографическое мониторирование для выявления и лечения аритмии или брадикардии.
- Катеризация лёгочной артерии для мониторинга сердечного выброса, центрального венозного давления, давления в лёгочной артерии и обеспечения прямого доступа к образцам крови для цитологического анализа околоплодных вод.
- Использование Норэпинефрина или Допамина для поддержания сердечного выброса.
- Уменьшение лёгочной нагрузки при помощи ингаляционного оксида азота или ингаляционного/внутривенного Простациклина.
Вторая фаза обусловлена левожелудочковой недостаточностью и отёком лёгких.
- Для поддержания гемодинамики важно применение Норэпинефрина и инотропов, таких как Добутамин, Мильринон или Левосимендан (объём инфузионной терапии 20 мл на кг массы тела).
- Немедленное родоразрешение (оперативные вагинальные роды или кесарево сечение). Быстрое родоразрешение при возникновении эмболии околоплодными водами во время беременности и в родах увеличивает шанс на хороший исход для матери, потому что давление матки на нижнюю полую вену отрицательно влияет на кровоснабжение сердца и родоразрешение способствует улучшению гемодинамики. Кроме этого, быстрое родоразрешение способствует остановлению попадания амниотической жидкости в кровоток матери. Поэтому, как только состояние матери стабилизируется, родоразрешение должно быть ускорено.
- Коагулопатия сразу следует за сердечно-сосудистым шоком. Поэтому немедленно приступите к радикальным методам остановки кровотечения.
Об эффективности лечения можно судить по следующим показателям:
- происходит восстановление сердечной деятельности;
- нормализуется гемодинамика (кровяное давление, скорость кровотока и тонус сосудов);
- совершается экстренное родоразрешение;
- отсутствует кровотечение;
- прекращается искусственная вентиляция лёгких.
Возможные осложнения и последствия
Все осложнения, вызванные излиянием околоплодных вод, имеют негативный характер. Среди них:
- Острая почечная недостаточность;
- геморрагический, кардиогенический или анафилактический шок;
- нарушение мозгового кровообращения;
- послеродовые гнойно-воспалительные осложнения;
- смерть матери и плода.
Только при своевременно оказанной помощи и адекватном подходе к лечению можно рассчитывать на благоприятный исход.
Профилактика
Профилактика рецидива развития аномалии подразумевает:
- планирование и подготовка к беременности
- своевременная постановка на учёт в женской консультации и её регулярное посещение с прохождением всех диагностических исследований;
- ежедневное выполнение специальной лечебной физкультуры для беременных в течение 30 минут (дыхательная гимнастика, ходьба, занятия на гимнастическом мяче);
- соблюдение специальной диеты с ограниченным употреблением жареной и острой продукции;
- исключение интенсивных психоэмоциональных нагрузок.
Видео — эмболия околоплодными водами
Отзывы пациенток, столкнувшихся с эмболией
Здравствуйте! В 2012 году были роды. Экстренное кесарево на 31 неделе + многоплодие + многоводие. Был синдром ТТС у близнецов на 5-м месяце. Была проведена лазерная операция на плаценте в Германии. Во время накладывания швов после кесарева начала кашлять. Дальше состояние только ухудшалось. Диагноз: эмболия околоплодными водами. Мне не давали шансов вообще, был сильный шок, судороги, озноб, испуг и когда уже практически перестала дышать, ввели в медикаментозный сон. Дальше реанимация, ИВЛ, интубация трахеи. Очнулась через 2 дня. Потом долго приходила в себя. Все это свежо в памяти и вызывает сильные расстройства. Врачи сотворили чудо и сделали все для того, чтобы меня спасти. У нас выжил только один ребёнок. И вот сейчас начинаем хотеть второго. Просто дикое желание, но и страх умереть в родах такой же дикий. Врачи говорят, что может случиться рецидив, так как матка всё равно слабая на месте шва. Хоть и прошло уже много лет.
Ксения 26–01–2015 14:50:26
https://www.minzdrav.com/45760/
Крайне важно понимать, что патология протекает очень стремительно. Большинство смертей происходят в первые несколько минут с начала заболевания!
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