前赴后继，风雨兼程——羊水栓塞产妇成功抢救纪实

2015-09-27 上海国妇婴中国妇产科网

抢救现场手术现场 2015年9月的第一个周末，注定是一个不平凡的假日，一群忙碌一天刚刚准备享用周末晚餐的医务人员，在一阵急促的电话铃声后，从四面八方匆匆赶到上海交通大学医学院附属国际和平妇幼保健院，因为一位正在死亡线上挣扎的产妇需要立即手术挽救生命。羊水栓塞，一个让久经沙场见识多广的妇产科医生听见都能谈虎色变的疾病正在折磨着一位产后的年轻妈妈，产妇的生命危在旦夕。 9月4日

抢救现场

手术现场

2015年9月的第一个周末，注定是一个不平凡的假日，一群忙碌一天刚刚准备享用周末晚餐的医务人员，在一阵急促的电话铃声后，从四面八方匆匆赶到上海交通大学医学院附属国际和平妇幼保健院，因为一位正在死亡线上挣扎的产妇需要立即手术挽救生命。

羊水栓塞，一个让久经沙场见识多广的妇产科医生听见都能谈虎色变的疾病正在折磨着一位产后的年轻妈妈，产妇的生命危在旦夕。

9月4日

产妇吴某是单独二胎妈妈，9月4日上午因胎膜早破入院，下午17:00宫口开全，17:08娩出胎儿，17:10娩出胎盘，然而随着胎盘的娩出，一股殷红的鲜血几乎同时出现在手术台上。就在胎盘娩出的短短半小时里，产妇出血已达1600ml，初步判断患者存在羊水栓塞的可能。一边输血，加用激素地塞米松，并开始输注凝血酶原复合物和纤维蛋白原，同时联系放射科准备子宫动脉栓塞治疗。产后1hr累计出血已达1800ml，并且产妇开始出现心率加快、血压下降的趋势，迅即开始子宫动脉栓塞手术，期间血压波动明显，心率一直较快，补液输血的治疗不敢出现丝毫懈怠，18:45栓塞结束，出血速度减缓。19:15，产妇再次出现不凝血400 ml，同时血压明显下降，最低达78/35 mmHg，心率达140 bpm，3p试验：+，D-二聚体：+，FDP：+。INR:7.45，APTT:90.3 秒，TT:88.2 秒，PT: 58.2 秒。综合判断患者已经处于失血性休克、DIC，高度怀疑为羊水栓塞，如果不进行子宫切除手术，出血很可能危及产妇生命。简短讨论后，陈炎主任当机立断电话通知主管业务院长程蔚蔚和医务科长邱骏，启动产妇抢救预案。这才出现了本文开头出现的情况。

手术立即展开。然而，由于已经发生的休克和DIC，手术并没有想象中顺利，产妇全身只要有创伤的部位（手术切口、阴道、栓塞子宫动脉穿刺部位、深静脉置管部位、包括前期手背留置静脉的部位）、鼻腔、口腔到处都在出血，连导尿管里的小便都是红色的。由于血容量一直都无法达到基本的生理需求，产妇血压一直处于较低水平，升压药的剂量逐渐在加大。尽管麻醉科已经考虑到所有可能影响血压异常的因素，努力调整使之能够恢复至正常水平，并且手术在黄勇主任的主导下有序的进行，但血仍然是抢救产妇最为关键的因素。

晚上22:10，产妇累计失血已达6800ml左右。为了挽救产妇生命，前后已经输注血细胞悬液20u，新鲜冰冻血浆15u，血小板1u，纤维蛋白原8g，凝血酶原复合物2200IU ，冷沉淀45ml*10袋，输入平衡液2000ml，万汶1500ml。监护数据显示，产妇心率95次/分、血压102/56 mmHg。产妇手背上的出血已经停止，皮肤的破损点也出现了血痂，似乎出现了好转的迹象。大家怀着忐忑的心情，焦急等待着手术结束后抽血复查的实验室报告，希望能够带来好消息。

22:30，报告终于回来了，但产妇病情依然严重，血色素70.2g/l，PLT:50.0*10^9/L，HCT:21.2%。INR:2.69，APTT:133.8 秒，TT:22.2 秒，PT:26.8 秒，FIB:2.95 g/L。凝血指标全部异常，甚至有些已经达到了危机值。3P试验+，D-二聚体+，FDP+，DIC仍在继续。这意味着全身各处的损伤点仍在出血，仍然随时可能出现大出血。

9月5日

9月5日子夜1:00，新的救治方案再次出炉，继续输血补液治疗休克，继续补充凝血药物纠正凝血异常，补充钙剂、血钾，调整内环境正常；很快，在血库和药剂科同志的全力配合下，1000ml血、400ml血浆，800u凝血酶原复合物、4g纤维蛋白原，氯化钾、葡萄糖酸钙剂都已准备齐全，战斗的号角再次吹响了。
9月5日凌晨3:00，产妇再次鼻腔出血明显，下身的流血也有增多的趋势，监护发现血压明显出现波动，需要不断调整升压药物剂量才能维持在基本正常范围，实验室报告显示凝血状况依然没有明显改善，而且休克、DIC有逐渐加重的迹象，凝血指标甚至出现了危机值，血氧含量也出现了降低的迹象，查体发现产妇右肺呼吸音减轻，这预示着产妇情况有恶化的迹象。至目前，已经输血补液超过12000ml。经过协商，专家决定应尽快完善监测项目，指导治疗。动脉压直接监测和中心静脉直接监测很快完成了，结果果然是低血容量造成的低血压，经过试探性补液后，血压状况很快得到了改善。
9月5日早晨5:30，产妇全身出现明显水肿，血压依然是起起伏伏，这强烈撞击着每个坚守在产妇身边彻夜未眠的天使的心灵。贫血、DIC、出凝血依旧异常。难道真的已经束手无策了吗？
查体中任何一个细节都没有躲过专家们的法眼。右侧肺部的啰音似乎较昨天夜里有所增多、腹部有少量的移动性浊音，他们立即通知B超室和放射科，以进一步明确肺部和腹部情况来协助诊断。果然如他们所料，肺部和腹部都有积液，这在一定程度上解释了为什么输注如此多的液体，仍然存在低血容量休克，DIC迟迟不能纠正。为了慎重起见，分管院长程蔚蔚组织全院抢救小组会诊，徐汇区妇保所值班医生徐小芳也赶到我院协助抢救。
8:00，抢救小组会诊结论为：目前产妇胎盘早剥，足月顺产，羊水栓塞，产后出血，宫腔水囊填塞术后，双侧子宫动脉栓塞术后，失血性休克，DIC，重度贫血，全子宫切除术后。
目前存在的主要问题：1.羊水栓塞，病理生理状态持续中；2.产后大出血，低血容量性休克、DIC、凝血功能异常纠正困难，已经出现多功能脏器损伤迹象，可能出现MODS等；3.手术创伤大，手术时间长，出血多，抵抗力差，术后感染风险高；4.内环境紊乱，低钾、低钙、酸中毒；5.病情凶险，产妇病危。
处理：1.积极纠正贫血及低血容量，继续输血，补充晶体液；2.严密监测患者出入量情况，适当控制补液速度，预防心衰、肺水肿等；3.严密监测生命体征变化、胸、腹部体征、腹腔引流量变化，重点监测腹部情况，谨防内出血；4.积极纠正DIC、凝血功能障碍，再次输注纤维蛋白原、凝血酶原复合物，加用氨甲环酸或其他止血药止血；5.积极纠正电解质紊乱，补钾，补钙，动态随访血气分析、血电解质等；6.积极预防感染；7.营养支持；8.注意全身创伤部位护理，做好口腔会阴护理，预防感染；9.请六院血液内科主任常春康会诊，协助纠正DIC；

10.及时与家属沟通，通报产妇状况及可能发生的情况。

9月5日上午11:15，检查发现患者右侧腹腔引流管留置处引流孔渗出，按压下腹部见腹腔引流管留置处渗血明显，色鲜红，不凝；腹部叩诊呈浊音。生命体征：BP 117/68mmHg，HR 136bpm。予新鲜血浆及血小板输注。

11:40，盆腔内见混合回声，范围约67*50mm。右侧腹积液深约37mm，左侧腹积液深约67mm，内见中高回声。(左侧卧位）左胸水14mm，右胸水54mm。（平卧位）左胸水17mm，右胸水54mm。
11:54，动脉血气分析：PH 7.34，pCO2 40.4mmHg，pO2 79mmHg，BE -3，sO2 95%，Hb 6.1g/dL，Na 143mmol/L，K 4.6mmol/L，CA 0.92mmol/L。凝血功能：INR 1.18，APTT 50.6s，TT 20.9s，PT 14.7s,FIB 2.42g/l.DIC监测见3P试验+，D-二聚体+，FDP+。

12:00，在程院长的主持下，全院抢救小组再次协商会诊。大家一致认为患者羊水栓塞后出现大出血，引发出血性休克、DIC，至目前累计出血已达11000ml。产妇病情危重。根据临床观察和实验室报告综合判断，存在腹腔内出血可能，必须开腹行腹腔彻底止血，才能从根本上治疗休克和DIC。

13:10，在麻醉科余大松主任的亲自参与和指挥下，安小虎、徐子锋副主任一起上阵，很快麻醉就绪。13:25，王玉东院长和黄勇主任亲自上台，争分夺秒再次展开与死神的较量。随着腹腔被逐层打开，见见产妇腹腔广泛渗血，积血已达3000ml左右，仔细清理了腹腔积血后行双侧髂内动脉结扎术。术中出血250ml许，再次输血2000ml，血小板2u。15:40随着手术渐进结束，患者生命体征趋于平稳，心率85bpm。BP 112/66mmHg，指末氧饱和度96%，开始减小了升压药物剂量。产妇贫血、凝血功能、DIC异常指标好转，此时中心血站又拿来了10u新鲜血浆及10u红细胞悬液，为产妇后续的治疗提供了有利保证。

考虑到产妇病情刚刚出现好转，手术结束后并没有转出手术室，而是继续在手术室内监护治疗。为了维护手术治疗的效果，血、血浆和其他的血液制品仍然源源不断的流进产妇的体内，改善着产妇体内的环境状态。

晚上，黄荷凤院长赶到了医院，在详细询问了产妇病情和病程演化过程后对产妇状况做出了重要批示，果断指出根据产妇胎盘早剥、血性羊水、胎盘附着有血块、产后出现即刻大出血、初凝血很难止住等现象判断，该产妇羊水栓塞诊断成立；为进一步明确诊断，通知病理科做好相关病理检查，为临床诊断提供依据；要加强生命体征监护，继续纠正贫血，内环境紊乱；积极预防感染，加强对重要脏器的保护，防止并发症的发生。积极主动和家属做好沟通，随时通报患者病情，争取家属理解和支持。

9月6日

9月6日早晨，产妇全身无明显出血现象，经过一夜的不断调整，内环境有了进一步改善，血色素在不断提高，凝血状况和电解质情况进一步稳定，但经过两次大的急诊手术，产妇病情依然充满变数，仍然存在贫血的可能。感染风险增高，必须时刻监测生命体征和内环境状态，防止病情反复9月6日15:00，ICU主任安小虎再次赶到医院，和坚守在此的徐子锋主任仔细讨论患者病情后，认为目前患者生命体征趋于平稳，贫血和内环境紊乱已基本纠正，肝脏、肾脏功能基本正常，目前主要问题是预防感染，预防大出血并大抢救后肺损伤的发生，经过精心准备，考虑众多细节后决定将产妇转入了ICU继续治疗。

17:40，黄荷凤院长再次来到产妇身边，了解产妇情况，在全面听取安小虎和陈焱主任汇报后，指出产妇羊水栓塞抢救已获初步成功。

9月7日

9月7日上午，B超和X线复查再次证实胸腹腔内存在积液，但考虑到产妇状况，经全院专家会诊后，决定暂时观察处理，必要时邀请外院专家会诊指导治疗。

9月8日

9月8日，在尝试停用呼吸机辅助治疗的过程中，危机再次出现，产妇突然出现呼吸窘迫，并再次出现了低血压。紧张的气氛再次扰乱了大家的心情，经过大出血和两次手术，产妇身体已经受到巨大损伤，尽管生命体征平稳，一旦有少许变化，会随时将产妇推入危险的境地。

全院抢救小组再次聚集，研究和判断产妇状况。程薇薇院长再次前来查看产妇状况，并对进一步治疗提出宝贵意见，应提高警惕，防止意外事件发生，同时积极请外援专家指导治疗。

下午16:00，上海市第六人民医院ICU王学敏主任受邀前来会诊，认为产妇右侧胸腔有大量积液，目前性质和发病原因不明，有必要需要进行穿刺引流以明确诊断，同时引流可能会对肺功能恢复有积极意义。穿刺的结果正如专家的判断，胸腔内引流出暗红色血液500ml。考虑到出血原因不明，协商后决定先抽取一部分，观察患者反应再决定下一步治疗方案。第六人民医院胸外科副主任吴伟铭也前来会诊，经过近2小时观察，认为目前没有外科手术的明确指征，应该进行保守治疗。

9月9日

9月9日上午，在程蔚蔚院长的主持下，全院抢救小组再次集结，讨论患者下一步处理方案。经过引流处理，患者肺功能有了一定改善，胸片和B超均提示胸腔积液减少，但积液量依然较多，原因未明，如果存在活动性出血有可能危急患者循环稳定，同时出血达不到积极处理，DIC有可能出现反复，应加强血色素动态检查，继续积极治疗肺损伤的情况，争取尽早脱机，拔管防止继发性呼吸系统感染。

9月9日临近下班，患者再次出现危机，血压下降，心率加快，辛苦了一天的各位主任，再次被召集在一起，六院外科主任再次被请到医院，经过观察处理，胸腔引流管开放，以进一步明确是否存在活动性出血，引流达到1500ml，至此，困扰大家近两天的循环状况反复和肺功能改善不佳终于找到了原因。此期间，产科陈焱主任、范建霞主任、钱卫主任、医务科邱峻科长也赶到了医院，协助治疗和处理患者。徐汇区妇保所杨剑所长也对治疗和协调会诊提出来宝贵意见和建议。

9月10日

9月10日上午，针对循环出现反复的情况，在积极纠正贫血纠正低血容量外，为排除其他因素的影响，抢救小组决定对产妇心脏做B超检查，报告提示产妇二尖瓣、三尖瓣存在返流现象，这意味着产妇情况更趋复杂。

9月10日中午，产妇胸腔再次引流出鲜红色血液，胸腔内出血，而且和前面不同，这次的血很鲜艳，尽管量只有75ml，不足以影响患者生命，但预示着胸腔内的确存在出血点，前期的凝血治疗没有取得预想中的结果，而且，活动性出血完全超出了妇产科专科医院治疗的范畴，闻讯赶来的黄荷凤院长和程蔚蔚院长指示，应该尽快请外院专家会诊，确定下一步的治疗，同时积极进行保守相关治疗，纠正贫血，补充凝血因子和纤维蛋白原。

15:00，六院ICU主任王学敏和胸外科主任吴伟铭会诊后认为，目前产妇胸腔内活动性出血，同时存在心脏的相关问题，应该转到综合性医院治疗。

16:00，产妇被转往六院ICU。

9月17日

9月17日，经过第六人民医院一周的监护治疗，产妇状况大为改观，六院ICU专家认为已经可以出院，并将消息通知了我们。

9.17上午，产妇被接回我们医院，送到了8楼病区。医院为了给产妇提供良好安静的休养环境，华玲护士长特意将她安排在病人较少的房间，吸氧装置早已安排到位并在楼梯口热情等候患者。看到这么多人关心她的情况，浴火重生的产妇及家属深受感动不停地说着感谢我们医务人员的话，程蔚蔚院长代表医院衷心祝贺产妇有一个良好的康复情况。中午ICU安小虎主任在详细询问产妇状况和体检后认为产妇仍有咳嗽、痰多、呼吸频率较快、气喘等现象。安主任立即嘱咐病区医师进行雾化吸入，同时静脉滴注必漱平。并鼓励患者做适当的锻炼，促进肺功能回复并有利于肠胃功能康复。

9月20日

经过两天观察处理，产妇恢复情况良好，体力明显好转，不光可以下地走路，还可以自理一些生活细节。经过会诊大家认为患者已基本康复，可以放心出院了。

黄荷凤院长在外地出差，听说患者要出院后特意发短信给产妇，表达了真诚的祝愿。

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#插入话题

插入图片

[GetPortalCommentsPageByObjectIdResponse(id=81217, encodeId=b5818121e32, content=感动，真的很棒，这个过程其实最重要的体现就是责任心，现代医学不可能技术全面，所以更加需要多学科精英集体努力，而不是单独作战，这是保证抢救成功的关键。听说过许多羊水栓塞的病人，没有一例抢救成功的，真的是很难，失败的因素应该很多，像这次成功，真的很厉害，必赞, beContent=null, objectType=article, channel=null, level=null, likeNumber=173, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=54541716341, createdName=责任心第一位, createdTime=Fri Apr 22 19:49:00 CST 2016, time=2016-04-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1667967, encodeId=9f57166e967b8, content=<a href='/topic/show?id=1e12e9674b8' target=_blank style='color:#2F92EE;'>#羊水#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79674, encryptionId=1e12e9674b8, topicName=羊水)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=915326217791, createdName=陈吴1243, createdTime=Mon Aug 15 21:12:00 CST 2016, time=2016-08-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=37964, encodeId=2dba3e9641b, content=很好的文章哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=124, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=332823945, createdName=hlycom3356, createdTime=Wed Oct 07 22:00:00 CST 2015, time=2015-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=37635, encodeId=8da73e63563, content=致敬, beContent=null, objectType=article, channel=null, level=null, likeNumber=124, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=, createdTime=Fri Oct 02 22:10:00 CST 2015, time=2015-10-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=37548, encodeId=e8903e54816, content=抢救过程很艰辛，结局很美好, beContent=null, objectType=article, channel=null, level=null, likeNumber=138, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=acab1653249, createdName=mei666057, createdTime=Tue Sep 29 15:25:00 CST 2015, time=2015-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1387947, encodeId=a53d138e9477f, content=<a href='/topic/show?id=6077e967794' target=_blank style='color:#2F92EE;'>#羊水栓塞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79677, encryptionId=6077e967794, topicName=羊水栓塞)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83erCiat0j36p5MejdM9yCLtcVcY8WS5VIKuCMqXFNs56U6iacZib5CJvh6mVxGERicM6ZAkl91jMgpcDrw/132, createdBy=37622500012, createdName=ms2999106592497887, createdTime=Tue Sep 29 10:12:00 CST 2015, time=2015-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1471239, encodeId=629514e12393f, content=<a href='/topic/show?id=ac13558e9cb' target=_blank style='color:#2F92EE;'>#抢救#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55879, encryptionId=ac13558e9cb, topicName=抢救)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=be1a7117101, createdName=lfyang, createdTime=Tue Sep 29 10:12:00 CST 2015, time=2015-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=37505, encodeId=19793e505ab, content=感动！, beContent=null, objectType=article, channel=null, level=null, likeNumber=158, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=96871613250, createdName=medcardio, createdTime=Sun Sep 27 20:20:00 CST 2015, time=2015-09-27, status=1, ipAttribution=)]
2016-04-22 责任心第一位

感动，真的很棒，这个过程其实最重要的体现就是责任心，现代医学不可能技术全面，所以更加需要多学科精英集体努力，而不是单独作战，这是保证抢救成功的关键。听说过许多羊水栓塞的病人，没有一例抢救成功的，真的是很难，失败的因素应该很多，像这次成功，真的很厉害，必赞

173 0
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2016-08-15 陈吴1243

#羊水#

58 0
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2015-10-07 hlycom3356

很好的文章哦

124 0
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2015-10-02 匿名用户

致敬

124 0
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2015-09-29 mei666057

抢救过程很艰辛，结局很美好

138 0
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2015-09-29 ms2999106592497887

#羊水栓塞#

80 0
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2015-09-29 lfyang

#抢救#

70 0
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2015-09-27 medcardio

感动！

158 0

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