县级医疗保健机构羊水栓塞导致孕产妇死亡的相关因素分析

Factors related to maternal deaths induced by amniotic fluid embolism in county-level medical institutions

目的了解县级医疗保健机构羊水栓塞导致孕产妇死亡的病例的相关影响因素,为基层临床诊断、预防及有效救治羊水栓塞提供参考。方法对湖南省县级医疗保健机构2011-2015年71例羊水栓塞导致孕妇死亡的患者病例资料进行回顾性分析,所有个案资料经省级孕产妇死亡评审专家组分析评审,按全国统一使用的孕产妇死亡十二格表分析死亡原因以及死亡主要影响因素。结果 71例死亡孕产妇中,30~34岁占29.58%,35岁及以上者占35.21%;初产妇占32.69%,经产妇占67.61%;死亡孕产妇中92.96%为农村户籍;主要临床表现以产后出血为主的占57.75%,紫绀、血压骤降或呼吸困难等急性症状为主的占32.39%,缺乏典型症状死后推断占9.86%;发病到死亡时间在1 h之内的有11例,占15.49%,2~12 h的为44例,占61.97%,12 h以上的为16例,占22.54%;产前诊断或处理不及时19例,占26.76%;产后输血大于2 000 ml的28例,占39.43%;产后输血不及时的31例,占43.66%,其中23例血源不足,8例出血量估计失误;县级抢救过程中启动县级产科急救专家组参与救治的共21例,占29.58%;省级评审为不可避免33例,占46.48%,可避免38例,占53.52%。结论县级医疗保健机构在医疗软硬件条件局限的情况下,应当重视以产后出血或急性缺氧为首发表现的孕产妇,提高早期识别意识,及早启动多学科协同救治,保障血源供给,争取提高抢救成功率;羊水栓塞诊断绝大部分依据临床表现,存在不准确性,今后应提高尸体解剖比例,明确死因。

Objective To investigate the factors influencing the maternal death cases resulting from amniotic fluid embolism in medical institutions at the county level in Hunan Province during 2011-2015, and to provide a basis for clinical diagnosis, preven- tion and effective treatment of amniotic fluid embolism in grass-roots medical institutions. Methods We retrospectively ana- lyzed the data regarding 71 maternal deaths caused by amniotic fluid embolism in county level medical institutions in Hunan Prov- ince from 2011 to 2015. All the data about the 71 death cases were evaluated by the provicial expert group of maternal death assess- ment. The causes and influencing factors of the deaths were analyzed according to national uniform twelve tables of maternal death. Results Among the 71 cases of maternal dealth, 30-34 years old accounted for 29.58%, 35 years old and above 35.21%, primipara 32.69% and multipara 67.61%. 92.96% of the maternal deaths had rural household registration. The death cases with postpartum hemorrhage and acute symptoms （ including cyanosis, sudden drop in blood pressure or breathing difficuhies） as the main clinical manifestations accounted for 57.75% and 32.39% respectively. The death cases without typical symptoms and with de- ductive causes of death accounted for 9.86%. There were 11 （ 15.49% ） cases of death occurring within 1 hour of illness onset, 44 （61.97%） cases of death occurring within 2-12 hours of illness onset and 16 （22.54%） cases of death occurring more than 12 hours. The death cases with delayed prenatal diagnosis or treatment and postpartum blood transfusion more than 2,000 ml accoun- ted for 26.76% （ 19/71 ） and 39.43% （ 28/71 ） respectively. There were 43.66% （ 31/71 ） death cases with delayed postpartum blood transfusion, of which 23 death cases induced by blood supply deficiency and 8 by bleeding volume estimation error. County e- mergency obstetric care expert group was initiated and involved in the treatment of 29.58% （21/71 ） death cases during the countyrescue process. The provincial-level assessment indicated that 46.48% （33/7l） of the death cases were inevitable and 53.5% （38/71） were avoidable. Conclusions More attention should be paid to primiparas who have postpartum hemorrhage or acute hypoxia as the first manifestation in the county-level medical institutions with the limited medical software and hardware. It is nec- essary to improve the consciousness of early identification, timely initiate multidisciplinary synergetic rescue and treatment and guarantee blood supply so as to strive to boost the rescue success rate. Diagnosis of amniotic fluid embolism is largely based on clin- ical manifestations, which may be inaccurate; and hence, the proportion of autopsy should be increased in the future to clarify the causes of death.