妊娠和產(chǎn)褥期動(dòng)脈瘤性蛛網(wǎng)膜下腔出血的診療課件

妊娠和產(chǎn)褥期動(dòng)脈瘤性蛛網(wǎng)膜下腔出血的診療一、妊娠和產(chǎn)褥期蛛網(wǎng)膜下腔出血是指發(fā)生在整個(gè)妊娠期及產(chǎn)后6周內(nèi)的SAH。二、流行病學(xué)及病因妊娠和產(chǎn)褥期蛛網(wǎng)膜下腔出血發(fā)病率約1/100000-5/100000。成為日本妊娠期婦女的第二大死因。成為美國(guó)妊娠期婦女第三大死因。常見病因是顱內(nèi)動(dòng)脈瘤、AVM破裂引起出血，其次是妊娠期高血壓、子癇、靜脈竇血栓、煙霧病、非動(dòng)脈瘤性蛛網(wǎng)膜下腔出血等。32Y,Headache,9thweekofpregnancy,seizure,lossofconsciousnessEclampticsubarachnoidhaemorrhage32YG1P0Fivedaysafterdeliverysevere‘pounding’painoverthevertexnausea95/60-130/74妊娠和產(chǎn)褥期動(dòng)脈瘤性蛛網(wǎng)膜下腔出血的流行病學(xué)妊娠和產(chǎn)褥期動(dòng)脈瘤性SAH發(fā)病率約3/100000。動(dòng)脈瘤性SAH的引起的妊娠期婦女死亡率約13%-15%。妊娠不會(huì)增加動(dòng)脈瘤的破裂機(jī)率。輔助檢查首選CT檢查，在放射吸收劑量<50mGY下不會(huì)增加胎兒畸形、生長(zhǎng)受限和流產(chǎn)的機(jī)率。腰椎穿刺術(shù)。MRI。CTA、MRA、腦血管造影術(shù)明確AN，MRA推薦為未破裂動(dòng)脈瘤患者的篩選。鑒別診斷先兆子癇和子癇的臨床表現(xiàn)很相似，難以鑒別。研究顯示，30％妊娠期SAH可反應(yīng)性引起血壓升高、一過性蛋白尿。而40％致命性子癇可同時(shí)并發(fā)SAH。四、治療與非妊娠期動(dòng)脈瘤性SAH處理類似。積極的手術(shù)治療，文獻(xiàn)報(bào)道：手術(shù)組孕婦死亡率11%，胎兒死亡率5%；非手術(shù)組死亡率63%，27%。不輕易放棄胎兒，妊娠28周后可進(jìn)行剖腹產(chǎn)，24周-28周視胎兒成熟度選擇手術(shù)方式。合并大量腦出血、腦積水等患者可以先進(jìn)行腦血腫清除及腦室外引流術(shù)，但必須要做好胎兒監(jiān)測(cè)，出現(xiàn)胎兒窘迫，需要同時(shí)進(jìn)行剖腹產(chǎn)手術(shù)。麻醉方式選擇氣管全麻，做好胎兒監(jiān)測(cè)等。多學(xué)科的協(xié)作（神經(jīng)科、產(chǎn)科、麻醉科、新生兒科），以神經(jīng)科醫(yī)師為主導(dǎo)。動(dòng)脈瘤的手術(shù)方式動(dòng)脈瘤夾閉術(shù)動(dòng)脈瘤栓塞術(shù)術(shù)中射線影響及防護(hù)Embryogenesis(firsttwoweeksofpregnancy)thedeathoftheembryo.Duringorganogenesis(weeks2through7ofgestation)congenitalabnormalitiesinthesurvivingfetus.Thefetalperiod(week8untilbirth)growthretardationwithmicrocephaly,retardationduetoneurondepletion,anddevelopmentofchildhoodcancer.

Shieldingpatient’slowerabdomenwithdouble-layered0.5mmleadaprons,mayreducethereceiveddosebymorethan97%。Accordingtothepreviousreports,calculatedexpectedvalueofthefetaldosewasbetween11.5and43.3mGycm.AccordingtotheICRP,atexposurelevelsbelow100mGy,theradiationeffectissosmallthatterminationofpregnancyisnotjustified.21Y,headache,29thweekofpregnancy,caesariansectionatthe38thweekofgestation39Y,18thgestationalweek,headache,deliveredahealthymaleinfant4monthsFivecoils,cesareansectionatthe38thweek總結(jié)妊娠和產(chǎn)褥期動(dòng)脈瘤性蛛網(wǎng)膜下腔出血是孕婦死亡的一個(gè)重要原因。該階段以頸內(nèi)動(dòng)脈瘤為常見，破裂時(shí)期以妊娠第3個(gè)3月為常見，妊娠期再破裂機(jī)率高，死亡率高。診斷要結(jié)合臨床表現(xiàn)及影像學(xué)檢查