分娩中に発症して救命しえたが重度の後遺障害を生じた羊水塞栓症の1例 A case of a patient who had amniotic fluid embolism during labor but who was successfully resuscitated with severe neurological sequelae

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羊水塞栓症は,羊水および胎便中の胎児成分による肺内小血管の物理的閉塞および羊水中の液性成分によるアナフィラキシー様反応が原因とされる疾患である.今回われわれは,分娩中に羊水塞栓症を発症し,いったん心停止に陥り,救命できたものの重篤な神経学的後遺症が生じた症例を経験したので報告する.症例は32歳未経産で,妊娠経過はとくに異常なく,妊娠38週6日で陣痛発来にて入院となった.翌日,分娩第I期に破水し,子宮口全開大後に高度変動一過性徐脈が出現したためクリステレル圧出法にて男児を娩出した.分娩直後より子宮収縮は不良で子宮収縮剤を投与しても改善せず,分娩1時間後までに約1600gの出血をきたし,分娩から72分後に収縮期血圧が50mmHgまで低下し意識も消失した.昇圧剤投与,濃厚赤血球の輸血を開始したが,分娩から137分後に心肺停止となったため蘇生処置を行い心拍は再開した.抗DIC治療にもかかわらず子宮や静脈ライン留置のため皮膚を切開した右足踝からの出血が持続し,ICUでの総出血量は分娩17時間後までに10000gを超え,分娩翌日に開腹子宮摘出を行った.手術後,抗DIC療法を中心とした集学的治療にて出血傾向は改善したが,大量出血による多臓器不全のため2カ月間ICUでの管理を要した.脳虚血による低酸素脳症は回復することなく,意思疎通困難と左片麻痺のため自宅に退院することができず,分娩から半年後に介護専門病院へ転院となった.本症例では分娩直後から非凝固性の出血があり,分娩1時間後の血液データで著明な凝固・線溶系の亢進を認めたこと,血清中のシアリルTn抗原(STN)が異常高値を示したこと,および摘出子宮の組織診断で体部間質に著明な浮腫と体部筋層の血管内に羊水由来成分を認めたことから羊水塞栓症と考えられた.〔産婦の進歩67(4):381-387,2015(平成27年10月)〕

Amniotic fluid embolism (AFE) is a rare obstetric emergency involving a maternal pulmonary embolism caused by amniotic fluid or fetal cells. AFE has recently been thought of as a process of anaphylaxis occurring when amniotic fluid or fetal debris enters the maternal circulation. We report a case of AFE occurring during labor, leading the patient to suffer cardiac arrest. The patient's life was eventually saved, but she suffered severe sequelae. A 32-year-old primipara was admitted in labor. The following day the patient's membranes ruptured before the cervix was fully dilated. Severe variable decelerations were noted during the second phase of labor, so delivery was assisted by pushing on the uterus. The patient delivered a boy, and the amniotic fluid was highly turbid. After delivery, massive bleeding from the uterus continued despite use of oxytocic drugs. Seventy-two minutes after delivery, the patient's blood pressure had dropped to 50 mmHg and the patient lost consciousness. Noradrenaline was given and blood was transfused. The patient was transferred to the ICU. One hour later, the patient suffered cardiac arrest and she was revived after cardiopulmonary resuscitation. More blood was transfused and anti-DIC drugs were administered, but massive bleeding of 10000g from the uterus and the site of the venous catheter continued until the following morning. We performed surgery to remove the bleeding uterus. After the surgery, bleeding decreased. However, the patient suffered multiple organ failure due to hypovolemic shock, so the patient remained in the ICU for two months. The patient was confined to her bed due to left limb paralysis caused by brain ischemia, and she also had difficulty communicating because of brain damage. These conditions precluded the patient's return home, and she was transferred to another hospital for rehabilitation after six months from delivery. A blood sample obtained when the patient lost 1600g of blood from her uterus one hour after delivery suggested severe DIC and a high level of sialyl-Tn (STN). Probably DIC is presumed to have occurred after delivery. Pathological findings from the uterus suggested the presence of amniotic fluid in blood vessels of the myometrium. Based on these findings, we concluded this case was amniotic fluid embolism. [Adv Obstet Gynecol, 67 (4) : 381-387, 2015 (H27.10)]

収録刊行物

  • 産婦人科の進歩

    産婦人科の進歩 67(4), 381-387, 2015

    近畿産科婦人科学会

各種コード

  • NII論文ID(NAID)
    130005110849
  • NII書誌ID(NCID)
    AN00099490
  • 本文言語コード
    JPN
  • ISSN
    0370-8446
  • NDL 記事登録ID
    026795791
  • NDL 請求記号
    Z19-310
  • データ提供元
    NDL  J-STAGE 
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