The elucidation of amniotic fluid embolism

我们将AFE患者分为两组。一种是已建立的AFE组：尸检时在母体肺血管中发现胎儿物质。另一个是潜在的AFE组谁填写修改本森的标准。1)目前怀孕或分娩后12小时内，2）以下一种或多种情况需要进行严重的医学治疗，a）心脏骤停B）分娩后2小时内大量出血（超过1500 ml，除失张力性出血外），c）弥散性血管内凝血，d）呼吸窘迫，3）临床过程没有其他医学解释。我们发现了存在于胎粪中的特异性胎儿抗原，唾液酸Tn（Sialyl Tn）和粪卟啉锌1（Zn-CP 1），并开发了定量方法来确定胎儿抗原泄漏到母体循环中。从包括日本在内的世界各地的机构招募了135名患者，其中20名患有确诊的AFE，115名患有潜在的AFE。这些病人是ava ...更多信息 不能评价血清中锌和锌-CP 1的水平。血清中的截止点分别为46.0U/ml（Zn-CP 1）和1.6pmol/ml（Zn-CP 1），作为平均值加2SD。135例AFE患者血清中Zn-CP_1和Zn-CP_1浓度均高于对照组（分别为163.4±229.1U/ml和70.5±198.5 [潜在AFE] vs.29.5 ±8.8U/ml; Zn-CP_1浓度分别为30.2±26.7pmol/ml和84.0±193.9 [潜在AFE] vs.0.50 ±0.54pmol/ml）。AFE、确诊AFE和潜在AFE患者的血清CRP阳性率分别为84.6%和18.5%。Zn-CP 1阳性率分别为75.0%和57.0%。AFE的肺切片表现可分为2型。一是患者死亡后1天内肺组织结构基本正常;死亡原因为肺通气系统和循环功能障碍，肺血管内可见栓子和纤维蛋白沉积。二是患者死亡数天后，肺组织结构几乎被破坏，类似于成人肺动脉窘迫综合征。TKH-2免疫染色阳性的肺血管区的白细胞主要由中性粒细胞组成。使用抗中性粒细胞弹性蛋白酶的单克隆抗体，该区域显示中性粒细胞的强染色。可以设想，活化的嗜酸性粒细胞衍生的高细胞因子血症可能导致AFE几天后死亡的原因。考虑到这一结果，在AFE患者中测量炎性细胞因子IL-8。死亡患者IL-8水平明显高于存活患者。提示当血清IL-8水平超过400 pg/ml时，AFE患者预后不良。一项最新的分析，与其他并发症相比，AFE患者中的早产和先兆子痫更多。AFE的发生率在经产妇和引产产妇中均较高。经产妇及合并早产、子痫前期者，无医学指征不宜轻易引产。2003年8月，日本妇产科学会正式启动AFE注册制度。AFE患者的登记正在迅速增加。少

We classified AFE patients into two groups. One is the established AFE group : fetal materials are found in maternal pulmonary vessels at autopsy. Another is the potential AFE group who fills with modified Benson's criteria. 1) currently pregnant or within 12 hours after delivery, 2) one or more of the following to require medical treatment severely, a) cardiac arrest b) large amount of bleeding after delivery within 2 hours (more than 1500ml except for atonic bleeding), c) disseminated intravascular coagulation, d) respiratory distress, 3) absence of other medical explanations for clinical course. We discovered specific fetal antigens, Sialyl Tn (STN) and Zinc coproporphyrin1 (Zn-CP1), which present in meconium and developed quantitative methods to determine fetal antigen leakage into maternal circulation. One hundred thirty five patients, 20 with established AFE and in 115 with potential AFE, were recruited from institutions all over the world including Japan. These patients were ava … More ilable to evaluate the STN and Zn-CP1 level in serum. The cut-off points in serum were provided 46.0U/ml(STN) and 1.6pmol/ml (Zn-CP1), respectively, as mean plus 2SD. The serum levels of STN and Zn-CP1 in 135 patients with AFE showed higher concentrations than those in control(STN:163.4±229.1U/ml [established AFE], 70.5±198.5 [potential AFE]vs. 29.5±8.8U/ml [control], Zn-CP1:30.2±26.7pmol/ml[established AFE], 84.0±193.9 [potential AFE] vs. 0.50±0.54pmol/ml[control]). Positive rate of STN in patients with AFE, established AFE and potential AFE was 84.6% and 18.5% respectively. Meanwhile positivity of Zn-CP1 was 75.0% and 57.0%, respectively. The findings of AFE in lung sections were divided 2 types. One was that the structure of the lung tissues were almost normal when the patients died within 1 day. This cause of death was the dysfunction of pulmonary ventilated system and circulation, because the embolus and fibrin deposite could be found out intra pulmonary vessels. Second was that the structure of the lung tissues were almost destroyed similar to adult respiratoly distress syndrome when the patients died after a few days. The leukocytes in the region of pulmonaty vasculature, where the TKH-2 immunostaining was positive, were mainly composed of neutrophils. Using a monoclonal antibody against neutrophil elastase, this region showed strong staining for neutrophils. It is conceivable that the activated neutrophils-derived hypercytokinemia may result in the cause of death of AFE after a few days. In concern of this result, the inflammatory cytokine IL-8 was measured in the patients with AFE. IL-8 in the died patients was significant higher than in the survived patients. We suggest when the values of IL-8 are indicated over 400pg/ml, the prognosis of AFE patients is poor. An updated analysis, preterm labor and pre-eclampsia was approved more in the patients with AFE compared with the other complication. The appearance of AFE was occurred frequently in both multipara and inducted delivery. The pregnant women with multipara and the complications of preterm labor and pre-eclampsia should not be inducted easily without the medical indication. The registration system of AFE was started from August 2003 officially in the society of Japan obstetrics and gynecology. The registration of the patients with AFE are rapidly increasing. Less