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The Early Diagnosis and Treatment Strategy of Maternal Near Miss

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The Early Diagnosis and Treatment Strategy of Maternal Near Miss Central Archives of Emergency Medicine and Critical Care Bringing Excellence in Open Access Short Communication *Corresponding author Youguo Chen, Center of Studies for Psychology and Social Development, Southwest University, 188 Shizi The Early Diagnosis and Street, Suzhou, Jiangsu, PR of China, 215006, Email: Submitted: 17 May 2016 Treatment Strategy of Maternal Accepted: 13 June 2016 Published: 14 June 2016 near Miss Copyright © 2016 Chen et al. Fangrong Shen1, Rong Jiang2, and Youguo Chen3* 1Department of Obstetrics and Gynecology, Soochow University, China OPEN ACCESS 2Laboratory of Stem Cell and Tissue Engineering, Chongqing Medical University, China 3Center of Studies for Psychology and Social Development, Southwest University, China Keywords • Maternal near miss • Early diagnosis Abstract • Management The WHO criteria for maternal near miss (MNM), defined as “a woman who nearly • Socioeconomic factors died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”. This review mainly analyses the amniotic fluid embolism (AFE), acute fatty liver of pregnancy (AFLP), HELLP syndrome and severe preeclampsia which may lead most cases of MNM. Finally, summarize the factors and managements associated with maternal near-miss morbidity. INTRODUCTION Amniotic fluid embolism (AFE) Maternal near miss refers to someone who survived a severe Introduction: complication in pregnancy, childbirth, or the postpartum period. catastrophic obstetrics complication occurring during labor Amniotic fluid embolism (AFE) is a With the developing of our society, more and more people are and delivery or immediately postpartum, and is characterized concerned about the maternal near-miss morbidity and mortality. by sudden cardiovascular collapse, respiratory distress, altered measures to decrease the mortality of MNM-most happened They also pay attention to the scientific and effective treatment mental status and disseminated intravascular coagulation (DIC). AFEDiagnosis: is one of the leading causes of maternal death worldwide [1]. cell and other debris of presumed fetal origin may be found, Thisin cases review of amnioticwill focus fluid on the embolism factors, the(AFE), early acute clinical fatty diagnosis liver of In women with AFE, we will find that squamous andpregnancy the management (AFLP), HELLP measures syndrome of MNM. and severe preeclampsia. iseither clinical, at autopsy based oron pulmonary the presence artery of catheter,these elements but is difficult and the to diagnose early. The early diagnosis of amniotic fluid embolism Kowloon Hospital is a private hospital, located in a new Clinical Symptoms industrial park in Suzhou (SIP), Jiangsu Province, China. The SIP exclusion of other likely causes [2]. ais newone industrialof the biggest district. industrial We conducted parks in aChina, retrospective and comprises study in3 : The onset time of AFE varied from 10 towns with an estimated population of 723 000 inhabitants, and andmin tocyanosis, 48 h. Clinical sudden signs hypotension, and symptoms cardiac of AFEarrest, are ventricularoutlined in (Table 1). The manifestations of typical AFE are acute dyspnea which cases of maternal near miss were identified among women who were admitted to Kowloon Hospital between January 1, fibrillation, ventricular tachycardia or seizures, acute confusion 2008 and December 31, 2012. occurred within 10–30 min. Meanwhile, the atypical AFE showed postpartum hemorrhage with DIC as the initial presenting Over the 5-year period of the study, there were 18104 live symptom, and usually occurred after delivery or up to 2 days [2]. births at Kowloon Hospital and 208 cases of potentially life- into three phases. The initial phase is characterized by transient threatening conditions (PLTC). Because PLTC may progress to pulmonaryAFE symptomatology and systemic evolution hypertension can beresulting divided inclassically severe thenear forefront—formiss or death, example,the process severe started pre-eclampsia; with scrutiny placental of PLTC ventilation to perfusion mismatch, hypoxemia, and potentially abruption;is important. and Such hemolysis, specified elevated conditions liver may enzymes, be brought and low to development of right heart failure. The second phase involves decreased left ventricular function and development of acute such as seizures or shock. Urgent management, such as admission pulmonary edema. The third phase is characterized by heart platelets (HELLP) syndrome and some non-specified conditions failure, worsening acute lung injury/acute respiratory distress to intensive care unit (ICU), blood transfusion, or return to an operating room, also constitutes PLTC. syndrome (ARDS), and coagulopathy [3]. Cite this article: Shen F, Jiang R, Chen Y (2016) The Early Diagnosis and Treatment Strategy of Maternal near Miss. Arch Emerg Med Crit Care 1(1): 1004. Chen et al. (2016) Email: Central Bringing Excellence in Open Access Table 1: CardiovascularClinical signs and symptomsRespiratory of amniotic fluid embolism. Hematologic Neurologic Obstetric Hypotension Respiratory arrest Coagulopathy statusAltered mental UterineFetal distress atony Cardiogenic shock HypoxemiaTachypnea/dyspnea DIC Seizure Right heart failure Hemorrhage Left heart failure Pulmonary DysrhythmiasTachycardia edema/ARDS V:Q mismatch Abbreviations Cardiac arrest : ARDS: Acute Respiratory Distress Syndrome; DIC: Disseminated Intravascular Coagulation; V/Q: Ventilation/Perfusion particular clinical form of pre-eclampsia, a severe complication monitoring will demonstrate decelerations, loss of variability, andIn terminal cases bradycardiaoccurring prioras oxygenated to delivery, blood iselectronic shunted awayfetal can occur in isolation in the absence of pre-eclampsia symptoms. from the uterus, and catecholamine induced uterine hypertonus of the second half of pregnancy [6]. Sometimes, this syndrome Diagnosis: causes a further decline in uterine perfusion. Clinical Symptoms Laboratory tests: : Clinicians should take caution not The criteria of diagnosis for DIC included to undervalue clinical signs and symptoms in (severe) pre- thrombocytopenia<100*109/L or a gradually decrease, eclampsia (Table 2) because they can be no specific (eg, nausea prolonged prothrombin time (PT) and activated partial or clotting failure, broken red cell in the peripheral blood slide. and vomiting). HELLP syndrome complicates 10–20% of cases thromboplastin time (APTT) with fibrinogen levels <1.2 g/L, of severe pre-eclampsia, and develops mostly preterm (50%) [5]. Typical clinical symptoms of HELLP syndrome are pain in Otherwise, Platelet count, prothrombin time, fibrinogen, and the right upper quadrant abdomen or epigastric pain, nausea and d-dimer levels were measured to calculate the DIC score. A score Table 2: of 5 or higher was considered compatible with DIC and a lower VasculatureDifferential diagnoses in severeRespiratory pre-eclampsia system by organ system. scoreManagement: was considered as non-DIC. and directed towards maintenance of oxygenation, cardiac output and blood pressure,The management and correction of ofAFE the iscoagulopathy. supportive Phaeochromocytoma Pneumonia ThyrotoxicosisHyperaldosteronism syndrome Pulmonary embolus Cushing’s disease (Catastrophic)antiphospholipid hemodynamic instability. The treatment ideally operated Initial goal of the treatment is the rapid correction of maternal Renal system Cardiovascular system Aorta coarctation Myocardial infarction or ischaemia cardiopulmonarywithin an intensive resuscitation, care unit uterine(ICU) byevacuation, an interdisciplinary continuous glomerulonephritis Lupus nephritis Peripartum cardiomyopathy respiratory/bloodteam. In case of necessity, pressure aggressive monitoring, support pulmonary treatment suchartery as Acute and chronic catheter, transesophageal echocardiography should be followed. Interstitial nephritis Liver Brain Pyelonephritis postmortem cesarean section can be performed during the erythematosus If patient has no response to cardiopulmonary resuscitation, Acute fatty liver of pregnancy Cerebral systemic lupus to treat postpartum hemorrhage in patients who do not have Pregnancy cholestasis highresuscitation. circulating Recombinant tissue factor factor concentrations, VIIa has been such used as successfully those with Hyperemesis gravidarum Epilepsy uterine atony, uterine rupture, and abnormal placentation. Cholecystitis Brain tumour Cholangitis MetabolicCerebrovascular disease accident GastritisViral hepatitis Hypertensive encephalopathy Acute pancreatitis However, it is recommended that recombinant factor VIIa should Gastric ulcer Haemostasis Eyes reportsbe considered also show only that in AFE patients patients who when received the hemorrhagerecombinant cannot factor be stopped by massive blood component replacement. Previous pregnancy thrombosis ThromboticBenign thrombocytopenia thrombocytopenic of Retinal arterial or venous HELLPVIIa had syndromesignificantly andworse severe outcomes preeclampsia [4]. purpura Retinal ischaemia Introduction Retinal detachment disease characterised by de-novo development of concurrent Haemolytic uraemic syndrome Persistent spasm of retinal vessels : Pre-eclampsia is a pregnancy-specific purpura Uveal melanoma hypertension and proteinuria, sometimes progressing into Idiopathic thrombocytopenic Central serous retinopathy SystemicAntiphospholipid lupus erythematosus syndrome Choroidal osteoma a multiorgan cluster of varying clinical features [5]. HELLP SepticFolate ordeficiency
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