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羊水塞栓症

著者: 金山尚裕 静岡医療科学専門大学校

監修: 金山尚裕 静岡医療科学専門大学校

著者校正/監修レビュー済:2018/05/10
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. 羊水塞栓症とは、羊水が母体血中へ流入することにより生じる病態で、流入した羊水によりアナフィラクトイド反応が発生し補体、凝固、線溶系、キニン系が活性化し播種性血管内凝固症候群(DIC)、子宮弛緩症となる状態である。また、羊水が母体血中に流入すると子宮・血管の平滑筋攣縮により子宮胎盤循環不全が発生し急激な胎児機能不全となる。
  1. 症状は、分娩周辺期の特に破水後の呼吸困難、胸痛、意識消失、ショック症状などの心肺虚脱、分娩後のサラサラした出血および弛緩出血、原因不明の胎児機能不全、原因不明の強度の下腹痛などがある。
  1. 羊水塞栓症の分類:
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
金山尚裕 : 特に申告事項無し[2021年]
監修:金山尚裕 : 特に申告事項無し[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 羊水塞栓症の発症頻度は以前、約2万から8万分娩に対し1例程度と考えられていが、播種性血管内凝固症候群(DIC)・弛緩出血を主体とする疾患に羊水塞栓症が含まれる例があることより、実際の頻度はもっと高いと考えられている。
  1. わが国で平成元年から16年までの間に193例が妊産婦死亡で剖検されたが、その中で羊水塞栓症が24.3%と第1位であった[1]
  1. 最新の英国の報告では10万分娩中2例とされている。死亡率は以前は60~80%と非常に高率であったが、最近の報告では20~40%との報告がある[2]
  1. 帝王切開や吸引・鉗子分娩は羊水塞栓症のリスクが高い[3]
問診・診察のポイント  
  1. 分娩周辺期:特に破水後の呼吸困難、胸痛、意識消失、ショック症状などの心肺虚脱

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文献 

著者: Naohiro Kanayama, Junko Inori, Hatsue Ishibashi-Ueda, Makoto Takeuchi, Masahiro Nakayama, Satoshi Kimura, Yoshio Matsuda, Jun Yoshimatsu, Tomoaki Ikeda
雑誌名: J Obstet Gynaecol Res. 2011 Jan;37(1):58-63. doi: 10.1111/j.1447-0756.2010.01319.x. Epub 2010 Nov 18.
Abstract/Text AIM: To clarify the cause of maternal deaths, an autopsy is essential. However, there has been no systemic analysis of maternal death in Japan based on autopsy cases.
MATERIAL & METHODS: Maternal death reports were retrieved from a large amount of registered autopsy data on maternal death in the series of 'Annual of pathological autopsy cases in Japan'. These files contain 468,015 autopsy records from 1989 to 2004. We collected 193 cases of maternal death due to direct obstetric causes. We recorded all the data into Excel files. Then we analyzed the causes of death and classified them into 11 categories.
RESULTS: The causes of maternal death were as follows: amniotic fluid embolism (AFE), 24.3%; disseminated intravascular coagulation (DIC) related to pregnancy-induced hypertension, 21.2%; pulmonary thromboembolism, 13.0%; injury to the birth canal, 11.4%; medical and surgical complications, 9.8%; and atonic bleeding or DIC of unknown cause, 8.3%. A discrepancy between the clinical diagnosis and pathological diagnosis was frequently observed in cases of AFE, septic DIC and injury to the birth canal. AFE diagnosed by autopsy was often clinically diagnosed as atonic bleeding or DIC of unknown cause before death. Half of the cases of AFE diagnosed by autopsy were associated with DIC.
CONCLUSION: We found that AFE, DIC related to pregnancy-induced hypertension, pulmonary thromboembolism and injury to the birth canal were the major causes of maternal death in Japan. AFE had various clinical features such as uterine atony and DIC in addition to pulmonary cardiac collapse.

© 2010 The Authors. Journal of Obstetrics and Gynaecology Research © 2010 Japan Society of Obstetrics and Gynecology.
PMID 21083840  J Obstet Gynaecol Res. 2011 Jan;37(1):58-63. doi: 10.11・・・
著者: S L Clark, G D Hankins, D A Dudley, G A Dildy, T F Porter
雑誌名: Am J Obstet Gynecol. 1995 Apr;172(4 Pt 1):1158-67; discussion 1167-9.
Abstract/Text OBJECTIVE: We analyzed the clinical course and investigated possible pathophysiologic mechanisms of amniotic fluid embolism.
STUDY DESIGN: We carried out a retrospective review of medical records. Forty-six charts were analyzed for 121 separate clinical variables.
RESULTS: Amniotic fluid embolism occurred during labor in 70% of the women, after vaginal delivery in 11%, and during cesarean section after delivery of the infant in 19%. No correlation was seen with prolonged labor or oxytocin use. A significant relation was seen between amniotic fluid embolism and male fetal sex. Forty-one percent of patients gave a history of allergy or atopy. Maternal mortality was 61%, with neurologically intact survival seen in 15% of women. Of fetuses in utero at the time of the event, only 39% survived. Clinical and hemodynamic manifestations were similar to those manifest in anaphylaxis and septic shock.
CONCLUSIONS: Intact maternal or fetal survival with amniotic fluid embolism is rare. The striking similarities between clinical and hemodynamic findings in amniotic fluid embolism and both anaphylaxis and septic shock suggest a common pathophysiologic mechanism for all these conditions. Thus the term amniotic fluid embolism appears to be a misnomer.

PMID 7726251  Am J Obstet Gynecol. 1995 Apr;172(4 Pt 1):1158-67; disc・・・
著者: Michael S Kramer, Jocelyn Rouleau, Thomas F Baskett, K S Joseph, Maternal Health Study Group of the Canadian Perinatal Surveillance System
雑誌名: Lancet. 2006 Oct 21;368(9545):1444-8. doi: 10.1016/S0140-6736(06)69607-4.
Abstract/Text BACKGROUND: Amniotic-fluid embolism is a rare, but serious and often fatal maternal complication of delivery, of which the cause is unknown. We undertook an epidemiological study to investigate the association between amniotic-fluid embolism and medical induction of labour.
METHODS: We used a population-based cohort of 3 million hospital deliveries in Canada between 1991 and 2002 to assess the associations between overall and fatal rates of amniotic-fluid embolism and medical and surgical induction, maternal age, fetal presentation, mode of delivery, and pregnancy and labour complications.
FINDINGS: Total rate of amniotic-fluid embolism was 14.8 per 100,000 multiple-birth deliveries and 6.0 per 100,000 singleton deliveries (odds ratio 2.5 [95% CI 0.9-6.2]). Of the 180 cases of amniotic-fluid embolism in women with singleton deliveries during the study period, 24 (13%) were fatal. We saw no significant temporal increase in occurrence of amniotic-fluid embolism for total or fatal cases. Medical induction of labour nearly doubled the risk of overall cases of amniotic-fluid embolism (adjusted odds ratio 1.8 [1.3-2.7]), and the association was stronger for fatal cases (crude odds ratio 3.5 [1.5-8.4]). Maternal age of 35 years or older, caesarean or instrumental vaginal delivery, polyhydramnios, cervical laceration or uterine rupture, placenta previa or abruption, eclampsia, and fetal distress were also associated with an increased risk.
INTERPRETATION: Medical induction of labour seems to increase the risk of amniotic-fluid embolism. Although the absolute excess risk is low, women and physicians should be aware of this risk when making decisions about elective labour induction.

PMID 17055946  Lancet. 2006 Oct 21;368(9545):1444-8. doi: 10.1016/S014・・・
著者: Wakako Hikiji, Naoaki Tamura, Akio Shigeta, Naohiro Kanayama, Tatsushige Fukunaga
雑誌名: Forensic Sci Int. 2013 Mar 10;226(1-3):e16-9. doi: 10.1016/j.forsciint.2012.12.008. Epub 2012 Dec 27.
Abstract/Text Despite the decrease in maternal mortality rate, amniotic fluid embolism (AFE) is still one of the most feared complications of pregnancy due to the high rate of mortality in Japan. The authors present a fatal case of a healthy 39-year-old woman who died during delivery after a normal 40-week second pregnancy. Shortly after the arrival at hospital, an abrupt drop of foetal heart rate was observed, followed by deterioration of consciousness and cardiac arrest of the patient. Prompt cardiopulmonary resuscitation (CPR) was performed but the patient died about an hour and a half after her arrival at hospital. Forensic autopsy confirmed the pathohistological diagnosis of amniotic fluid embolism supported by histochemical analysis results and excluded other possible causes of death. This paper stresses the fundamental importance of autopsy in an unexpected maternal death in conjunction with the significance of data accumulation on maternal death.

Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
PMID 23273942  Forensic Sci Int. 2013 Mar 10;226(1-3):e16-9. doi: 10.1・・・
著者: Naohiro Kanayama, Naoaki Tamura
雑誌名: J Obstet Gynaecol Res. 2014 Jun;40(6):1507-17. doi: 10.1111/jog.12428.
Abstract/Text The registry program of amniotic fluid embolism (AFE) in Japan started in 2003. More than 400 hundred clinical diagnosed amniotic fluid embolism has been accumulated. Those data showed that there were two etiologies of AFE: the fetal materials create physical obstructions in the maternal microvessels in various organs, such as the lung; and (ii) the liquids cause an anaphylactoid reaction that leads to pulmonary vasospasm and activation of platelets, white blood cells and/or complements. The clinical findings showed that AFE was characterized mainly by cardiopulmonary collapse, the other involves the presence of disseminated intravascular coagulation (DIC) and atonic bleeding. Zinc coproporphyrin-1, sialyl Tn antigen (STN), complement C3, C4 and interleukin-8 have been used as serum markers of AFE. The levels of zinc coproporphyrin-1 and STN were increased in cardiopulmonary collapse type AFE, and a marked reduction of C3 and C4 was observed in DIC type AFE. At the primary medical institution, initial treatments for shock airway management, vascular management, fluid replacement, administration of anti-DIC therapy such as antithrombin, and administration of fresh frozen plasma should be provided. C1 esterase inhibitor activity in AFE cases was significantly lower than those of normal pregnant women. C1 esterase inhibitor may be a promising candidate of treatment of AFE.

© 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.
PMID 24888909  J Obstet Gynaecol Res. 2014 Jun;40(6):1507-17. doi: 10.・・・
著者: Naoaki Tamura, Satoshi Kimura, Mustari Farhana, Toshiyuki Uchida, Kazunao Suzuki, Kazuhiro Sugihara, Hiroaki Itoh, Tomoaki Ikeda, Naohiro Kanayama
雑誌名: Crit Care Med. 2014 Jun;42(6):1392-6. doi: 10.1097/CCM.0000000000000217.
Abstract/Text OBJECTIVES: Amniotic fluid embolism exhibits activation of the complement system and the kallikrein-kinin and coagulofibrinolytic systems. C1 esterase inhibitor is a major inhibitor of C1 esterase and can inhibit plasma kallikrein and also factors XIIa and XIa. Its activity has been shown to be significantly lower in pregnancy and labor than in the nonpregnant state. The purpose of this study was to determine C1 esterase inhibitor activity levels in amniotic fluid embolism.
DESIGN: Retrospective study.
SETTING: A single university-based center.
PATIENTS: One hundred six cases with amniotic fluid embolism in a total of 194 singleton pregnant women between January 2010 and December 2011.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: One hundred six cases of amniotic fluid embolism had applied to the Japan amniotic fluid embolism registration center in Hamamatsu University School of Medicine between January 2010 and December 2011. In amniotic fluid embolism cases, 85 cases were nonfatal and 21 cases were fatal. Eighty-eight women who delivered without amniotic fluid embolism were regarded as a control. C1 esterase inhibitor activity levels were significantly lower in amniotic fluid embolism patients (30.0% ± 1.8%) than in control women (62.0% ± 2.0%) (p < 0.0001). C1 esterase inhibitor activity levels in fatal amniotic fluid embolism cases (22.5% ± 3.4%) were significantly lower than those in nonfatal amniotic fluid embolism cases (32.0% ± 2.1%) (p < 0.05).
CONCLUSIONS: These results demonstrated that low C1 esterase inhibitor activity levels were closely associated with the pathogenesis of amniotic fluid embolism suggesting that C1 esterase inhibitor activity levels have potential as a prognosis factor of amniotic fluid embolism.

PMID 24561565  Crit Care Med. 2014 Jun;42(6):1392-6. doi: 10.1097/CCM.・・・
著者: Yusuke Todo, Naoaki Tamura, Hiroaki Itoh, Tomoaki Ikeda, Naohiro Kanayama
雑誌名: Clin Case Rep. 2015 Jul;3(7):673-5. doi: 10.1002/ccr3.316. Epub 2015 Jun 13.
Abstract/Text We present the successful application of C1 esterase inhibitor (C1INH) concentrate to a patient with clinical amniotic fluid embolism (AFE).

PMID 26273468  Clin Case Rep. 2015 Jul;3(7):673-5. doi: 10.1002/ccr3.3・・・

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