臺灣大學: 法醫學研究所孫家棟鄒忠宗Tsou, Chung-TsungChung-TsungTsou2013-04-082018-07-092013-04-082018-07-092012http://ntur.lib.ntu.edu.tw//handle/246246/256405前言：羊水栓塞是發生機率雖然極低，但卻是最難預防也最難處理的一項產科併發症，其結果往往是無可避免的快速死亡。其發生的時間常常都在產婦生產中或是剛生產完不久，產婦的臨床表現會有突然昏迷、血壓下降、心肺衰竭、大出血症狀，目前並無可以有效預測其發生的方法或相關檢查。司法解剖是能夠確定診斷羊水栓塞的最佳甚至是唯一的方法，而司法解剖鑑定報告也是法庭作為醫療糾紛判定的最佳證據。希望藉由經司法解剖後確認的羊水栓塞案例切入，可以更深入的窺探羊水栓塞的全貌，也希望能由臨床醫師與法醫師的不同角度，來對羊水栓塞案例作探討，以期給予臨床醫師或法醫師的一項參考。 研究方法：從法務部法醫研究所的資料庫中，搜尋從民國八十八年一月一日起到民國九十六年十二月三十一日止，已接受司法解剖鑑定並能調閱案卷的個案，鑑定報告死因含有羊水栓塞的案例有四十七件。再加上筆者於民國九十八年親身遇到的一個案例，總共四十八件。將個案死者之年齡、國籍、籍貫、疾病史、生產史、懷孕周數、新生兒狀況、生產方式、生產原因、事件發生地點、死亡地點、解剖發現、顯微鏡發現、鑑定結果等全都加以歸納與分析。 結果：死亡產婦的年齡最多的是滿30歲而未滿35歲。懷孕周數以滿39周和40周者為最多。第一胎者為最多。陰道生產者有27人，剖腹生產者17人，因發生羊水栓塞緊急剖腹產者共有4人。懷男嬰者21人，懷女嬰者14人，另有兩對龍鳳胎，一對女女雙胞胎，還有10個案例胎兒性別未註明。事件發生在診所者有27件，醫院19件，醫學中心2件。在醫學中心死亡宣告有30件，醫院18件，診所則一件也沒有。羊水栓塞發生在胎兒出生前共有17例，在產前半小時內發生者有11例，胎兒死亡率有18.18%；而發生在產前半小時之前者有6例，胎兒死亡率高達83.33%。發生在胎兒出生後則有31例，兩小時內者共有19例，超過兩小時以上則有12例。從事件發生到宣告死亡時間在6小時內者共有27例。在所有47個案例中，有10例在解剖時有其他同時存有的特殊發現：如子宮頸撕裂傷、肝臟撕裂傷、腦疝、肺栓塞、內出血、植入性胎盤、心肌炎等。有一例在家屬表達不願意接受解剖的狀況下，僅抽取右心室血液做檢驗而未接受解剖。而接受解剖的45個案例中，有一例在解剖及顯微鏡下均未發現羊水栓塞之證據。上述兩案例之鑑定法醫仍依病歷記載之臨床表現做出羊水栓塞之判斷。 討論：以臨床醫師的觀點來看，有四分之一的典型羊水栓塞案例無法在患者的肺部血管中發現胎兒細胞或其他羊水中的物質。但是某些法醫病理醫師則認為只有在肺部檢體中發現胎兒細胞或羊水中的物質才能做出診斷；若未能在產婦肺部找到胎兒細胞或羊水中的物質，雖然在肺動脈或右心室的血液中發現，仍然不能做出羊水栓塞的診斷，但是可以列入考慮。由此可見臨床醫師與法醫病理醫師的立場明顯不同。而即使是解剖鑑定結果為羊水栓塞的案例，臨床醫師與鑑定醫師或許也有不同的判斷標準。若能綜合婦產科醫師的臨床所見與法醫病理醫師的解剖結果，將有助於更準確診斷羊水栓塞。 結論：模擬兩可的鑑定結果將造成無窮盡的爭論，也可能讓檢察官或法官的心證成為判斷是非的唯一標準！本文並不做法醫鑑定好壞的評定，卻希望藉由討論可以突顯出羊水栓塞的無情與醫病間對於發生羊水栓塞的無奈，也期待未來臨床診斷標準的確立，進而促使相關的法醫鑑定標準建立，不僅可以建立法醫師鑑定的權威性，也讓檢察官或法官在案件審判時對法醫師的鑑定有更強的信心。Foreword: Although the amniotic fluid embolism (AFE) has extremely low probability, it is actually an item of obstetric complication which is very difficult to prevent or process, and cause inevitable fast death. It occurs frequently in the peripartum period. The clinical manifestations of such cases may be sudden collapse, hypotension, cardiopulmonary failure, or massive hemorrhage. Till now, there was not effective method or test to predict it to occur. The forensic autopsy seems the best and only method to confirm the diagnosis of AFE. The report of forensic autopsy is also the best evidence which the judge determines the medical malpractice or not. The author attempts to more thorough understand the AFE by study the cases that confirmed by the forensic autopsy. We try to discuss the cases of AFE from the two different viewpoints of clinician and forensic pathologist. We hope this article will become a reference for them in the future. Materials and methods: Forty seven cases were collected from the database of Institute of Forensic Medicine, Ministry of Justice from Jan 1, 1999 to Dec 31, 2007. All cases were AFE as cause of death and confirmed by the forensic autopsy. An addition case of AFE who was met by the author in 2009, altogether 48 cases was analyzed. We analyze and discuss the age, nationality, native place, medical history, obstetric history, gestational age of the cases. The fetus condition, delivery method, indication of labor, the place to happen, the death place of mother, the gross and microscopic findings of autopsy, and the differential diagnosis of death were also included. Results: The most cases fall in the range of 30 to 35 years old women with 39 or 40 gestational weeks. Primiparas are more than multiparas. The delivery methods are 27 cases by vaginal delivery, 17 cases by schedule cesarean section and four cases by emergency operation. The fetuses are 21 boys and 17 girls, two pairs of male and female twins, one pair of two female twins, and unrecorded in 10 fetuses. The locations of AFE occurrence are 27 cases in clinic, 19 cases in hospital, and two cases in medical center. The declaration of death was done for 30 cases in medical center, 18 in hospital, but none was done in clinic. The AFE occurs before childbirth in 17 cases, within 30 minutes in 11 cases with fetal mortality rate 18.18% and more than a half hour in six cases with fetal mortality rate as high as 83.33%. The numbers of cases that AFE occurred postpartum is 31, within two hours in 19, and more than two hours in 12. Twenty seven victims had survival interval less than six hours. There are 10 cases having associated autopsied findings in addition to AFE: cervical laceration, hepatic laceration, brain herniation, pulmonary embolism, internal bleeding, placenta accreta, and myocarditis. The other 34 cases have no other significant finding. One case has only blood examination due to family unwilling to receive autopsy. In the other 45 autopsy, there is just one case which has no evidence of AFE in gross finding and the microscopic review. In the two cases above, AFE was still the final diagnosis that was made by the forensic pathologist depending on the clinical manifestations recorded on the medical charts. Discussion: From clinician''s viewpoint, about one fourth such cases won’t have the evidence of fetal or amniotic materials in maternal lungs. But some pathologists insist that the AFE diagnosis must have fetal or amniotic fluid components in histopathological examination of lung sections. However, AFE should be considered but not confirmed when we just find out some fetal cells or amniotic fluid components in blood samples from pulmonary arteries or right ventricle. Due to clinician and forensic pathologist having the different standpoints, so even in the definite AFE was made after forensic autopsy performed, there would be different opinion between the clinician and forensic pathologist. If detail information of clinical manifestations and autopsied findings in such cases were collected, it should be helpful to make accurate diagnosis of AFE. Conclusion: Equivocal conclusion will lead to the inexhaustible argument! It also will possibly let the public prosecutor or judge''s volition become the sole criterion to determine right and wrong! This article does not give any comment about the quality of investigation report by forensic pathologist. We just hope the standard criteria or procedure to confirm AFE will be established soon after this discussion, regardless in clinic or forensic medicine.140 bytestext/htmlen-US羊水栓塞司法解剖法醫醫療糾紛孕產婦死亡amniotic fluid embolismforensic autopsyforensic pathologistmedical disputepregnancy- related maternal deaththesishttp://ntur.lib.ntu.edu.tw/bitstream/246246/256405/1/index.html