妊娠相关性静脉血管栓塞性疾病6例分析及文献复习
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摘要
目的:探讨妊娠相关性静脉血栓栓塞(PA-VTE)的危险因素、诊断、治疗和预防。方法:对2014年1月~2018年3月我院收治7462例孕产妇中6例妊娠合并VTE者的临床资料进行回顾性分析。采用病例对照研究方法,比较VTE患者(病例组)发生VTE前与正常孕妇(对照组)血常规及凝血功能的差异。结果:6例VTE患者均经彩色多普勒超声或CT肺动脉造影确诊,2例发生于妊娠期,4例发生于产后。≥35岁者2例,6例中5例均具有一项或多项VTE高危因素。病例组发病前红细胞压积及凝血功能与对照组比较无显著性差异(均P>0.05)。经抗凝及手术等治疗,6例VTE患者恢复良好出院。结论:VTE在产褥期发生率高于妊娠期。目前尚无良好的筛查VTE的实验室检验指标,低分子肝素抗凝是PA-VTE的首选治疗方法。孕期及孕前对高危者进行分层管理以预防VTE发生,或可降低VTE发病率。
Objective:To investigate the high risk factors,diagnosis,treatment and precaution of pregnancy associated venous thromboembolism(VTE).Methods:Data of 6 cases of VTE admitted in Department of Obstetrics and Gynecology,China-Japan Friendship Hospital from January 2014 to March 2018 were analyzed retrospectively.The differences of blood routine test and coagulation function between VTE patients(study group)and normal pregnantwomen(control group)were compared by independent-samples t test in this case-control study.Results:All patients were diagnosed with VTE by color Doppler ultrasound or CT pulmonary artery angiography.Two cases were found before delivery and 4 during postpartum.Two cases were older than or equal to 35 years old,and 5 cases had gestational complications.There were no statistical difference between the blood routine test and coagulation function of the two groups.After anticoagulant therapy or surgery,6 cases recovered.Conclusion:VTE is likely to happen in puerperium than in pregnancy.There are no good screening indicators for thromboembolism during pregnancy and puerperium.Low-molecular-weight heparins(LMWH)are recommended to be the first line anticoagulant therapy in pregnancy-associated VTE.It is suggested all women should undergo a documented assessment of risk factors for VTE in early pregnancy or prepregnancy to get individualized therapy.It may reduce the morbidity of VTE.
Objective:To investigate the high risk factors,diagnosis,treatment and precaution of pregnancy associated venous thromboembolism(VTE).Methods:Data of 6 cases of VTE admitted in Department of Obstetrics and Gynecology,China-Japan Friendship Hospital from January 2014 to March 2018 were analyzed retrospectively.The differences of blood routine test and coagulation function between VTE patients(study group)and normal pregnantwomen(control group)were compared by independent-samples t test in this case-control study.Results:All patients were diagnosed with VTE by color Doppler ultrasound or CT pulmonary artery angiography.Two cases were found before delivery and 4 during postpartum.Two cases were older than or equal to 35 years old,and 5 cases had gestational complications.There were no statistical difference between the blood routine test and coagulation function of the two groups.After anticoagulant therapy or surgery,6 cases recovered.Conclusion:VTE is likely to happen in puerperium than in pregnancy.There are no good screening indicators for thromboembolism during pregnancy and puerperium.Low-molecular-weight heparins(LMWH)are recommended to be the first line anticoagulant therapy in pregnancy-associated VTE.It is suggested all women should undergo a documented assessment of risk factors for VTE in early pregnancy or prepregnancy to get individualized therapy.It may reduce the morbidity of VTE.
引文
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[12] Konstantinides SV,Torbicki A,Agnelli G,et al.Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology(ESC).2014ESC guidelines on the diagnosis and management of acute pulmonary embolism[J].Eur Heart J,2014,35:3033-3080.
[13] Bates SM,Greer IA,Middeldorp S,et al.VTE,thrombophilia,antithrombotic therapy,and pregnancy.Antithrombotic therapy and prevention of thrombosis,9th ed:American college of chest physicians evidence-based clinical practice guidelines[J].Chest,2012,141(2 Suppl):e691S-e736S.
[14] Tang AW,Greer I.A systematic review on the use of new anticoagulants in pregnancy[J].Obstet Med,2013,6:64-71.
[15] Jamjute P,Reed N,Hinwood D.Use of inferior vena cava filters in thromboembolic disease during labor:case report with a literature review[J].J Matern Fetal Neonatal Med,2006,19:741-744.
[16] Greer IA.Thrombosis in pregnancy:updates in diagnosis andmanagement[J].Hematology Am Soc Hematol Educ Program,2012,2012:203-207.
[17] Royal College of Obstetricians and Gynaecologists.Thromboembolic disease in pregnancy and the puerperium:Acute management.Green-top guidelineNo.37a[S/OL].(2015-04-30)[2017-07-15].https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37b.pdf.
[2] Chan LY,Tam WH,Lav TK.Venous thromboembolism in pregnant Chinese women[J].Obstetrics and Gynecology,2001,98(3):416-475.
[3] Piovella F,Wang CJ,Lu H,et al.Deep vein thrombosis rates after major orthopedic surgery in Asia.An epidemiological study based on postoperative screening with centrally adjudicated bilateral venography[J].J Thromb Haemost,2005,3(12):2664-2670.
[4]葛志文,涂久生,陈久胜,等.急性肺栓塞的CTA表现及综合介入治疗[J].医学影像学杂志,2018,28:224-228.
[5] Virkus RA,Lkkegaard EC,Bergholt T,et al.Venous thromboembolism in pregnant and puerperal women in Denmark1995-2005.A national cohort study[J].Thromb Haemost,2011,106:304-309.
[6] Ray JG,Chan WS.Deep vein thrombosis during pregnancy and the puerperium:a meta-analysis of the period of risk and the leg of presentation[J].Obstet Gynecol Surv,1999,54:265-271.
[7] Villani M,Ageno W,Grandone E,et al.The prevention and treatment of venous thromboembolism in pregnancy[J].Expert Review of Cardiovascular Therapy,2017,15(5):397-402.
[8]胡晓雨,禹虹,边旭明.妊娠期及产褥期静脉血栓栓塞16例临床分析[J].中华围产医学杂志,2011,14:724-728.
[9] Righini M,Jobic C,Boehlen F,et al.the EDVIGE study group.Predicting deep venous thrombosis in pregnancy:external validation of the LEFT clinical prediction rule[J].Haematologica,2013,98:545-548.
[10] Blanco-Molina A,Rota L,Di Micco P,et al.the RIETE Investigators.Venous thromboembolism during pregnancy,postpartum or during contraceptive use.Findings from the RIETE Registry[J].Thromb Haemost,2010,103:306-311.
[11] Szeesi PB,Jorgensen M,Klajnbard A,et al.Haemostatic reference intervals in pregnancy[J].Thromb Haemest,2010,103:718-727.
[12] Konstantinides SV,Torbicki A,Agnelli G,et al.Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology(ESC).2014ESC guidelines on the diagnosis and management of acute pulmonary embolism[J].Eur Heart J,2014,35:3033-3080.
[13] Bates SM,Greer IA,Middeldorp S,et al.VTE,thrombophilia,antithrombotic therapy,and pregnancy.Antithrombotic therapy and prevention of thrombosis,9th ed:American college of chest physicians evidence-based clinical practice guidelines[J].Chest,2012,141(2 Suppl):e691S-e736S.
[14] Tang AW,Greer I.A systematic review on the use of new anticoagulants in pregnancy[J].Obstet Med,2013,6:64-71.
[15] Jamjute P,Reed N,Hinwood D.Use of inferior vena cava filters in thromboembolic disease during labor:case report with a literature review[J].J Matern Fetal Neonatal Med,2006,19:741-744.
[16] Greer IA.Thrombosis in pregnancy:updates in diagnosis andmanagement[J].Hematology Am Soc Hematol Educ Program,2012,2012:203-207.
[17] Royal College of Obstetricians and Gynaecologists.Thromboembolic disease in pregnancy and the puerperium:Acute management.Green-top guidelineNo.37a[S/OL].(2015-04-30)[2017-07-15].https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37b.pdf.