Caprini血栓风险评估表评估妊娠期及产褥期静脉血栓栓塞疾病风险的有效性研究

目的探讨Caprini血栓风险评估表预测妊娠期及产褥期静脉血栓栓塞疾病(venous thromboembolism,VTE)发病风险的有效性。方法采用病例对照研究,回顾性分析2004年1月至2015年12月入住福建医科大学附属第一医院的39例妊娠期及产褥期发生VTE的患者,作为病例组;随机选取同期妊娠期及产褥期非VTE患者156例作为对照组。根据Caprini血栓风险评估表对两组患者进行Caprini评分、危险度分级,分析危险度分级与VTE发病风险的相关关系,并分析Caprini风险评估量表中影响妊娠期及产褥期VTE发病的主要危险因素。结果妊娠期及产褥期血栓发生率为0.13%。病例组的VTE评分(5.7±2.9)高于对照组(3.6±1.7),差异有统计学意义(P0.05)。病例组的高危和极高危级别所占比例最大,为94.8%,比例高于对照组(75.0%),两组Caprini危险度分级的构成之间差异有统计学意义(P0.05)。Caprini风险评估量表的危险度分级与VTE发病存在显著的正相关关系(P0.05),极高危级是影响VTE发病的主要危险因素。随着危险度分级的升高,妊娠期及产褥期患者发生VTE的风险随之升高。极高危(评分≥5)患者发生VTE的风险为低中危(评分0~2分)患者的16.107倍。Caprini风险评估表中的静脉曲张、BMI≥25、需卧床休息的内科患者、大手术(手术时间45 min)是妊娠期及产褥期发生VTE的主要危险因素。结论Caprini血栓风险评估表在妊娠期及产褥期患者中也适用,对妊娠期及产褥期VTE发病风险有很好的预测性,在临床上适合推广应用。     

Caprini静脉血栓风险评估量表预测妇科恶性肿瘤患者手术后静脉血栓形成及风险模型构建

目的：评估Caprini静脉血栓风险评估量表（简称Caprini量表）在妇科恶性肿瘤手术患者中对静脉血栓栓塞症（VTE）的预测效果,分析妇科恶性肿瘤手术患者术后VTE的危险因素,并构建VTE风险预测模型。方法：采用回顾性队列研究分析中山大学肿瘤防治中心2015年1月至2020年12月期间诊治的妇科肿瘤患者手术后确诊VTE的患者50例（血栓组）;对照组根据同期妇科恶性肿瘤并行手术的患者的住院号,通过随机数字表法,按照1：2的比例随机抽取100例（非血栓组）。对两组患者一般资料与疾病资料进行收集,应用2013版Caprini评分表对患者手术前和手术后血栓风险动态进行评分,应用二元Logistic回归分析独立危险因素并构建风险预测模型。结果：①血栓组与非血栓组患者术前、术后Caprini评分差异无统计学意义（P>0.05）,但两组患者Caprini评分差值 (即Caprini评分术后-术前变化量)差异有统计学意义（P＜0.05）;两组患者术后Caprini评分风险分级差异存在统计学意义（P＜0.05）,其中血栓组极高危患者比例高于非血栓组（80% vs 58%）。②Logistic回归模型示：D-二聚体（D-D）、围手术期输血史、Caprini评分差值、术后Caprini极高危分级是妇科恶性肿瘤手术患者术后发生VTE的独立危险因素（OR＞1.0,P<0.05）。③根据纳入研究的独立危险因素所得回归预测模型,回归预测模型、D-D、Caprini评分差值的曲线下面积（AUC）分别为0.928（95%CI 0.882～0.974）,0.868（95%CI 0.805～0.931）,0.735（95%CI 0.644～0.827）。结论：Caprini量表评分对妇科恶性肿瘤接受手术的患者发生VTE的低、中风险分层效果不显著,但Caprini评分差值的预测效果显著。采用D-D、围手术期输血史、Caprini评分差值、术后Caprini极高危分级构建的风险预测模型对妇科恶性肿瘤患者术后VTE风险的预测效果较好,后续需扩大样本进行验证与完善。     

妊娠相关静脉血栓栓塞症风险评估模型研究进展

妊娠相关静脉血栓栓塞症（pregnancy associated venous thromboembolism，PA-VTE）包括妊娠期和产褥期发生的静脉系统的血栓形成疾病，由深静脉血栓形成（deep vein thrombosis，DVT）和肺栓塞（pulmonary embolism，PE）组成的PA-VTE是发达国家孕产妇发病和死亡的主要原因。采用高效、便捷的风险评估模型评估PA-VTE的发病风险并进行分级预防是目前多个国家推荐的主要措施，但由于各国医学水平、经济发展和传统习惯的不同，各国相继开发风险评估模型或根据实际情况对其他国家的风险评估模型进行改良，进而对妊娠期及产褥期VTE风险进行个体化评估，并实施相应的血栓预防策略。通过回顾国内外的PA-VTE风险评估模型，旨在为我国进一步建立孕产妇的VTE防治指南提供依据，为产科医务工作者制定出适合我国产科人群的VTE风险评估模型提供参考。     

妇科手术患者静脉血栓栓塞症的危险因素评估和改良评估模型建立

目的:探讨妇科手术患者静脉血栓栓塞症(VTE)的危险因素和改良VTE评估模型对妇科手术患者VTE发生风险的预测价值。方法:选择2020年1月1日至2022年12月31日妇科手术后并发VTE患者41例为血栓组，按照1∶4的比例抽取同期妇科手术患者164例作为非血栓组。运用单因素及多因素Logistic回归分析妇科手术后并发VTE的危险因素，构建改良VTE危险因素快速评估模型(简称改良VTE评估表),应用受试者工作特征(ROC)曲线分析其对妇科手术患者VTE的预测价值，并与Caprini血栓风险评估模型(简称Caprini量表)进行比较。结果:(1)多因素Logistic回归分析结果示，年龄≥60岁、体质量指数(BMI)≥28 kg/m2、恶性肿瘤、手术时间>3小时、血栓病史、手术前后D-二聚体(D-D)差值增大是影响妇科手术后并发VTE的独立危险因素(OR>1,P<0.05)。(2)改良VTE评估表的ROC曲线下面积(AUC)为0.963,约登指数81.10%、敏感度87.80%、特异度93.29%;Caprini量表的AUC为0.888,约登指数63.41%、敏感度73.17%、特异度90.24%。改良VTE评估表和Caprini量表分别可将92.68%和85.37%的VTE患者评估为高危或极高危，但差异无统计学意义(P<0.05)。结论:对于影响妇科手术患者VTE的6项独立危险因素临床上应重点关注。改良VTE评估表与Caprini量表对VTE识别水平相当，但其简单、易操作，具有更好的实用性，有一定的临床推广价值。     

妇科手术后静脉血栓栓塞症临床分析

目的:探讨妇科手术后静脉血栓栓塞症(VTE)的发生情况、危险因素及改良Caprini模型的运用。方法:选择四川大学华西第二医院2017年12月至2018年12月期间收治的妇科手术后发生VTE的35例患者为血栓组,另按照1∶4比例选择同期因相同疾病手术未发生VTE的140例患者为对照组。根据改良Caprini风险评估模型(不包括实验室检查结果,如V因子、凝血酶原20110A、血清同型半胱胺酸、狼疮抗凝物等)进行评分,对术后发生VTE的相关因素进行多因素Logistic回归分析。结果:①妇科手术患者共13211例,术后VTE发生率为0.26%(35/13211)。②血栓组改良Caprini平均得分高于对照组(5.20±1.83分vs 4.27±1.82分,P=0.011),血栓组改良Caprini评分≥5分的比例高于对照组(62.86%vs 44.29%,P=0.049)。③单因素分析发现妇科手术后发生VTE与年龄、BMI、手术时间及住院天数有关;多因素Logistic回归分析提示BMI≥24 kg/m^2(OR2.862,95%CI 1.277~6.417)、手术时间(OR 1.004,95%CI 1.001~1.008)是妇科术后VTE发生的独立危险因素(P<0.05)。④采用低分子肝素皮下注射抗凝治疗,同时对血栓所在的下肢制动,35例患者在观察期间均未继发出血。结论:VTE是妇科手术后严重的并发症,术后VTE发生的危险因素包括BMI(≥24 kg/m^2)、手术时间。根据改良Caprini风险度分级采取适当的预防措施,减少临床VTE的发生。     

妇科手术患者静脉血栓栓塞症的危险因素评估和评分简表的有效性验证

目的:探讨妇科手术患者静脉血栓栓塞症(VTE)危险因素及制定VTE危险因素评分简表,并对评分简表进行有效性验证。方法:收集2015年10月至2017年10月在西安交通大学第一附属医院妇科接诊并手术治疗后并发VTE的妇科肿瘤患者53例,对照组选择时间上相邻的2个妇科手术非VTE妇科肿瘤患者共106例。对年龄、体质量指数(BMI)、肿瘤性质、血栓相关病史、合并症、手术方式、手术时间、出血量、术后卧床时间、妊娠或产褥期、激素服用史进行单因素分析和多因素分析,并制定VTE危险因素的评分简表,应用该评分简表和Caprini评分表对所有患者进行评分比较。结果:单因素分析中,两组在BMI、肿瘤性质、手术时长、出血量、有无输血、卧床时间、血栓相关病史等方面差异有统计学意义(P0.05)。多因素Logistic回归结果,年龄60岁、BMI28 kg/m~2、恶性肿瘤、手术时长≥3小时、腹腔镜手术、血栓相关病史是影响妇科手术患者并发VTE的独立危险因素(P0.05)。评分简表与Caprini评分表评分情况比较,两者差异无统计学意义(P0.05)。结论:年龄大、BMI高、恶性肿瘤、手术时间长、腹腔镜手术及有血栓相关病史患者妇科手术后更易发生VTE。评分简表简便易操作且对于VTE识别度高,有一定临床实用价值。     

妊娠合并乙肝病毒感染与早产的相关性研究

目的分析妊娠相关静脉血栓栓塞症(pregnancy associated venous thromboembolism, PA-VTE)的临床特点。方法回顾性分析2010年10月至2019年4月年北京大学第三医院产科收治的PA-VTE 53例临床资料。结果(1) 53例患者中,30例(56.6%)发生于产褥期,23例(43.4%)发生于妊娠期;(2)肺栓塞4例(7.55%),均为急诊剖宫产术后发生;(3)晚期妊娠8例(15.1%),中期妊娠4例(7.5%),早期妊娠11例(20.8%),妊娠早中期VTE多合并非妊娠相关高危因素;(4)剖宫产后产褥期23例(76.7%),阴道分娩后7例(23.3%),均无VTE家族史。结论不同妊娠阶段PA-VTE致病因素不同,妊娠早期多与血栓前状态等非产科因素相关,随妊娠进展至产褥期,妊娠相关高危因素逐步增加,分娩期并发症是产褥期PA-VTE重要因素。     

妊娠相关静脉血栓栓塞症的预防和治疗

妊娠相关静脉血栓栓塞症(pregnancy associated venous thromboembolism,PA-VTE)系指妊娠期及产褥期发生的静脉血栓栓塞症(venous thromboembolism,VTE)。PA-VTE可以发生在妊娠的不同时期,产褥期风险最高,发生率为产前的2～5倍,尤以产后6周内风险最高。PA-VTE危害极大,目前已成为发达国家孕产妇死亡的重要原因之一。PA-VTE的提出,意在强调其预防和诊治应基于妊娠这一特殊阶段的病理生理学特征,制定专科管理规范。而目前一些国家已有针对PA-VTE的防治指南和共识,但中国仅在少数VTE管理指南中提及对该类疾病的防治,具体防治方案仍不明确,临床中迫切需要制定适合我国妊娠患者VTE预防和治疗的指南,以规范临床实践。本文综述PA-VTE病理生理学特征、临床筛查、预防、治疗和我国临床实践现状。     

子宫肌瘤经腹腔镜剔除术后并发下肢深静脉血栓风险评分系统的建立

目的：探讨子宫肌瘤经腹腔镜剔除术后并发下肢深静脉血栓（deep vein thrombosis,DVT）的危险因素,并构建风险列线图模型。方法：回顾性分析2017年1月—2021年1月在中国人民解放军联勤保障部队第九一○医院行腹腔镜剔除术的子宫肌瘤患者493例的临床资料,根据患者术后是否发生DVT分为DVT组和非DVT组,比较2组的临床情况,采用单因素和多因素Logistic回归分析筛选子宫肌瘤经腹腔镜剔除术后并发DVT的影响因素,根据独立危险因素建立列线图风险模型并进行预测效能验证。结果：493例行腹腔镜剔除术的子宫肌瘤患者中,术后并发下肢DVT者41例,发生率为8.32%（41/493）;2组年龄、体质量指数、术前合并症、麻醉方式、手术时间、术中气腹压力、血浆D-二聚体以及术后卧床时间等比较,差异有统计学意义（P<0.05）。多因素Logistic回归分析结果显示,年龄≥60岁（OR=3.786,95%CI：1.749~8.197）、术前合并症（OR=3.390,95%CI：1.524~7.543）、全身麻醉（OR=3.778,95%CI：1.722~8.287）、手术时间≥2 h（OR=2.884,95%CI：1.384~6.010）、术中气腹压力≥15 mmHg（1 mmHg=0.133 kPa,OR=3.295,95%CI：1.539~7.055）、血浆D-二聚体≥500 ng/mL（OR=4.141,95%CI：1.925~8.909）以及术后卧床时间≥5 d（OR=3.628,95%CI：1.710~7.697）均为子宫肌瘤患者术后并发下肢DVT的独立危险因素（P<0.05）。基于7项独立危险因素建立子宫肌瘤患者腹腔镜剔除术后并发DTV的列线图预警模型,结果显示年龄≥60岁为93分、术前合并症为85分、全身麻醉为93分、手术时间≥2 h为74分、术中气腹压力≥15 mmHg为83分、血浆D-二聚体≥500 ng/mL为100分、术后卧床时间≥5 d为91分,模型验证结果显示一致性指数为0.853（95%CI：0.822~0.884）,校正曲线的预测值与实测值基本一致,内部验证妇科腹部手术患者合并下肢DVT的风险列线图模型的ROC曲线下面积为0.832（95%CI：0.804~0.860）。结论：年龄≥60岁、术前合并症、全身麻醉、手术时间≥2 h、术中气腹压力≥15 mmHg、血浆D-二聚体≥500 ng/mL以及术后卧床时间≥5 d均为子宫肌瘤经腹腔镜剔除术后并发下肢DTV的独立危险因素,基于以上7项独立危险因素所建立的列线图有助于预测子宫肌瘤经腹腔镜剔除术后并发下肢DTV的发生风险。     

子宫腺肌病发生血栓性病变的风险及临床特点

子宫腺肌病（adenomyosis）是育龄期女性常见的良性疾病之一,主要临床表现为痛经、月经过多及不孕,严重影响患者的生活质量。近年来,国内外学者相继报道了30多例子宫腺肌病发生血栓性病变的病例,包括脑梗死、弥散性血管内凝血和静脉血栓栓塞症,这些病例多发生于月经期。分析这些患者的病变特点后发现,子宫腺肌病患者发生血栓性病变的危险因素包括炎症、组织因子表达增加、血糖类抗原125（CA125）水平升高、月经过多和子宫体积增大等。子宫腺肌病患者一旦发生血栓性病变,将增加临床上诊断和治疗的难度。了解子宫腺肌病患者凝血功能的变化和警惕其发生血栓性疾病的风险将有助于提高子宫腺肌病的诊疗准确率和安全性。     

建立预测妊娠期高血糖患者分娩巨大儿风险的列线图模型

目的：构建并验证妊娠期高血糖（hyperglycemia in pregnancy,HIP）患者分娩巨大儿风险的列线图模型。方法：回顾性分析2020年11月—2022年2月在太原市妇幼保健院分娩的HIP患者资料。采用多因素Logistic回归分析筛选发生巨大儿的独立影响因素,R软件构建列线图模型,采用受试者工作特征曲线下面积对该模型的效能进行评估,决策曲线分析（decision curve analysis,DCA）评估模型的临床使用价值。结果：(1)纳入1 098例HIP患者进行建模,其中92例（8.38%）孕妇分娩巨大儿。按7∶3比例将所有患者随机分为训练集（761例）和测试集（337例）。(2)多因素Logistic回归分析发现,经产妇（OR=3.19,95%CI:1.58～6.54,P=0.001）、高血压家族史（OR=2.28,95%CI:1.06～4.90,P=0.034）、妊娠前体质量指数（OR=1.18,95%CI:1.08～1.30,P<0.001）、双顶径（OR=13.52,95%CI:4.04～48.38,P<0.001）、腹围（OR=2.83,95%...     

Calcium to creatinine ratio in a spot sample of urine for early prediction of pre-eclampsia

Objectives: Based on the fact that urinary calcium excretion decreases in pre-eclampsia, this study was designed to determine the predictive value of calcium to creatinine ratio in a spot urine sample. Methods: The calcium to creatinine ratio was measured in a spot urine sample of 102 normotensive women at 20–24 weeks’ gestation who attended the prenatal care clinic of the Shiraz University of Medical Sciences. The women were followed-up until delivery and grouped according to pre-eclampsia occurrence. The prevalence of pre-eclampsia was measured and compared with the calcium to creatinine ratio. Results: Ninety-four women remained normotensive during pregnancy and eight developed pre-eclampsia. Mean age, gestational age at the beginning of the study, and gestational age at delivery did not differ significantly between the two groups. Mean urinary calcium concentration (15.9±8.5 mg/dl in normotensive vs. 10.2±7.5 mg/dl in pre-eclamptic women), and mean birth weight (3192±336.3 g vs. 2712±468.9 g) were significantly lower in pre-eclamptic patients (P=0.03 and 0.005, respectively). Mean calcium to creatinine ratio was also significantly lower in the pre-eclamptic group (P<0.03). Conclusions: Single urine calcium to creatinine ratio may be an effective method for screening women at greatest risk for pre-eclampsia.     

Validation of a venous thromboembolism risk assessment model in gynecologic oncology

Objectives

Gynecologic oncology patients undergoing surgery are at an increased risk for venous thromboembolism (VTE). We attempted to validate a VTE risk assessment model in gynecologic oncology patients.

Methods

All gynecologic oncology patients who underwent a laparotomy for the diagnosis or suspicion of gynecologic malignancy from 2004 to 2010 were included. Demographic, surgicopathologic, and complication data were collected. VTE was based on the symptomatic diagnosis. Data for the Caprini risk assessment model (RAM) was used to score and stratify patients on their risk for VTE.

Results

1123 gynecologic oncology patients were included within this study. Ovarian cancer was the most common diagnosis (39%) with a median age of 56.1. All patients received SCDs with 40% receiving double prophylaxis. The overall incidence of VTE was 3.3%, with lower extremity deep venous thrombosis (DVT) n = 17 and pulmonary embolism (PE) n = 20. Complication rates were similar in each group. Based on the Caprini scoring model 92% of patients scored in the “Highest Risk” category. The Caprini RAM accurately predicted all 37 VTEs, all of which scored in the “Highest Risk” category. The percentage of patients that received double prophylaxis increased with time from 12% in 2004 to 63% in 2010. Importantly, 25 of the 37 VTEs (68%) did not receive double prophylaxis.

Conclusions

The use of the Caprini RAM accurately predicted patients at the highest risk of experiencing VTE. Considering accurate identification of patients allows proper administration of double prophylaxis, we recommend the use of this scoring model preoperatively in patients undergoing surgery for gynecologic malignancies.     

Serum CA 125 levels before, during and after treatment for endometriosis

Objectives: The aim of this study was to assess the treatment of endometriosis with a gonadotropin-releasing hormone (GnRH) agonist in terms of changes to the extent of disease and to CA 125 levels as well as to recurrence during follow-up. Methods: The levels of serum CA 125 were evaluated in 66 patients with endometriosis diagnosed and staged by laparoscopy according to the revised American Fertility Society classification, who received a 6-month course of a GnRH agonist. Serum CA 125 levels were measured before, during (3 and 6 months after the initiation of therapy) and 6 months after cessation of therapy. Results: Patients with minimal and mild endometriosis had significantly higher mean pretreatment values than control subjects in the luteal phase of the cycle or than postmenopausal women (P < 0.05), but the overall mean value was still below 35 U/ml. Levels of CA 125 fell during treatment to those found in normal controls, but rose again after the end of treatment. The sensitivity and specificity of CA 125 were 75% and 83.3%, respectively, and its positive predictive value as a marker of recurrence was 46.36%. Conclusion: These data suggest that CA 125 may be a reliable indicator for monitoring the efficacy of GnRH agonist treatment of endometriosis, but its value as a predictor of recurrence is low, probably due to the suppression of all CA 125 sources such as endometrium, ovaries and implants.     

Meconium stained amniotic fluid in very low risk pregnancies at term gestation

Objective: To determine the prevalence and clinical significance of meconium stained amniotic fluid (MSAF) in a low risk population at term gestation and to investigate whether MSAF is a predictor for intrapartum and neonatal morbidity. Methods: A very low risk population including 37 085 consecutive deliveries at term composed the study population. A cross-sectional study was conducted and two groups of patients were identified according to the presence (n=6164) or absence (n=30 921) of meconium in the amniotic fluid at delivery and the outcomes of the two groups compared. Results: The prevalence of MSAF was 16.6%. The incidence of cesarean section (5.6% vs 2.3% P<0.01), instrumental deliveries (3.2% vs 1.8% P<0.01), fetal distress (6.5% vs. 2.1% P<0.01), clinical chorioamnionitis (0.2% vs. 0.1% P<0.01), post-partum infection (0.5% vs. 0.2% P<0.01), 1-minute Apgar score <3 (1.9% vs. 1.1% P<0.01), small for gestational age (7.4% vs. 6.4% P<0.01). was significantly higher in the MSAF compared with the clear amniotic fluid group. Intrapartum and neonatal mortality in this low risk population was significantly higher in the MSAF group ( ) compared with women with clear AF ( ). Conclusions: MSAF in a low risk population at term gestation is a predictor for adverse perinatal outcome and peripartum complications.     

HPV DNA和HPV E6/E7 mRNA检测在宫颈病变诊治中应用价值的比较

目的: 比较人乳头瘤病毒（human papillomavirus,HPV）E6/E7 mRNA检测和HPV DNA检测在宫颈病变诊治中的应用价值。方法: 选取2018年1月—2019年9月在石家庄市妇幼保健院行宫颈液基薄层细胞学检查（thin-prep cytology test,TCT）的患者共33 496例,其中符合纳入标准的诊断意义不明的非典型鳞状上皮细胞（atypical squamous cells of undetermined significance,ASCUS）患者共3 190例,将其随机分为2组,各1 595例,分别进行HPV DNA检测（对照组）及HPV E6/E7 mRNA检测（观察组）,再对每组的阳性患者进行阴道镜下活检及病理组织学检测,比较2种方法对宫颈病变的检出率。从对照组和观察组阳性的患者中随机各抽取184例,共368例,分别进行HPV E6/E7 mRNA和HPV DNA检测,比较2种方法的诊断效能。结果: 对照组高级别宫颈上皮内病变患者的检出率为4.8%（77/1 595）,观察组为4.1%（66/1 595）,差异无统计学意义（χ²=0.886,P=0.347）。但与HPV DNA检测相比,HPV E6/E7 mRNA检测具有较高的敏感度（87.50%）、特异度（71.79%）、阳性预测值（49.36%）、阴性预测值（94.81%）、约登指数（0.593）和较低的阴道镜转诊率（42.4%,P<0.05）。结论: 对于高级别宫颈上皮内病变,HPV E6/E7 mRNA检测比HPV DNA检测具有更高的诊断效能,可以作为ASCUS患者分流的新方法。