重视产科血栓性疾病的预防和处理

        近年来,随着社会的发展及人们生活习惯的改变,血栓性疾病逐渐成为威胁人们生命健康的重要危害,已引起人们的重视,成为当代医学研究的重点和热点。对于产科而言,妊娠所特有的生理性改变增加了孕妇发生血栓性疾病的风险,其发生率是非妊娠妇女的4~5倍。研究发现,妊娠期血栓性疾病已经成为孕产妇死亡的重要因素之一,临床医生应提高警惕,高度重视产科血栓性疾病的孕期预防、保健和及时处理,进而保证妊娠的顺利进行,并有效改善母儿预后。     

妊娠相关血栓性疾病临床特征及其危险因素分析

目的:分析孕产妇发生血栓性疾病的临床特征及其高危因素,为临床诊断及治疗提供借鉴及指导.方法:选取2009年1月至2019年12月上海交通大学附属第六人民医院妇产科收治的113例妊娠相关血栓性疾病患者(研究组)以及同期住院分娩的未发生血栓的孕产妇(对照组),单因素、多因素分析血栓形成的危险因素,并对其预测价值评估.结果:...     

辅助生殖技术相关血栓性疾病的防治

辅助生殖技术(ART)并发血栓性疾病的报道逐年增加,口服避孕药(OCs)、促排卵药物的应用、卵巢过度刺激综合征(OHSS)以及多胎妊娠是血栓性疾病发生的高危因素。在促排卵治疗过程中,应高度警惕高危人群血栓性疾病的发生,早期诊断并积极治疗。血栓性疾病的发生重在预防。对于既往有血栓病史或血栓家族史的高危患者必要时可行相关易栓症的遗传性筛查。     

异位妊娠相关的高危因素

异位妊娠是早期妊娠妇女死亡的首要原因,近几十年发病率有上升趋势。对异位妊娠相关高危因素的认识有助于早期诊断、治 疗及预防该病的发生。国内外对其相关高危因素的研究主要包括：盆腔炎性疾病、腹部手术史、吸烟、既往异位妊娠史、不孕史、辅助生育技术 、避孕方法失败、流产和年龄等。其中盆腔炎性疾病,输卵管手术史及吸烟为异位妊娠的三大主要高危因素。异位妊娠往往是一种或多种高危因 素同时作用的结果。     

异位妊娠相关的高危因素

异位妊娠是早期妊娠妇女死亡的首要原因,近几十年发病率有上升趋势。对异位妊娠相关高危因素的认识有助于早期诊断、治疗及预防该病的发生。国内外对其相关高危因素的研究主要包括：盆腔炎性疾病、腹部手术史、吸烟、既往异位妊娠史、不孕史、辅助生育技术、避孕方法失败、流产和年龄等。其中盆腔炎性疾病,输卵管手术史及吸烟为异位妊娠的三大主要高危因素。异位妊娠往往是一种或多种高危因素同时作用的结果。     

易栓症与复发性流产

研究表明,易栓症与不良妊娠结局呈正相关。孕妇存在凝血、抗凝血功能紊乱或者障碍,可导致母体血液高凝状态,并且伴随妊娠的进展而加重,增加各种妊娠并发症的发病率,约66%的复发性流产患者存在凝血功能障碍。本文就遗传性及获得性易栓症与复发性流产的关联性,对有血栓栓塞病史或相关高危因素的复发性流产女性进行易栓症筛查的必要性,以及对复发性流产合并易栓症的治疗手段,预防各种产科并发症的发生,降低妊娠丢失率进行讨论。     

血栓弹力图在高危妊娠中的研究进展

血栓弹力图(thrombelastography,TEG)是一种反映全血凝血功能的图像,是一种能从整体上动态评价凝血和纤溶过程的检测手段。妊娠期凝血-抗凝系统及纤溶-抗纤溶系统的变化使妊娠妇女的凝血系统处于高凝状态,这种高凝状态既是一种生理性保护机制,又是诱发凝血功能障碍的高危因素。一旦这种高凝状态的动态平衡被打破,可参与产科并发症的发生,严重威胁着孕产妇和胎儿的安全。TEG能够真实、全面地反映妊娠期妇女凝血功能的变化,对复发性流产、妊娠期高血压疾病、羊水栓塞、产后出血和产科血栓栓塞性疾病等高危妊娠及妊娠期并发症的预测及病情评估具有重要的临床价值,为指导临床决策、早期干预、缓解或延迟并发症和预防不良妊娠结局提供科学依据。     

易栓症与不良妊娠结局

妊娠高血压综合征、胎盘早剥、胎儿生长受限、死胎及不明原因的习惯性流产可导致妊娠不良结局，其病因尚不清楚，凝血功能增强和纤溶降低导致子宫螺旋动脉或绒毛血管血栓形成使胎盘灌注不良可能是其原因之一。近年来研究发现许多妊娠结局不良的妇女具有血栓形成倾向，这种因持续高血凝状态而导致的血栓形成风险增加称为易栓症(thrombophilia)，也称为血栓前状态。这种血栓前状态不一定发生血栓性疾病，但可能选择性影响子宫胎盘循环而导致胎盘的微血栓形成。     

血栓前状态与复发性流产及抗凝治疗

摘要：复发性流产是一种常见的妊娠相关疾病，发生率大约1%～3%。目前，妊娠期血栓前状态是复发性流产领域的研究热点。遗传性血栓前状态及获得性血栓前状态都是自然流产的高危因素。抗凝治疗是针对血栓前状态有效的治疗措施，仍需更完善的循证医学证据来证实其对于复发性流产患者的有效性。     

小剂量阿司匹林预防子痫前期的循证医学意义

循证医学证据表明,小剂量阿司匹林能够预防高危孕妇发生子痫前期,减少其不良妊娠结局。推测小剂量阿司匹林通过抗血栓作用,改善胎盘微循环及妊娠结局。现有的研究证据也表明,未发现孕期使用小剂量阿司匹林有明确的危害,特别是针对高危孕妇,获益大于潜在的风险。然而,使用阿司匹林预防子痫前期的最佳剂量和时机、高危人群的有效覆盖尚无法断定。     

Venous thromboembolism in pregnancy

Venous thromboembolism remains a common cause of direct maternal deaths in high-income settings such as the United Kingdom. Pregnancy alone increases the risk of deep vein thrombosis and pulmonary embolus at least five-fold, and many women develop or have additional risk factors for venous thrombosis during pregnancy and the puerperium, the latter representing the period of highest risk. Early and repeated risk stratification and adequate thromboprophylaxis, usually with low molecular weight heparin, is the key to preventing venous thromboembolism (VTE). Women with a past history of VTE, and those affected by thrombophilia, require multidisciplinary care involving an obstetric haematologist. Women suspected of having acute thromboembolism should be commenced on empirical treatment promptly prior to diagnostic confirmation. Pulmonary embolism should be considered as a differential diagnosis in maternal collapse.     

The risk of venous thromboembolism associated with the use of tranexamic acid and other drugs used to treat menorrhagia: a case–control study using the General Practice Research Database

Objective  To assess whether use of tranexamic acid is associated with an increased risk of venous thromboembolism (VTE).
Design  Nested case–control study.
Setting  Database study using the General Practice Research Database for the years 1992–1998.
Population  Women aged 15–49 years with a diagnosis of menorrhagia.
Methods  Multivariate conditional logistic regression was used to estimate the risk for VTE associated with different drug treatments for menorrhagia, adjusting for confounders.
Main outcome measures  Adjusted odds ratios with 95% CI.
Results  A total of 134 cases of VTE and 552 matched controls were identified. Recent use of tranexamic acid was scarce, yielding an adjusted odds ratio for VTE of 3.20 (95% CI 0.65–15.78). The use of mefenamic acid (OR_adj 5.54 [95% CI 2.13–14.40]) or norethisterone (OR_adj 2.41 [95% CI 1.00–5.78]) was associated with an increased risk of VTE, as was a recent—in relation to menorrhagia—diagnosis of anaemia or a haemoglobin value <11.5 g/dl (OR_adj 2.23 [95% CI 1.02–4.86]).
Conclusions  We found that tranexamic acid was associated with an increased risk of VTE, although the risk estimate did not reach statistical significance. Increased risks of VTE associated with other treatments for menorrhagia were observed. The increased risk of VTE observed with a diagnosis of anaemia—a proxy for more severe menorrhagia—suggests that menorrhagia could be a prothrombotic condition. The observed association between VTE, tranexamic acid and other treatments for menorrhagia may thus partly be explained by confounding by indication. The possibility that menorrhagia is itself a risk factor for VTE merits further investigation.     

Inherited thrombophilias and anticoagulation in pregnancy

Thromboprophylaxis, primary or secondary, should be considered in selected pregnant women with inherited thrombophilias; such women may be divided into high-, medium- and low-risk categories on the basis of the specific thrombophilic defect and any personal or family history of venous thromboembolism (VTE). Women at high risk of VTE should receive treatment doses of low-molecular-weight heparin (LMWH) throughout pregnancy and should remain on anticoagulation for 6 weeks postpartum, or, where appropriate, long-term. Women at moderate risk should be treated with prophylactic fixed-dose LMWH throughout pregnancy and for 6 weeks postpartum. Women at low risk should receive prophylactic fixed-dose LMWH for 6 weeks postpartum, and low-dose aspirin LDA should be considered during pregnancy. LWMH offers important advantages over unfractionated heparin (UFH); heparin-induced thrombocytopaenia (HIT) and osteopaenia are rarely seen. For treatment doses of LMWH, dosage adjustment based on anti-Xa levels is usually required as pregnancy progresses. Warfarin should be avoided throughout pregnancy. LMWH, UFH and warfarin are safe for breast-feeding mothers.     

Hormonale Kontrazeption

Women’s needs and physicians’ requirements for the best possible individual contraceptive method are manifold. A thorough evaluation of the personal and family history combined with a brief physical examination can reveal important risk factors contraindicating the use of, e.g. combined hormonal contraceptives. The main focus of risk evaluation lies on the risk of venous thromboembolism (VTE) which varies depending on the contraceptive method chosen. In 2013 the German Society for Gynecological Endocrinology and Reproductive Medicine (Deutsche Gesellschaft für Gynäkologische Endokrinologie und Fortpflanzungsmedizin, DGGEF) and the Professional Association of Gynecologists (Berufsverband der Frauenärzte, BVF) published a joint position statement on contraceptives and the risk of VTE. Furthermore, the World Health Organization (WHO) recommendations provide help in finding a suitable contraceptive method for (almost) every situation in life and prevalent comorbidity. The use of the WHO recommendations in daily practice is presented using an increased risk of VTE as an example.     

A local risk score model for venous thromboembolism prophylaxis for caesarean section in Chinese women and comparison with international guidelines

ObjectiveRecommendations for venous thromboembolism (VTE) prophylaxis from authoritative guidelines for women undergoing caesarean delivery differed significantly and may not be applicable to Chinese populations. We aim to formulate a local risk model for VTE prophylaxis for caesarean section women.Material and methodsA local risk score model based on demographic, obstetric and medical parameters was used to assess the risk of VTE in women undergoing caesarean delivery from May 2017 to April 2018 in a regional obstetric unit. Women with increased risk (VTE Score ≥ 2) are given mechanical prophylaxis with pneumatic cuff and those with high risk (VTE Score ≥ 3) are additionally prescribed low molecular weight heparin (LMWH) as pharmacological prophylaxis in the early postpartum period. The risk scores obtained by applying other major guidelines were then compared.ResultsOf 859 patients were included for analysis, overweight (15.3%), advanced maternal age (9.7%), multiple pregnancy (5.1%), obesity (4.7%), and primary postpartum haemorrhage (4.1%) were the most common risk factors. Overall, 109 (12.7%) patients required mechanical prophylaxis and 28 (3.3%) patients required additional pharmacological prophylaxis. No patient had postpartum VTE events nor serious haemorrhage after receiving LMWH prophylaxis. In contrast, applying the Royal College of Obstetricians and Gynaecologists guidelines to our cohort, 649 (75.6%) patients would receive LMWH after caesarean section, compared with no patients under the American College of Obstetrics and Gynaecology guidelines.ConclusionsOur local risk score model avoided the need for large proportions of women to be subjected to pharmacological prophylaxis, and appeared safe and practical.     

Can we identify risk factors during pregnancy for thrombo-embolic events during the puerperium and later in life?

Objectives: To investigate parturients at risk to develop venous thrombo-embolic events (VTE) in the puerperium or later in life, during a follow-up of more than a decade and compare risk factors for VTE during the puerperium with VTE later in life.

Methods: A nested case–control study was conducted to profile parturients at risk for VTE and a secondary analysis to compare risk factors for VTE during or after puerperium. We used a cohort of 95?257 women who gave birth between the years 1988 and 1998.

Results: Independent risk factors to develop VTE were peripartum hysterectomy, stillbirth, cesarean delivery (CD), obesity, pregnancy-related hypertension, grandmultiparity and advanced maternal age. Women undergoing CD and those receiving blood transfusion were more likely to develop early versus late VTE (OR?=?2.0, 95% CI?=?1.15–3.5 and OR?=?11.0, 95% CI?=?2.25–55.5; respectively). Patients that encountered VTE during the puerperium had more pulmonary emboli and less deep vein thrombosis, compared with the late VTE group (p?Conclusions: Maternal age, grandmultiparity, pregnancy-related hypertension, CD, obesity, stillbirth and peripartum hysterectomy are independent risk factors for the development of VTE. CD and blood transfusion were predictive of early versus late VTE.     

Pulmonary embolism associated with combined oral contraceptives: reporting incidences and potential risk factors for a fatal outcome

BACKGROUND: It is established that combined oral contraceptive (COC) treatment increases the risk of a pulmonary embolism (PE), but specific risk factors for a fatal outcome from a PE remain to be determined. This study aimed to identify such risk factors, and to calculate the reporting rates of fatal and non-fatal PE. METHODS: Cases of suspected PE during treatment with COCs reported to the Swedish Adverse Drug Reactions Advisory Committee (SADRAC) between 1965 and 2001 were included. Medical records were scrutinized for potential risk factors for a venous thromboembolism (VTE). Annual sales data were obtained from the National Corporation of Pharmacies. RESULTS: A total of 248 cases of a suspected PE were reported; 207 non-fatal and 41 fatal. A VTE was verified in all fatal, and in 83.5% of non-fatal cases. The presence of nausea or abdominal pain, an age >35 years, concomitant treatment with other drugs which may increase the VTE risk, vein or lymph vessel malformation, and a deep vein thrombosis above the knee level were positively associated with a fatal outcome. Chest pain and previous COC use were negatively associated with a fatal outcome. The reporting rate of a PE with a verified VTE was 1.72 (95% confidence interval 1.47-2.00) cases per 100 000 treatment years, and of a fatal PE 0.25 (95% confidence interval 0.16-0.37) cases per 100 000 treatment years. CONCLUSION: Several specific potential risk factors for a fatal outcome from a COC-induced PE were identified. Recognition of these in combination with a high suspicion of VTE in COC users may reduce the risk of a fatal outcome.