摘要
目的探讨妊娠合并静脉血栓栓塞性疾病（VTE）的发病特点及诊疗方法。方法对2006年6月至2011年6月山东大学齐鲁医院妇产科收治的20例妊娠合并VTE患者的临床资料进行回顾性分析。结果（1）一般情况：20例妊娠合并VTE患者均为妊娠期发病，发病孕周〈12周6例（30％），孕12-28周7例（35％），〉28周7例（35％）。20例患者中发病1周内就诊12例，≥1周就诊8例。（2）临床表现：20例患者中18例为深静脉血栓形成（DVT），1例为DVT合并肺栓塞（PE），1例为PE。19例DVT患者中16例累及左下肢，3例累及右下肢，均为突发性下肢肿胀、疼痛。19例DVT患者中17例患肢周径较健侧增粗，平均增粗〉（4．0±0．5）cm；12例血D-二聚体水平升高。19例DVT患者均经静脉彩色多普勒超声检查明确诊断。19例DVT患者的静脉血栓类型为中央型7例，周围型2例，混合型10例。（3）抗凝治疗：给予低分子肝素类药物抗凝，终止妊娠后联合应用低分子肝素和华法林钠，两者至少有3～5d重叠用药时间，根据凝血指标调整凝血酶原时间国际标准化率（PT—INR）在2．0～2．5之后，停用低分子肝素。对于DVT患者，若规范抗凝时间〈30d，建议分娩或流产前放置下腔静脉滤器（IVCF）；若规范抗凝时间I〉30d，产后24h重新开始规范抗凝治疗；对于血栓稳定、无新发PE者于放置IVCF后12d内取出IVCF。（4）溶栓治疗：一般情况下不推荐使用，尤其是分娩前。对于PE患者，终止妊娠后可考虑使用。对于大面积PE患者予以大剂量溶栓，应用尿激酶每天600000U连续静脉滴注3d。（5）临床结局：20例VTE患者中，19例给予低分子肝素抗凝治疗。3例患者置人IVCF，均于术后12d成功取出IVCF，未出现并发症。20例患者经治疗后症状、体征均缓解，2周后患肢肿痛基本消失，患肢周径较健侧差异在（2．0±0．3）em。维持至晚期妊娠的18例患者中，行抗凝治疗的17例患者产前检查均无明显异常涪0宫产分娩10例（50％，10／20），经阴道分娩8例（40％，8／20），新生儿无畸形，10分钟Apgar评分均在8分以上。出院后随访1-24个月，2例周围型DVT患者的腓肠肌静脉血栓分别在治疗后4周、8周消失，余17例DVT患者的静脉血栓没有蔓延，肢体症状无反复。2例PE患者出院后3个月复查心脏彩超提示肺动脉压力恢复正常。所有患者在治疗期间未出现症状性PE，无出血并发症，无死亡。结论低分子肝素抗凝治疗妊娠合并VTE是安全有效的，妊娠合并VTE并非终止妊娠的指征，不需要常规使用溶栓治疗。应严格掌握放置IVCF的指征，必要时行可回收IVCF置人术以预防致命性PE的发生。
Objective To evaluate the clinical features,diagnostic methods and treatment of venous thromboembolic disease （VTE） during pregnancy. Methods From June 2006 to June 2011, a total of 20 pregnant women were diagnosed VTE at the Department of Obsterics and Gynaecology, Qiiu Hospital of Shandong University. Clinical data of these patients were analyzed retrospectively. Results （1） Characteristics of patients：the symptoms of all the 20 patients commenced in pregnancy. Of these, 6 （30%）happened in the first trimester, 7 （35%） in the second trimester, and 7 （35%） in the third trimester. Twelve （60%） patients went to hospital in one week after they had symptoms, while 8 （40%） went to hospital after one week. （2）Clinical manifestation： 18 patients were diagnosed deep venous thrombosis （DVT）, one was diagnosed pulmonary embolism （PE）. One patient was diagnosed DVT and PE simultaneously. Among the 19 DVT patients, 16 （ 16/19 ） were on the left side, 3 （3/19） were on the other. They all came with sudden swelling and pain of the affected lower extremity. In 17 （17/19） patients, the circumference differences between two legs were beyond （4. 0 ＋ 0. 5 ） em. In all the 20 patients, 12 （60%） had elevated plasma level of D-dimmer. The diagnosis of DVT was made mainly by a Doppler ultrasound. Among the 19 DVT events, 7 （7/19） were proximal DVT,2 （2/19） were distal,and 10（10/ 19） were mixed type. （3）Anticoagulant therapy：patients with VTE during pregnancy were treated with low molecular weight heparin （LMWH） （ enoxaparin, once 1 mg/kg subcutaneous, twice a day）. After delivery, patients were treated with subcutaneous LMWH and warfarin simultaneously for at least 5 days, until the prothrombin time-international normalized ratio （ PT-INR ） was 〉 2. 0 for 24 hours. （ 4 ） Thrombolytic therapy ： for most patients with VTE, we are against the routine use of thrombolytic therapy, especially before delivery. For patients with acute massive PE, urokinase of 600 000 units intravenously daily was recommended for 3 days. For those patients with DVT whose standard antieoagulation therapy was 〈 30 days, an inferior vena cava fiher（IVCF） placement was recommended before delivery or abortion. If it was I〉 30 days, IVCF was not recommended as a routine, and anticoagulant therapy was used 24 hours after delivery. If there was no recurrent DVT or PE, IVCF was retrieved routinely in 12 days. （ 5 ） Outcome ： among patients treated with LMWH （95 %, 19/20）. Three received IVCF placement, which was retrieved successfully in 12 days, with no interventional complication. All patients recovered well after 2 weeks, and the circumference differences between two legs were within （2.0 -0. 3 ） cm. Of the 18 patients maintained to the third trimester, 17 received anticoagulant therapy, and no abnormal findings were found during antenatal examination. Ten patients received cesarean section （ 50% , 10/20 ） , while 8 had vaginal delivery （ 40% , 8/ 20）. Neither neonatal asphyxia nor malformation was observed. The patients were followed-up for 1 - 24 months, no venous thrombus extension was found in 17 cases by Doppler ultrasound, thrombus disappeared in 2 cases of distal DVT after 4 weeks and 8 weeks respectively. By eehocardiography, the pulmonary arterial pressure of the 2 patients with PE was found normal 3 months after hospital discharge. There was no maternal death during the study, no recurrent PE or bleeding oecured. Conclusions LMWH is safe and effective for VTE during pregnancy. Routine use of thrombolytic therapy is not recommended. VTE in pregnancy is not the absolute indication of termination of pregnancy. The indication of an IVCF placement should be stricter, and a retrievable suorarenal IVCF is recommended under certain circumstances.
出处
《中华妇产科杂志》
CAS
CSCD
北大核心
2011年第12期911-916,共6页
Chinese Journal of Obstetrics and Gynecology
基金
山东省中青年科学家科研奖励基金（BS2011YY025）
关键词
妊娠并发症
心血管
静脉血栓栓塞
肝素
低分子量
Pregnancy complications, cardiovascular
Venous thromboembolism
Heparin,low-molecular-weight
