心脏瓣膜置换术后妊娠妇女围手术期的抗凝管理

Anticoagulant management of pregnant women with mechanical heart valve replacement during perioperative period

目的:探讨心脏机械瓣膜置换术后妊娠妇女围手术期适宜的抗凝方案。方法:回顾分析2008年10月到2012年7月就诊于四川大学华西第二医院的34例孕期口服小剂量华法林抗凝治疗的心脏机械瓣膜置换术后患者的临床资料。34例患者中,7例行急诊剖宫产,术前维生素K1静脉注射,术后给予"桥接"抗凝治疗;27例行择期剖宫产,其中13例术后仅接受口服华法林抗凝治疗,14例接受"桥接"抗凝治疗。比较术后不同抗凝方案的并发症发生情况及国际标准化率(INR)达到目标水平所需的时间。结果:34例患者均妊娠至足月行剖宫产,孕期未见血栓发生,新生儿健康。急诊剖宫产前使用维生素K1患者的术后INR增长速度明显低于未使用者。单纯口服华法林治疗组与"桥接"治疗组患者的术后出血量比较,差异无统计学意义(P>0.05)。单纯口服华法林治疗组发生1例瓣膜血栓并导致患者死亡。两组患者均无周围血栓、血肿、一般性出血及过度抗凝并发症发生。结论:术前使用维生素K1可能导致术后发生华法林抵抗,择期剖宫产前应尽量避免使用维生素K1纠正凝血功能。剖宫产术后使用口服华法林联合皮下注射低分子肝素的"桥接"抗凝治疗对机械瓣膜置换术后患者更安全、有效。

Objective： To investigate suitable anticoagulation in perioperative with women who received mechanical heart valve replacement. Method：34 pregnant women with mechanical heart valve replacement who received low-dose oral anticoagulation treatment from Oct. 2008 to Jul. 2012 treated at West China Women＆#39;s and Children＆#39;s Hospital were retrospec-tively reviewed. 7 patients received emergency cesarean section,while 27 patients received se-lective cesarean section,in which 13 patients received single oral warfarin postpartum and 14 patients received “bridging treatment”. Morbidity of complications and the time to achieve the target INR after operation were compared. Results：34 full-terms healthy babies were delivered and no maternal thromboembolic was observed during pregnancy. There was no significant difference of the amount of vaginal bleeding between single oral warfarin group and “bridging treatment” group during postpartum period. In single oral warfarin group,one valve thrombosis was observed and leaded to sudden death. No periphery thrombosis,hematoma,general hemor-rhage or other sign of over-anticoagulation was observed. The INR increased more slowly in the group who received emergency operation with preoperative application of vitamin K1 than other two groups. Conclusion：The use of vitamin K1 preoperatively might result in warfarin resistance and discontinue warfarin therapy before selective cesarean section might be more appropriate than application of vitamin K1. The “ bridging treatment” which combines oral warfarin and subcutaneous LMWH might be more effective and safer than single oral warfarin therapy for pa-tients with mechanical heart valve replacement during postoperative period,no matter selective or emergency cesarean section. The safty of low-dose oral wafarin therapy thoughout preganancy is still under controversy.