围术期应用低分子肝素预防孕产妇深静脉血栓形成的疗效研究

Therapeutic effects of low molecular heparin on deep venous thrombosis in pregnant women during perioperative period

目的研究围术期使用低分子肝素对具有深静脉血栓(DVT)高危因素孕产妇深静脉血栓形成的预防作用。方法选取住院有DVT高危因素的择期剖宫产的孕妇150例和正常妊娠择期剖宫产的孕妇50例。随机分为干预1组、干预2组、对照1组及对照2组,每组50例。干预1组在术前3~5 d(术前24 h停药)和术后24 h后给予低分子肝素钙4 100 U皮下注射1次/d,疗程3~5 d;干预2组于术后24 h开始使用低分子肝素钙4 100 U皮下注射,1次/d,疗程3~5 d,对照1组和对照2组均不进行预防性抗凝。4组分别于术前及用药3 d后检测PLT、PT、APTT、FIB、D-Dimer、TXB2、v W值。比较治疗组及对照组术前及术后血栓前状态参数,比较4组深静脉血栓发生率及产后出血的发生率。结果干预1组和干预2组用药3 d后的D-Dimer、FIB值均低于对照1组和对照2组(P <0. 05);干预1组和干预2组用药3 d后的PLT、PT、APTT值与对照1组和对照2组相比,差异均无统计学意义(P> 0. 05)。干预1组和干预2组TXB2、v WF的浓度明显低于对照1组和对照2组(P <0. 05)。干预1组与干预2组未发现深静脉血栓形成。对照1组2例患者发生下肢深静脉血栓,对照2组1例患者。患者术后出现单侧或双侧小腿明显肿胀,患侧腓肠肌有明显压痛,彩超未见明显血栓形成影像,根据临床表现予以确诊。干预1组和干预2组深静脉血栓发生率显著低于对照1组和对照2组(P <0. 05)。干预1组与干预2组的深静脉血栓发生率差异无统计学意义(P> 0. 05)。干预1组发生产后出血1例,干预2组发生产后出血2例,对照1组发生产后出血2例,对照2组发生产后出血1例。干预组的产后出血发生率与对照组比较差异无统计学意义(P> 0. 05)。结论围术期使用低分子肝素预防性抗凝治疗能显著改善孕产妇的血栓前状态,显著降低深静脉血栓发生率;在手术前和术后均使用低分子肝素与仅术后使用低分子肝素预防性抗凝治疗对降低深静脉血栓的发生率无明显差异;使用低分子肝素抗凝治疗不增加产后出血的发生率。

Objective To investigate the preventive effects of low molecular heparin on deep venous thrombosis （DVT） in pregnant women during perioperative period. Methods A total of 150 hospitalized pregnant women with high risk factors of DVT, who were waiting for selective cesarean section, and the other 50 normal pregnant women waiting for selective cesarean section, were randomly divided into intervention group1 （ n =50）, intervention group 2 （ n =50）, control group 1 （ n =50） and control group 2 （ n =50）. The pregnant women in intervention group 1 were given low molecular heparin calcium 4100 IU at days 3-5 before surgery （ stopped before surgery ） and at 24h after surgery, once a day for 3 to 5 days. The pregnant women in intervention group 2 were given low molecular heparin calcium 4100U at 24h after surgery, once a day for 3 to 5 days. However the pregnant wome in control group1 and control group 2 were not treated by anticoagulation drugs. The levels of PLT, PT, APTT, FIB, D Dimer, TXB2, vWF values of the pregnant women in the four groups before surgery and at 3 days after suegery were detected, respectively. Moreover, thrombosis parameters before and after surgery and the incidence rates of deep vein thrombosis and postpartum hemorrhage were compared between the four groups. Results The levels of D Dimer and FIB at days 3 after medication in intervention group 1 and intervention group 2 were significantly lower than those in control group 1 and control group 2 （ P 〈0.05）. However there were no significant differences in the levels of PLT,PT, APTT at days 3 after medication between intervention group1, intervention group 2, control group 1 and control group 2 （ P 〉0.05）. The levels of TXB2 and vWF in intervention group 1 and intervention group 2 were significantly lower than those in control group 1 and control group 2 （ P 〈0.05）. No deep venous thrombosis was found in intervention group 1 and intervention group 2. However, DVT was found in 2 cases in control group 1 and 1 case in control group 2. Furthermore, the incidences of deep vein thrombosis in intervention group 1 and intervention group were significantly lower than those in control group1 and control group 2 （ P 〈0.05）, there was no significant differnce in the incidence of deep vein thrombosis between intervention group 1 and intervention group2 （ P 〉0.05）. In addition, there was 1 case of postpartum hemorrhage in intervention group1, 2 cases in intervention group 2, 2 cases in control group1and 1 case in control group2,respectively. There were no significant differences in incidence of postpartum hemorrhage between intervention groups and control groups （ P 〉0.05）. Conclusion As anticoagulant, low molecular heparin at perioperative period can markedly improve pro-thrombosis status and reduce the incidence of deep vein thrombosis, without the increase of the incidence of postpartum hemorrhage. There is no significant difference in reducing the incidence of deep vein thrombosis between using low molecular heparin before and after surgery and using it after suegery.