妊娠和产褥期静脉血栓栓塞的临床特征及治疗

Clinical characteristics and treatment of maternal venous thromboembolism

目的分析妊娠和产褥期静脉血栓栓塞(venous thromboembolism,VTE)患者的临床特征、治疗方式及妊娠结局。方法本研究为回顾性研究。研究对象为2014年1月至2017年12月山西医科大学附属大医院血管外科收治的81例妊娠和产褥期VTE患者。根据VTE的发生时机,分析妊娠和产褥期发病患者的临床资料。采用t检验、秩和检验或χ^2检验(或Fisher精确概率法)对数据进行统计分析。结果(1)研究对象年龄为(30.9±5.2)岁,20例(24.7%)年龄≥35岁。妊娠期患者41例(50.6%),产褥期患者40例(49.4%)。产褥期发病的患者中,34例(85.0%)发生在产后30 d内。(2)VTE首发症状和体征主要表现为肿胀[43.4%,33/76,剔除5例单纯肺血栓栓塞症(pulmonary thromboembolism,PTE)患者]和疼痛(28.9%,22/76),以急性发病为主。血栓范围以周围型为主(61.8%,47/76),其中妊娠期患者多为周围型(80.0%,32/40),而产褥期患者以混合型为主(44.4%,16/36,χ^2=13.417)。血栓部位主要是下肢深静脉(74.1%,60/81),其中妊娠期患者下肢深静脉血栓(deep venous thrombosis,DVT)较多(87.8%,36/41),而产褥期DVT合并PTE较多(30.0%,12/40,χ^2=7.961)。累及静脉以肌间静脉最多(72.4%,55/76),其中妊娠期患者主要累及肌间静脉(85.0%,34/40),而产褥期患者累及肌间(58.3%,21/36)、股(58.3%,21/36)、腘(50.0%,18/36)、髂(47.2%,17/36)、胫(44.4%,16/36)和腓(38.8%,14/36)等多条静脉。(3)占比例最高的危险因素是年龄≥35岁(24.7%,20/81);其次是抗凝血酶缺乏(23.5%,19/81)和妊娠期高血压疾病(21.0%,17/81)。不同危险因素在妊娠期和产褥期患者间的分布差异均无统计学意义。产褥期患者D-二聚体水平较高[1029(639~1778)与619(355~1117)μg/L,Z=-3.336,P<0.001]。(4)所有患者均行系统抗凝治疗。24例患者(29.6%,包括妊娠期5例,产褥期19例)因血栓范围广泛而行溶栓治疗。住院时间为(7.3±2.1)d。(5)41例妊娠期VTE患者中,治疗后9例(21.9%)选择引产,其余32例继续妊娠至分娩,包括26例剖宫产,6例经阴道分娩;8例(25.0%)为早产儿,1例(3.1%)为巨大儿。结论孕产妇相关VTE主要发生于妊娠晚期和产后30 d内。其中产褥期VTE累及静脉多、血栓范围广。对于年龄≥35岁、抗凝血酶缺乏或合并妊娠期高血压疾病的孕产妇,要尤其警惕VTE。妊娠期VTE可能影响患者的妊娠结局,要密切观察。

Objective To analyze the clinical features,treatment,and pregnancy outcomes of women with venous thromboembolism(VTE)during pregnancy and puerperal period.Methods Clinical data of 81 patients with gestational and puerperal VTE admitted to the Department of Vascular Surgery of Dayi Hospital Affiliated to Shanxi Medical University from January 2014 to December 2017 were retrospectively analyzed.Rank-sum test,t-test or Chi-square test(or Fisher's exact test)were used for statistical analysis.Results(1)The average age of these women was(30.9±5.2)years old and 20(24.7%)were≥35 years old.Pregnant women accounted for 50.6%(41/81).Forty cases were in the puerperium,of which 34 developed VTE within 30 days after delivery.(2)The thrombus was predominantly peripheral type in all subjects after excluding five patients with isolated pulmonary thromboembolism(PTE)(61.8%,47/76),especially in pregnant patients(80.0%,32/40),while mixed type was often occurred in the puerperium(44.4%,16/36,χ^2=13.417).The initial symptoms and signs were mainly swelling(43.4%,33/76)and pain(28.9%,22/76)with acute onset.Thrombi were mainly found in the deep veins of lower extremities(74.1%,60/81).More pregnant patients had deep venous thrombosis(DVT)in the lower limbs(87.8%,36/41),while DVT in the puerperium was often complicated by PTE(30.0%,12/40,χ^2=7.961).Intermuscular veins were the most common affected veins(72.4%,55/76),especially during pregnancy(85.0%,34/40),while for those cases during puerperium,multiple veins,such as intermuscular(58.3%,21/36),femoral(58.3%,21/36),popliteal(50.0%,18/36),iliac(47.2%,17/36),tibial(44.4%,16/36)and fibular vein(38.8%,14/36)were involved.(3)The highest risk factor was age≥35 years old(24.7%,20/81),followed by antithrombin deficiency(23.5%,19/81)and hypertensive disorders of pregnancy(HDP,21.0%,17/81).There were no significant differences in the distribution of different risk factors between patients during pregnancy and puerperium.D-dimer levels were higher in puerperal patients than in pregnant women[1029(639-1778)vs 619(355-1117)μg/L,Z=-3.336,P<0.001].(4)All patients received systemic anticoagulant therapy.Twenty-four patients(29.6%,including five in pregnancy and 19 in puerperium)were treated with thrombolytic therapy due to extensive thrombus formation.The average hospital stay was(7.3±2.1)d.(5)Among the 41 patients developing VTE during pregnancy,nine(21.9%)received induced labor;26(63.4%)underwent cesarean section;six(14.6%)delivered vaginally.Among the 32 pregnancies continuing to deliver,eight(25.0%)premature infants and one(3.1%)macrosomia were born.Conclusions Maternal VTE mainly occurs in the third trimester or within 30 days after birth.VTE in the puerperal period commonly involves multiple veins and is characterized by extensive thrombus formation.Pregnant women aged≥35 years,with antithrombin deficiency or complicated with HDP,should be closely observed to prevent VTE as it may affect pregnancy outcomes.