孕产妇合并肺血栓栓塞症临床诊治的分析研究

Clinical analysis of pulmonary thromboembolism in pregnant women

目的应用“孕产妇静脉血栓栓塞症(VTE)危险因素评分”分析围产期患者发生肺血栓栓塞症(PTE)的相关因素,以探究孕产妇VTE发生的危险因素及其诊治要点。方法回顾性分析上海交通大学医学院附属仁济医院产科重症病房自2015年9月开设以来至2020年12月期间接诊及被转诊的孕产妇资料,其中经CT肺动脉造影(CTPA)确诊为PTE的15例患者纳入本研究。收集患者的临床资料,包括一般情况、临床表现、体格检查结果、实验室检查结果、影像学检查结果、诊治经过及预后资料,并统计纳入患者的“孕产妇VTE危险因素评分”,以分析影响孕产妇发生VTE的危险因素。结果15例患者中,3例在妊娠期和分娩前后未出现PTE相关临床症状及体征,其余12例患者均有不同程度的症状及体征,其中胸闷伴气促者8例、咳嗽伴咯血者2例、下肢肿胀者1例、仅表现为术后持续低氧血症者1例。10例患者发病时心率≥100次/min,12例患者呼吸频率≥20次/min。4例患者妊娠合并内科疾病;8例患者发生妊娠并发症;4例患者诊断PTE同时确诊DVT。根据“孕产妇VTE危险因素评分”,极高危(≥4分)患者8例,高危(产前3分,产后2~3分)患者6例,低危(0~1分)患者1例。所有患者的D-二聚体水平均不同程度升高,11例患者脑钠肽(BNP)>100 pg/mL。所有患者PaO 2均<95 mmHg(1 mmHg=0.133 kPa);PaCO 2处于正常范围(35~45 mmHg)6例,<35 mmHg者6例,>45 mmHg者3例;氧饱和度处于正常范围(95%~98%)者12例,<95%者3例;pH值处于正常范围(7.350~7.450)者10例,>7.450者4例,<7.350者1例。肌钙蛋白水平升高者2例。15例患者均行静脉加压超声(CUS)检查,其中4例的检查结果提示DVT;所有患者均在产前或产后行CTPA确诊PTE。1例患者行溶栓+低分子肝素(LMWH)+华法林序贯治疗,3例行LMWH+华法林序贯治疗,11例行LMWH治疗。患者的妊娠结局为14例存活,1例因晚期胃癌于产后2个月死亡。患者的新生儿结局为均存活。结论需要进一步完善“孕产妇VTE危险因素评分”,提高危险因素评分预测的灵敏度,对不同阶段的孕产妇均须进行VTE风险评估,实现早预防、早诊断、早治疗,降低孕产妇死亡率。

Objective To analyze related factors of pulmonary thromboembolism(PTE)in pregnant women by using“maternal venous thromboembolism(VTE)risk factor score”,so as to explore the risk factors and key points of diagnosis and treatment of VTE in pregnant women.Methods The clinical data of pregnant women admitted to the obstetric intensive care unit of Renji Hospital affiliated to Shanghai Jiao Tong University School of Medicine from September 2015 to December 2020 were retrospectively analyzed.Among them,15 patients with PTE confirmed by computed tomography pulmonary angiography(CTPA)were included in this study.The general information,clinical manifestations,physical examination results,laboratory examination results,imaging examination results,diagnosis and treatment process,prognosis and“maternal VTE risk factor score”were collected to analyze the risk factors of VTE in pregnant women.Results Among the 15 patients,no clinical symptoms or signs related to PTE occurred in 3 patients during pregnancy and before and after pregnancy,while the other 12 patients had varying degrees of symptoms and signs,including chest distress accompanying with short breath in 8,cough with hemoptysis in 2,lower limb swelling in 1,and postoperative persistent hypoxemia in 1.At onset,10 patients had heart rate≥100/min and 12 patients had respiratory rate≥20/min.Four patients had internal medical diseases.Pregnant complications occurred in 8 patients.Four patients were diagnosed with PTE and DVT.The results of“maternal VTE risk factor score”showed that there were 8 cases with very high risk(≥4 points),6 cases with high risk(prenatal 3 points,postpartum 2-3 points)and 1 case with low risk(0-1 point).The level of D-dimer increased in all the patients,and brain natriuretic peptide(BNP)was higher than 100 pg/mL in 11 patients.PaO 2 was lower than 95 mmHg in all the patients.PaCO 2 was in the normal range(35-45 mmHg)in 6 patients,<35 mmHg in 6,and>45 mmHg in 3.The oxygen saturation was in the normal range(95%-98%)in 12 patients and<95%in 3 patients.The pH value was in the normal range(7.350-7.450)in 10 patients,>7.450 in 4 patients and<7.350 in one patient.The level of troponin increased in 2 patients.Compressed ultrasound(CUS)was performed in 15 patients,and 4 of them showed DVT.PTE was finally confirmed by CTPA in all the patients before or after delivery.One patient was treated with thrombolysis+low molecular weight heparin(LMWH)+warfarin,3 were given LMWH and warfarin,and 11 were given LMWH only.14 patients survived and 1 patient died of advanced gastric cancer 2 months after delivery.All newborns survived.Conclusion It is necessary to further modify the“maternal VTE risk factor score”,and improve the sensitivity of risk factor scores.VTE risk assessment must be carried out at different stages of the perinatal period to reduce maternal mortality.