孕产妇肺血栓栓塞症临床特点:16例分析

Clinical features of maternal pulmonary thromboembolism:analysis of 16 cases

目的总结孕产妇肺血栓栓塞症(pulmonary thromboembolism,PTE)的临床特点、妊娠结局及处理策略。方法回顾性分析首都医科大学附属北京安贞医院2012年1月至2022年12月收治的16例PTE孕产妇的临床资料。总结其临床特点、治疗情况及妊娠结局。采用描述性统计分析。结果16例患者的年龄为(29.5±3.5)岁(26~35岁)。妊娠期发病者6例,中位发病孕周为12周(7~38周);产褥期发病者10例,中位发病时间为产后4 d(16 h~40 d)。高危型2例,中危型9例(中-高危6例,中-低危3例),低危型5例。6例妊娠期发病者中4例有明确高危因素,静脉血栓栓塞症危险因素评分均≤2分;10例产褥期发病者中9例有明确高危因素,静脉血栓栓塞症危险因素评分2~9分。妊娠期发病者均无预防性抗凝治疗指征,产褥期发病者中9例有预防性抗凝治疗指征,但均未给予预防性抗凝治疗。高危型患者2例行溶栓治疗,后行低分子肝素序贯华法林/利伐沙班治疗;中危型及低危型患者均低分子肝素序贯华法林/利伐沙班治疗。妊娠期发病者均抗凝±溶栓后适时终止妊娠,后续抗凝治疗。16例孕产妇均存活。妊娠期发病者中,早、中孕期发病者5例,均医源性终止妊娠;晚孕期发病者1例,新生儿存活。产褥期发病者中,1例为中孕期胎死宫内行中期引产后发病,胎儿结局为死胎;1例为早孕期要求终止妊娠后发病,胎儿结局为流产;其余8例均为晚孕期剖宫产术后发病,新生儿均存活。结论孕产妇为PTE高危人群,大多有高危因素,因此要重视高危因素的筛查,适时启动预防性抗凝。孕产妇PTE治疗后母亲结局好,胎儿结局取决于发病时间。

ObjectiveTo summarize the clinical features,pregnancy outcomes,and treatment strategies of pulmonary thromboembolism(PTE)in pregnant women and puerperae.MethodsClinical data of 16 pregnant women or puerperae with PTE who were admitted to Beijing Anzhen Hospital from January 2012 to December 2022 were retrospectively collected.Descriptive statistical analysis was used to summarize the clinical features,treatment strategies,and pregnancy outcomes in these cases.ResultsThe average age of the 16 patients was(29.6±3.5)years(26-35 years)and the median onset time was 12 weeks(7-38 weeks)of gestation in six pregnant women and 4 d(16 h-40 d)after delivery in ten puerperae.There were two cases of high-risk type;nine cases of medium-risk type(six of medium-high risk and three of medium-low risk);and five cases of low-risk type.Definite high-risk factors were detected in four pregnant women(venous thromboembolism risk score≤2)and nine puerperae(venous thromboembolism risk score of 2-9).None of the six pregnant women had any indications for preventive anticoagulant therapy and nine puerperae had indications but without preventive therapy.All the patients were treated with low molecular weight heparin and sequential administration of warfarin/rivaroxaban,in addition to that,two high-risk patients also received thrombolytic therapy.After therapy,all pregnant women terminated their pregnancies in time and then continued to receive anticoagulation treatment.All 16 patients survived.Among the six pregnant women,five who developed PTE in the first or second trimester underwent iatrogenic termination of pregnancy,and one who developed PTE in the third trimester gave live birth.Among the 10 puerperae,one had PTE after the termination of pregnancy in the second trimester due to intrauterine fetal death;one developed PTE after abortion in the first trimester;the other eight cases developed PTE after cesarean section in the third trimester,with all newborns surviving.ConclusionsPregnant women and puerperae are at high risk of PTE and most have high-risk factors.Therefore,more attention should be paid to the screening of high-risk factors and the initiation of preventive anticoagulant therapy.Maternal outcomes are good after PTE treatment,but fetal outcomes depend on the time of onset.