妊娠合并机械心脏瓣膜患者血栓形成抗凝治疗的研究

Study on mechanical heart valve thrombosis during pregnancy under anticoagulation

目的探讨妊娠期机械心脏瓣膜患者血栓形成的原因、抗凝治疗方案的选择及母婴结局。方法根据北京大学深圳医院收治的1例及国内外文献报道的23例妊娠合并机械心脏瓣膜血栓形成患者(共24例)的临床资料,对预防妊娠期机械心脏瓣膜血栓形成的抗凝治疗方案及母婴结局进行回顾性分析。结果本例患者32岁,因"停经15+5周,要求终止妊娠"于2023年6月27日收入北京大学深圳医院妇产科。患者4年前因"风湿性心脏病"行"二尖瓣置换术+三尖瓣成形术",术后长期口服华法林抗凝,妊娠后于孕早期在外院改用肝素抗凝。孕10周无明显诱因出现胸闷、心慌,伴气促,活动及平卧时症状明显,影像学检查提示二尖瓣瓣环内血栓及血管翳形成,遂行二尖瓣机械瓣再次置换术。术后多次因"先兆流产"口服保胎药物治疗,孕15+5周患者及其家属要求终止妊娠,孕16+4周行药物引产和清宫术。检索2009-2023年文献报道的23例妊娠合并机械心脏瓣膜血栓形成病例并结合本病例资料显示,23例患者曾在血栓形成前更换抗凝药物,其中16例在孕早期由华法林改用其他种类肝素。此外,孕早期擅自停用华法林、不规律使用华法林、孕前即更换抗凝药物的各1例。1例孕产妇死亡,6例早产,6例流产,1例胎儿华法林综合征。结论妊娠期如何更换抗凝药物是预防心脏机械瓣膜血栓形成的关键,需要根据指南和患者实际情况决定是否更换抗凝药物,由有经验的医生完成不同抗凝药物之间的衔接。

Objective This study aims to explore the causes of mechanical heart valve thrombosis during pregnancy,anticoagulation regimens,and the maternal and infant outcomes.Methods Based on the clinical data of 1 case treated at Peking University Shenzhen Hospital and 23 cases of pregnancy with mechanical heart valve reported in the literature,a retrospective analysis was conducted to review the anticoagulation treatment plans for preventing mechanical heart valve thrombosis during pregnancy and assess the maternal and infant outcomes.Results The patient in this case,a 32-year-old woman,was admitted to the Department of Obstetrics and Gynecology of Peking University Shenzhen Hospital on June 27,2023,due to"15+5 weeks of gestation and request for pregnancy termination".The patient underwent mitral valve replacement and tricuspid valvuloplasty due to rheumatic heart disease more than four years ago.After the operation,she has been on long-term oral warfarin anticoagulation,and changed to heparin anticoagulation during first trimester of pregnancy in another hospital.At 10 weeks of gestation,she developed chest distress,palpitation,and shortness of breath without obvious inducement,and the symptoms were obvious when she was physically active or supine.Imaging examination showed the formation of thrombosis and pannus in the mitral annulus,so the mechanical mitral valve replacement was performed again.After the operation,oral tocolysis drugs were used several times due to the"portent miscarriage".The patient and her family requested pregnancy termination at 15+5weeks of gestation,and induced labor and curettage were performed at 16+4 weeks of gestation on July 3,2023.A review of 23 pregnant patients with mechanical heart valve thrombosis reported in the literature from 2009 to 2023,combined with the information of this case,found that 23 patients had changed anticoagulant drugs,and 16 of them changed from warfarin to heparin in the first trimester.In addition,there were 1 case of unauthorized discontinuation of warfarin in early pregnancy,irregular use of warfarin,and replacement of anticoagulant drugs before pregnancy.There were 1 maternal death,6 premature births,6 miscarriages,and 1 warfarin infant.Conclusions Reasonable replacing anticoagulant drugs is the key to prevent valve thrombosis.