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中华妇幼临床医学杂志(电子版) ›› 2019, Vol. 15 ›› Issue (06) : 623 -631. doi: 10.3877/cma.j.issn.1673-5250.2019.06.004

所属专题： 文献；

标准·方案·指南

妊娠相关静脉血栓栓塞的危险因素及其预防决策
陈倩1, 胡雅毅1,†()   
  1. 1. 四川大学华西第二医院妇产科、出生缺陷与相关妇儿疾病教育部重点实验室，成都　610041
  • 收稿日期:2019-05-11 修回日期:2019-11-12 出版日期:2019-12-01
  • 通信作者: 胡雅毅

Risk factors and prevention strategies of pregnancy-related venous thromboembolism

Qian Chen1, Yayi Hu1,†()   

  1. 1. Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
  • Received:2019-05-11 Revised:2019-11-12 Published:2019-12-01
  • Corresponding author: Yayi Hu
  • About author:
    Corresponding author: Hu Yayi, Email:
  • Supported by:
    Project of Applied Basic Research by Science and Technology Department of Sichuan Province(2019YJ0086); Fund Project of Clinical Research by West China Second University Hospital, Sichuan University(KL024)
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陈倩, 胡雅毅. 妊娠相关静脉血栓栓塞的危险因素及其预防决策[J]. 中华妇幼临床医学杂志(电子版), 2019, 15(06): 623-631.

Qian Chen, Yayi Hu. Risk factors and prevention strategies of pregnancy-related venous thromboembolism[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2019, 15(06): 623-631.

静脉血栓栓塞(VTE)是指静脉血管管腔内血液异常凝结，形成血栓而使血管完全或部分阻塞，引起血液循环障碍。VTE主要包括深静脉血栓形成(DVT)和肺栓塞，而颅内静脉窦血栓形成及卵巢静脉血栓形成等临床少见。VTE是一种非常严重，而且具有潜在致死性的妊娠并发症。孕产妇作为特殊人群，妊娠本身即为其发生VTE的危险因素，若同时合并其他可能导致VTE发生的危险因素，如孕前危险因素、产科危险因素及孕期新发或一过性危险因素等，均可导致妊娠期及产褥期妇女发生VTE的风险增高。临床如何识别VTE危险因素，并对这些高危因素进行相应管理，是产科临床亟待解决的难题。目前，我国孕产妇VTE死因构成比呈逐年上升趋势，但是迄今尚无孕产妇VTE管理的指南或专家共识。笔者拟主要参考现有的妊娠相关VTE的危险因素及其预防、诊治指南的研究证据，从妊娠期女性发生VTE的病因，妊娠期及产褥期孕产妇发生VTE的危险因素，妊娠相关VTE危险因素评估及妊娠相关VTE预防4个方面，阐述妊娠相关VTE危险因素、危险分级及其管理策略，旨在为我国妊娠相关VTE危险因素识别及规范管理，提供实用性临床指导。

关键词: 血栓形成, 静脉血栓栓塞, 妊娠期及产褥期血栓栓塞症, 肝素，低分子量, 妊娠相关静脉血检栓塞管理, 危险因素, 孕妇, 产妇

Venous thromboembolism (VTE) refers to abnormal coagulation of blood in the lumen of vein vessel, which formes a thrombus and causes blood vessel to be completely or partially blocked, then leads to blood circulation disorder. Among them, deep vein thrombosis (DVT) and pulmonary embolism are common, but cerebral venous sinus thrombosis and ovarian venous thrombosis are rare in clinical practice. VTE is a kind of very serious and potentially fatal complication of pregnancy. As a special population, pregnant women themselves are risk population of VTE. If other risk factors of VTE are combined at the same time, including pre-pregnancy risk factors, obstetric risk factors and new or transient risk factors during pregnancy, the risk of VTE in pregnancy and puerperium can be increased. How to identify the risk factors of VTE and manage these risk factors are the urgent problems in obstetrics. The proportion of causes of death of VTE in pregnant women is increasing gradually in China, but there is still no guideline or expert consensus on maternal VTE management. Based on the existing research evidences of the risk factors of pregnancy-related VTE and their prevention, diagnosis and treatment guidelines and consensus expert opinion, this paper expounds the risk factors, risk classification and management strategies of pregnancy-related VTE from four aspects: the causes of VTE in pregnancy, the risk factors of pregnancy and puerperal VTE, the risk factors assessment and prevention of pregnancy-related VTE, aiming at providing practical clinical guidance on the identification of VTE risk factors and management of pregnancy-related VTE.

Key words: Thrombosis, Venous thromboembolism, Thromboembolic disease in pregnancy and the puerperium, Heparin, low-molecular-weight, Management of pregnancy-related venous thromboembolism, Risk factor, Pregnant women, Puerperant
表1 与孕妇有关的凝血因子及抗凝物质在妊娠期的变化情况
与孕妇有关的凝血因子及抗凝物质 妊娠期变化情况a
凝血因子 ?
? 纤维蛋白原 增加
? 凝血因子Ⅶ 增加
? 凝血因子Ⅷ 增加
? 凝血因子Ⅹ 增加
? 凝血因子Ⅻ 增加
? vWF 增加
? PAI-1 增加
? PAI-2 增加
? 凝血因子Ⅱ 无变化
? 凝血因子Ⅴ 无变化
? 凝血因子Ⅸ 基本无变化
? 凝血因子Ⅺ 降低
? 凝血因子Ⅷ 先增加后逐渐降低
抗凝物质 ?
? 活性蛋白S 降低
? 蛋白C 无变化
? 抗凝血酶 无变化
表2 妊娠期及产褥期孕产妇VTE危险因素评分
危险因素 评分(分)
孕前危险因素 ?
? VTE病史(与手术相关的VTE病史除外) 4
? 与手术相关VTE病史 3
? 已知的高危易栓症a 3
? 内科合并症b 3
? 无明显诱因的VTE家族史，或一级亲属罹患与雌激素相关VTE 1
? 已知的低危易栓症(无VTE病史)c 1
? 孕产妇年龄≥35岁 1
? 肥胖(BMI≥30 kg/m2，BMI≥40 kg/m2)d 1或2
? 产次≥3次 1
? 吸烟史 1
? 静脉曲张 1
产科危险因素 ?
? 本次妊娠发生子痫前期 1
? 接受ART-IVF(仅限于产前阶段) 1
? 多胎妊娠 1
? 实施急诊剖宫产术 2
? 择期剖宫产术 1
? 接受内旋转或外倒转术 1
? 产程延长(>24 h) 1
? 产后出血(>1 000 mL，或需要输血治疗) 1
? 本次妊娠为早产(分娩时孕龄<37孕周) 1
? 本次妊娠为胎死宫内 1
孕期新发或一过性危险因素 ?
? 妊娠期或产褥期手术(急性会阴修复术除外)，如阑尾切除术、绝育术等 3
? 妊娠剧吐 3
? OHSS(仅限于早孕期) 4
? 当前系统性感染(需要采取静脉输注抗菌药物抗感染治疗或住院治疗)，如肺炎、伤口感染等 1
? 制动、脱水 1
表3 国外现有妊娠相关VTE诊治指南对孕产妇VTE危险因素预防及其推荐级别
产前或产后 SOGC指南 RCOG指南 ACCP指南
产前 对于采取ART受孕的孕妇，不常规采取VTE预防措施(Ⅲ-C级) 除非合并LMWH禁忌证，如分娩或急性活动性出血等，否则对于住院孕产妇应采取LMWH治疗措施预防VTE(D级) 对于采取ART受孕的孕妇，不推荐常规采取VTE预防措施(1B级)
对于合并严重OHSS的孕妇，则应待OHSS解决后，再采取LMWH治疗措施预防VTE，治疗时间≥8～12周(Ⅲ-B级) 由于妊娠剧吐住院的患者，应对其采取LMWH治疗措施预防VTE，直至其病情好转(C级) 对于合并严重OHSS的孕妇，则应待OHSS解决后，再采取LMWH治疗措施(3个月)预防VTE(2C级)
若孕产妇VTE风险增加，应考虑采取预防性皮下注射LMWH措施预防VTE(Ⅲ-B级) 对于采取ART受孕的孕妇，若合并OHSS，则应对其在早孕期采取LMWH治疗措施预防VTE(C级) ?
对于妊娠期进行非产科手术治疗的孕妇，需采取预防性皮下注射LMWH治疗，治疗时间取决于手术类别及孕妇情况(Ⅲ-B级) 对于IVF-ET孕妇，若合并≤3项VTE临床危险因素，则应在早孕期采取LMWH治疗措施预防VTE(C级) ?
若孕妇卧床时间≥7 d，并且初次产前检查时，BMI≥25 kg/m2，则应采取预防剂量LMWH治疗措施预防VTE(Ⅱ-2B级) 若孕妇合并≥4项VTE临床危险因素，则应考虑产前采取LMWH治疗措施预防VTE，并且应贯穿整个妊娠期；若孕妇合并3项VTE临床危险因素，则应考虑自孕龄为28孕周时，开始对其采取VTE预防措施(D级) ?
对于合并多个VTE危险因素的孕妇，若其VTE绝对风险>1%，特别是卧床者，则应对其采取预防剂量LMWH治疗措施预防VTE(Ⅱ-2B级) ? ?
产后 若分娩前孕妇卧床时间≥7 d，则需采取LMWH治疗措施预防VTE(Ⅱ-2B级) 剖宫产术分娩后，根据产妇体重调整预防性LMWH剂量预防VTE，疗程为10 d(D级) ?
对于产后出血(出血量≥1 000 mL、产时或产后需输注血液制品)的产妇，应采取LMWH治疗措施预防VTE(Ⅱ-2B级) 若系3级肥胖(BMI≥40 kg/m2)孕妇(D级)，或存在>2项VTE危险因素者时(B级)，则需常规进行VTE预防治疗 ?
对于围生期或产后感染孕产妇，需采取LMWH治疗措施预防VTE(Ⅱ-B级) ? ?
若合并多项VTE临床危险因素，并且风险持续存在的孕产妇，应在产后6周对其采取VTE预防措施(Ⅲ-C级) ? ?
住院期间或分娩后2周内存在VTE一过性危险因素孕产妇，应对其采取VTE预防措施(Ⅲ-C级) ? ?
若合并≥2项VTE绝对风险度<1%的独立危险因素(Ⅱ-2B级、Ⅲ-B级)，或>3项VTE绝对风险度<1%者的危险因素的孕产妇，则应对其采取VTE预防措施(Ⅱ-2B级、Ⅲ-B级) ? ?
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