Chinese Medical E-ournals Database

Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition) ›› 2019, Vol. 15 ›› Issue (06): 623 -631. doi: 10.3877/cma.j.issn.1673-5250.2019.06.004

Special Issue:

Standard·Proposal·Guideline

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)

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.

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
表2 妊娠期及产褥期孕产妇VTE危险因素评分
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) ? ?
[1]
中华医学会外科学分会血管外科学组. 深静脉血栓形成的诊断和治疗指南(第三版)[J/CD]. 中国血管外科杂志(电子版), 2017, 9(4): 201-208.
[2]
Heit JA, Kobbervig CE, James AH, et al. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study[J]. Ann Intern Med, 2005, 143(10): 697-706.
[3]
James AH, Jamison MG, Brancazio LR, et al. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality[J]. Am J Obstet Gynecol, 2006, 194(5): 1311-1315.
[4]
ACOG practice bulletin No. 197: inherited thrombophilias in pregnancy[J]. Obstet Gynecol, 2018, 132(1): e18-e34.
[5]
Practice bulletin No.132: antiphospholipid syndrome[J]. Obstet Gynecol, 2012, 120(6): 1514-1521.
[6]
Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium (green-top guideline No.37a) [R]. Royal College of Obstetricians and Gynaecologists, 2015: 1-40.
[7]
Bowyer L. The confidential enquiry into maternal and child health (CEMACH). Saving mothers′ lives: reviewing maternal deaths to make motherhood safer 2003-2005. The seventh report of the confidential enquiries into maternal deaths in the UK[J]. Obstet Med, 2008, 1(1): 54.
[8]
Arya R. How I manage venous thromboembolism in pregnancy[J]. Br J Haematol, 2011, 153(6): 698-708.
[9]
刘丹霓,王晓东,周芷伊,等. 危重孕产妇管理与孕产妇死亡防控[J/CD]. 中华妇幼临床医学杂志(电子版), 2018, 14(1): 8-17.
[10]
Liew NC, Alemany GV, Angchaisuksiri P, et, al. Asian venous thromboembolism guidelines: updated recommendations for the prevention of venous thromboembolism[J]. Int Angiol, 2017, 36(1): 1-20.
[11]
Chan WS, Rey E, Kent NE, et al. Venous thromboembolism and antithrombotic therapy in pregnancy[J]. J Obstet Gynaecol Can, 2014, 36(6): 527-553.
[12]
Royal College of Obstetricians and Gynaecologists. Thromboembolic disease in pregnancy and the puerperium: acute management (green-top guideline No. 37b) [R]. Royal College of Obstetricians and Gynaecologists, 2015: 1-40.
[13]
ACOG practice bulletin No. 196 summary[J]. Obstet Gynecol, 2018, 132(1): 243-248.
[14]
McLintock C, Brighton T, Chunilal S, et al. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period[J]. Aust N Z J Obstet Gynaecol, 2012, 52(1): 14-22.
[15]
Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed: american college of chest physicians evidence-based clinical practice guidelines[J]. Chest, 2012, 141(2 Suppl): e691S-e736S.
[16]
Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th Ed: American college of chest physicians evidence-based clinical practice guidelines[J]. Chest, 2012, 141(2 Suppl): e419S-e3494S.
[17]
Linkins LA, Dans AL, Moores LK, et al. Treatment and prevention of heparin-induced thrombocytopenia, antithrombotic therapy and prevention of thrombosis, 9th Ed: american college of chest physicians evidence-based clinical practice guidelines[J]. Chest, 2012, 141(2 Suppl): e495S-e530S.
[18]
Esmon CT. Basic mechanisms and pathogenesis of venous thrombosis[J]. Blood Rev, 2009, 23(5): 225-229.
[19]
Bremme KA. Haemostatic changes in pregnancy[J]. Best Pract Res Clin Haematol, 2003, 16(2): 153-168.
[20]
Medcalf RL, Stasinopoulos SJ. The undecided serpin. The ins and outs of plasminogen activator inhibitor type 2[J]. FEBS J, 2005, 272(19): 4858-4867.
[21]
Jacobsen AF, Skjeldestad FE, Sandset PM. Ante- and postnatal risk factors of venous thrombosis: a hospital-based case-control study[J]. J Thromb Haemost, 2008, 6(6): 905-912.
[22]
郄明蓉,段瑞岐. 妇科术后患者发生静脉血栓的发病原因分析及防治[J/CD]. 中华妇幼临床医学杂志(电子版), 2014, 10(6): 723-727.
[23]
Pabinger I, Grafenhofer H, Kaider A, et al. Risk of pregnancy-associated recurrent venous thromboembolism in women with a history of venous thrombosis[J]. J Thromb Haemost, 2005, 3(5): 949-954.
[24]
De Stefano V, Martinelli I, Rossi E, et al. The risk of recurrent venous thromboembolism in pregnancy and puerperium without antithrombotic prophylaxis.[J]. Br J Haematol, 2006, 135(3): 386-391.
[25]
Bezemer ID, van der Meer FJ, Eikenboom JC, et al. The value of family history as a risk indicator for venous thrombosis[J]. Arch Intern Med, 2009, 169(6): 610-615.
[26]
Wu O, Robertson L, Twaddle S, et al. Screening for thrombophilia in high-risk situations: systematic review and cost-effectiveness analysis. The thrombosis: risk and economic assessment of thrombophilia screening (TREATS) study[J]. Health t Technol Assess, 2006, 10(11): 1-110.
[27]
Brenner B. Clinical management of thrombophilia-related placental vascular complications[J]. Blood, 2004, 103(11): 4003-4009.
[28]
Jacobsen AF, Skjeldestad FE, Sandset PM. Incidence and risk patterns of venous thromboembolism in pregnancy and puerperium-a register-based case-control study[J]. Am J Obstet Gynecol, 2008, 198(2): 233.e1-233.e7.
[29]
Liu SL, Liston RM, Joseph KS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term[J]. J De L′association Med Can, 2007, 176(4): 455-460.
[30]
Jacobsen AF, Drolsum A, Klow NE, et al. Deep vein thrombosis after elective cesarean section[J]. Thromb Res, 2004, 113(5): 283-288.
[31]
Lumbiganon P, Laopaiboon M, Gülmezoglu AM, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-2008[J]. Lancet, 2010, 375(9713): 490-499.
[32]
Chan WS, Dixon ME. The " ART" of thromboembolism: a review of assisted reproductive technology and thromboembolic complications[J]. Thromb Res, 2008, 121(6): 713-726.
[33]
Engbers MJ, Blom JW, Cushman M, et al. The contribution of immobility risk factors to the incidence of venous thrombosis in an older population[J]. J Thromb Haemost, 2014, 12(3): 290-296.
[34]
James A, Committee on Practice Bulletins—Obstetrics. Practice bulletin No. 123: thromboembolism in pregnancy[J]. Obstet Gynecol, 2011, 118(3): 718-729.
[35]
Bain E, Wilson A, Tooher R, et al. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period[J]. Cochrane Database Syst Rev, 2014(2): CD001689.
[36]
Brill-Edwards P, Ginsberg JS, Gent M, et al. Safety of withholding heparin in pregnant women with a history of venous thromboembolism. Recurrence of Clot in This Pregnancy Study Group[J]. N Engl J Med, 2000, 343(20): 1439-1444.
[1] Huanyan Liu, Yang Hua, Lingyun Jia, Xinyu Zhao, Beibei Liu. Lumen structure and hemodynamic characteristics of occluded internal carotid artery[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2023, 20(08): 809-815.
[2] Yanbo Ma, Yang Hua, Guimei Liu, Xiufeng Meng, Liping Cui. Risk factors for carotid atherosclerotic lesions in middle adults[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2023, 20(08): 822-826.
[3] Yingxiong Huang, Zi Ye, Peng Jiang, Hong Zhan, Chen Yao, Ji Cui. Clinical risk factors for transmural intestinal necrosis in acute mesenteric venous thrombosis[J]. Chinese Archives of General Surgery(Electronic Edition), 2023, 17(06): 413-421.
[4] Zaibo Zhang, Bingyu Wang, Zhikai Jiao, Bibo Tan. Risk factors for lower extremity deep venous thrombosis after gastric cancer surgery: A Meta-analysis[J]. Chinese Archives of General Surgery(Electronic Edition), 2023, 17(06): 475-480.
[5] Xu Tang, Bing Han, Wei Liu, Ruxing Chen. Analysis of risk factors for metachronous liver metastases after radical colorectal cancer surgery and construction of a predictive model[J]. Chinese Journal of Operative Procedures of General Surgery(Electronic Edition), 2024, 18(01): 16-20.
[6] Fangyuan Wu, Xia Sun, Changfeng Lin, Zhensheng Zhang. Risk factors of HBV-associated cirrhosis complicated with acute upper gastrointestinal bleeding[J]. Chinese Journal of Operative Procedures of General Surgery(Electronic Edition), 2024, 18(01): 45-47.
[7] Xuyuan Chen, Shiyun Luo, Wenzhong Li, Yi Li. Analysis of risk factors for wound healing difficulties after operative treatment of adenogenic anal fistula[J]. Chinese Journal of Operative Procedures of General Surgery(Electronic Edition), 2024, 18(01): 82-85.
[8] Yonghuan Mao, Hanwen Tong, Ji Miao, Xingzhou Wang, Xiaofei Shen, Chunzhao Yu. Analysis of risk factors and prediction model of parastomal hernia[J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2023, 17(06): 682-687.
[9] Mei Liao, Hongjun Zhang, Jieyang Jin, Yan Lyu, Jie Ren. Diagnostic value of bedside contrast-enhanced ultrasound for early hepatic artery thrombosis after liver transplantation[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2023, 12(06): 630-634.
[10] Chao Hou, Meichen Pan, Wenming Wu, Xingguang Huang, Xiang Li, Lingxue Cheng, Yuxuan Zhu, Wenbo Li. Risk factors of esophageal stricture after endoscopic submucosal dissection for early esophageal carcinoma and intraepithelial neoplasia[J]. Chinese Journal of Digestion and Medical Imageology(Electronic Edition), 2023, 13(06): 383-387.
[11] Menggui Lu, Bin Huang, Qiulin Li, Yuanmei He. Risk factors for multiple organ dysfunction syndrome in patients with bee sting injury[J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(9): 1010-1015.
[12] Da Li, Daya Zhang, Runxiang Chen, Xiaodong Zhang, Shimei Huang, Chen Chen, fan Zeng, Shiju Chen, Feihu Bai. Epidemiological characteristics and risk factors of Helicobacter pylori infection in Dongfang city of Hainan province[J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(08): 858-864.
[13] Ke Meng, Yan Li, Jingshuang Yan, Bin Yan. Risk factors for prolonged gastric transit time in capsule endoscopy[J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(06): 671-675.
[14] Yanli Yang, Yu Chen, Ruochen Zhao, Wei Du, Haijuan Ma, Ke Xu, Liyun Zhang. Bloodstream infection in patients with systemic lupus erythematosus: risk factors and bacteriological analysis[J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(06): 694-699.
[15] Peipei Sun, Erming Zhang, Yanwei Shi, Chunyan Zhao, Pingping Song, Shuo Zhang, Ke Zhang, Yujiao Zhou, Can Zhao, Wei Yan, Rongju Wu, Liping Song, Weian Guo, Shitou Ma, Xinhua An, Caoxin Bao, Pingchao Xiang. Prevalence and risk factors of chronic obstructive pulmonary disease in residents aged 40 years and above in Shijingshan district of Beijing[J]. Chinese Journal of Clinicians(Electronic Edition), 2023, 17(06): 711-719.
Viewed
Full text


Abstract