Greer I A
Department of Obstetrics and Gynaecology, Glasgow Royal Infirmary, University of Glasgow, UK.
Haemostasis. 1998;28 Suppl 3:22-34. doi: 10.1159/000022402.
Pulmonary thromboembolism remains a major cause of maternal death in the Western world. The frequency of antepartum deaths, including deaths in the first and second trimester, which can be associated with early pregnancy problems such as hyperemesis, is similar in number to the deaths occurring following delivery. Risk factors for deep vein thrombosis have been identified and include age > 35 years, operative delivery (particularly emergency Caesarean section), obesity and a personal or family history of thrombosis or thrombophilia. These risk factors should be used to guide administration of thromboprophylaxis during both pregnancy and the post-partum period, particularly after Caesarean section. Specific consideration towards thromboprophylactic agents is required. Warfarin crosses the placenta, is a known teratogen when used in early pregnancy and can also be associated with bleeding problems in the foetus, particularly at the time of delivery. Thus, warfarin has a limited use in the antenatal period and is usually only employed in patients such as those with artificial heart valves who require long-term anticoagulation. However, as warfarin does not cross the breast in any significant amount, it is suitable during breast feeding. In contrast, heparin does not cross the placenta or the breast therefore foetal problems are not associated with this treatment. However, heparin can be associated with problems such as heparin-induced osteoporosis, allergy and heparin-induced thrombocytopenia. The risk of some of these complications can be reduced by the use of low-molecular-weight heparins. When venous thromboembolism is suspected in pregnancy, it is critically important to obtain an objective diagnosis. This will include real-time or duplex ultrasound scan of the legs to elaborate the venous system, ventilation perfusion lung scan and, occasionally, venography. Treatment of established venous thromboembolism is similar to that in the non-pregnant patient and it is likely that low-molecular-weight heparins will play a major role in thromboprophylaxis in the future.
在西方世界，肺血栓栓塞仍然是孕产妇死亡的主要原因。产前死亡（包括孕早期和孕中期死亡）的发生率与分娩后死亡的数量相近，产前死亡可能与诸如妊娠剧吐等早孕问题有关。已确定的深静脉血栓形成的危险因素包括年龄>35岁、手术分娩（尤其是急诊剖宫产）、肥胖以及个人或家族血栓形成或血栓形成倾向史。这些危险因素应用于指导孕期和产后，尤其是剖宫产后的血栓预防措施的实施。需要对血栓预防药物进行特殊考虑。华法林可穿过胎盘，在孕早期使用时是已知的致畸剂，还可能与胎儿出血问题有关，尤其是在分娩时。因此，华法林在孕期的使用有限，通常仅用于需要长期抗凝的患者，如有人工心脏瓣膜的患者。然而，由于华法林不会大量进入乳汁，因此在母乳喂养期间适用。相比之下，肝素不会穿过胎盘或进入乳汁，因此这种治疗与胎儿问题无关。然而，肝素可能与肝素诱导的骨质疏松症、过敏和肝素诱导的血小板减少症等问题有关。使用低分子量肝素可降低其中一些并发症的风险。当怀疑妊娠合并静脉血栓栓塞时，获得客观诊断至关重要。这将包括对腿部进行实时或双功超声扫描以检查静脉系统、通气灌注肺扫描，偶尔还包括静脉造影。已确诊的静脉血栓栓塞的治疗与非妊娠患者相似，低分子量肝素未来可能在血栓预防中发挥主要作用。
