Moores Lisa, Bilello Kathryn L, Murin Susan
Critical Care Medicine, Department of Internal Medicine, Uniformed Services University of Health Sciences and Walter Reed Army Medical Center, 6900 Georgia Avenue Northwest, Washington, DC 20307-5001, USA.
Clin Chest Med. 2004 Jun;25(2):281-97. doi: 10.1016/j.ccm.2004.01.013.
At least 250,000 episodes of VTE leading to hospitalization or death are estimated to occur in the United States each year. A number of clinical and demographic risk factors for VTE are recognized,with the latter including both age and race. Overall,the incidence of VTE does not appear to vary significantly by sex, as evidenced by a lack of consistency in the magnitude and even direction of effect of sex in a variety of epidemiologic studies of varying design. Several studies have shown a higher incidence among women than men during childbearing age. The issue of a gender effect on the natural history of VTE has not been well studied. The main influence of gender on VTE is the relationship between female gender and several well-recognized clinical risk factors for VTE:oral contraceptive use, hormone replacement therapy, estrogen receptor modulator therapy, and pregnancy. Hormonal therapies are associated with a twofold to threefold increase in VTE incidence. Risk is higher with some formulations than others, during initial use, and among women who are obese, smoke, or have one of several forms of heritable thrombophilia. The pregnant state is associated with a threefold to fivefold increase in VTE risk, and thromboembolism is a major cause of peripartum death. Heritable thrombophilias are also important co-determinants of VTE risk in pregnancy. The mechanisms through which pregnancy and hormonal therapies increase VTE risk have not been definitively established, but hormonal effects on levels of coagulation and anticoagulation factors likely play a role. Venous compression and venous injury also contribute to increased risk during pregnancy and the puerperium. Approaches to diagnosis of VTE in the pregnant woman are largely the same as in the nonpregnant patient, but special treatment considerations do apply. Warfarin is embryopathic, particularly between the 6th and 12th weeks of pregnancy, and should be avoided in favor or heparin or low-molecular weight heparin when treatment of the pregnant woman is necessary. Guidelines have been published to assist the clinician in decision making about prophylaxis of pregnant women at increased risk or pregnancy-related or post-partum VTE.
据估计，美国每年至少有25万例导致住院或死亡的静脉血栓栓塞（VTE）事件发生。人们已经认识到一些导致VTE的临床和人口统计学风险因素，后者包括年龄和种族。总体而言，VTE的发病率似乎不因性别而有显著差异，各种设计不同的流行病学研究中，性别影响的程度甚至方向缺乏一致性就证明了这一点。几项研究表明，育龄期女性的发病率高于男性。性别对VTE自然病程的影响问题尚未得到充分研究。性别对VTE的主要影响在于女性与几种公认的VTE临床风险因素之间的关系：口服避孕药的使用、激素替代疗法、雌激素受体调节剂疗法和怀孕。激素疗法会使VTE发病率增加两倍至三倍。某些制剂的风险高于其他制剂，在初始使用期间，以及在肥胖、吸烟或患有几种遗传性血栓形成倾向之一的女性中风险更高。怀孕状态会使VTE风险增加三倍至五倍，血栓栓塞是围产期死亡的主要原因。遗传性血栓形成倾向也是孕期VTE风险的重要共同决定因素。怀孕和激素疗法增加VTE风险的机制尚未明确确定，但激素对凝血和抗凝因子水平的影响可能起了作用。静脉受压和静脉损伤也会导致孕期和产褥期风险增加。孕妇VTE的诊断方法与非孕妇基本相同，但确实需要特殊的治疗考虑。华法林具有胚胎毒性，尤其是在怀孕第6至12周之间，在必要时治疗孕妇时应避免使用，而应选用肝素或低分子量肝素。已经发布了指南，以协助临床医生对VTE风险增加的孕妇或与怀孕相关或产后VTE进行预防决策。
