Rath W
Gynäkologie und Geburtshilfe, Universitätsklinikum Aachen, Wendlingweg 2, Aachen.
Z Geburtshilfe Neonatol. 2010 Dec;214(6):217-28. doi: 10.1055/s-0030-1269861. Epub 2011 Jan 4.
Venous thromboembolism (VTE) is one of the leading causes of maternal deaths worldwide. Mortality and morbidity of VTE are potentially preventable, since two-thirds of these women have identifiable risk factors and may benefit from appropriate thromboprophylaxis. Individual and careful assessment of the personal and family history as well as the assessment of pre-existing and new-onset/transient risk factors during pregnancy and after delivery are mandatory for an effective prevention of VTE. Current guidelines (American College of Chest Physicians 2008, AWMF-Guideline 003/001 2009 and the Royal College Guideline No. 37 2009) provide practical recommendations for risk stratification regarding low, intermediate and high risk conditions. At high risk are women with previous VTE or thrombophilia. Corresponding to risk stratification grade C recommendations have been made for VTE prophylaxis during pregnancy and the puerperium. Prophylaxis with low molecular weight heparin (LMWH) should begin as early in pregnancy as practical. In women with lower risk mobilisation, avoidance of dehydration and mechanical methods (e. g., graduated compressive stockings) are sufficient. After delivery women with intermediate risk should be given LMWH for 7 days, women at high risk for 6 weeks or as long as additional risk factors are present. All women who have additional risk factors and who have had an elective Caesarean section should receive prophylactic LMWH for 7 days as should also all women who have had a Caesarean section in labour or an emergency Caesarean section. At the onset of labour, in case of any vaginal bleeding, prior to induction of labour or 12 h before an elective Caesarean section, antenatal LMWH prophylaxis should be discontinued, LMWH prophylaxis can be continued for 4-6 h after vaginal and for 6-12 h after Caesarean delivery when the women do not have an increased risk of haemorrhage. Current guidelines recommend than LMWH are the agents of choice for antenatal thromboprophylaxis; in comparison to unfractionated heparin, LMWH are associated with a substantially lower risk of heparin-induced thrombocytopenia and osteoporosis. Both oral anticoagulants and heparin are safe when breast-feeding.
静脉血栓栓塞症（VTE）是全球孕产妇死亡的主要原因之一。VTE的死亡率和发病率具有潜在的可预防性，因为三分之二的此类女性具有可识别的风险因素，可能受益于适当的血栓预防措施。对个人和家族病史进行个体化且仔细的评估，以及对孕期和产后既有的和新出现/短暂的风险因素进行评估，对于有效预防VTE至关重要。当前的指南（美国胸科医师学会2008年版、德国医学质量与效率委员会指南003/001 2009年版以及英国皇家妇产科医师学院指南第37号2009年版）针对低、中、高风险情况的风险分层提供了实用建议。既往有VTE或血栓形成倾向的女性属于高风险人群。对应风险分层，已针对孕期和产褥期的VTE预防提出了C级建议。低分子量肝素（LMWH）预防应在孕期尽早开始。对于风险较低的女性，活动、避免脱水以及采用机械方法（如分级压力弹力袜）就足够了。产后，中度风险的女性应给予LMWH治疗7天，高风险女性治疗6周或直至存在其他风险因素。所有具有其他风险因素且接受择期剖宫产的女性，以及所有经阴道分娩或急诊剖宫产的女性，均应接受预防性LMWH治疗7天。临产时，若有任何阴道出血、引产之前或择期剖宫产术前12小时，应停止产前LMWH预防；若女性无出血风险增加，阴道分娩后LMWH预防可继续4 - 6小时，剖宫产术后可继续6 - 12小时。当前指南推荐LMWH是产前血栓预防的首选药物；与普通肝素相比，LMWH导致肝素诱导的血小板减少症和骨质疏松症的风险显著更低。口服抗凝剂和肝素在母乳喂养时都是安全的。
