Malik Humza T, Sepehripour Amir H, Shipolini Alex R, McCormack David J
Department of Cardiothoracic Surgery, The London Chest Hospital, London, UK.
Interact Cardiovasc Thorac Surg. 2012 Sep;15(3):484-8. doi: 10.1093/icvts/ivs178. Epub 2012 May 25.
A best evidence topic was written according to a structured protocol in order to identify the mode of anticoagulation that has the best safety profile for both the mother and the foetus in pregnant patients with mechanical prosthetic heart valves. A total of 281 papers were identified using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The reported measures were foetal mortality, maternal mortality, congenital abnormalities and embryopathy, and maternal thromboembolic and haemorrhagic complications. The medical orthodoxy has warned of the combination of oral anticoagulation and pregnancy due to the well-documented warfarin embryopathy. Yet only one of the reported papers identified a greater incidence of foetal aberrations among warfarin use, with the highest reported rate being 6.4% and two of the assessed papers reporting no embryopathy at all. Foetal mortality with oral anticoagulation use ranged from 1.52 to 76%. All reported publications demonstrated a superior maternal outcome with warfarin use, with a range of thromboembolic events from 0 to 10% in comparison with 4 to 48% where heparin was used. Thus, it is concluded that warfarin is a more durable anticoagulant with a better maternal outcome despite it carrying a greater foetal risk. Although, in contrast to previous teaching, the risks of embryopathy are not the major drawback of oral anticoagulation. Heparin is consistently less effective, but may be preferred for the superior foetal outcome. Heparin usage during the first trimester reduces the foetal risk but is still associated with an adverse maternal outcome. While the focus for clinicians looking after pregnant women with mechanical heart valves may be to prevent maternal thromboembolic complications, the overriding concern for many women is to avoid any harm to their unborn child, even when this places their health at risk. Thus women with mechanical heart valves must be fully informed of the risks involved with different anticoagulation for an informed decision to be made.
根据结构化方案撰写了一个最佳证据主题，以确定在患有机械人工心脏瓣膜的孕妇中，哪种抗凝方式对母亲和胎儿具有最佳的安全性。通过报告的检索共识别出281篇论文，其中8篇代表回答临床问题的最佳证据。作者、日期、期刊、研究类型、人群、主要结局指标和结果均列于表格中。报告的指标包括胎儿死亡率、孕产妇死亡率、先天性异常和胚胎病，以及孕产妇血栓栓塞和出血并发症。医学正统观念因有充分记录的华法林胚胎病而警告口服抗凝药与妊娠的联合使用。然而，在所报告的论文中，只有一篇发现使用华法林时胎儿畸形的发生率更高，报告的最高发生率为6.4%，而两篇评估论文根本没有报告胚胎病。使用口服抗凝药时胎儿死亡率在1.52%至76%之间。所有报告的出版物都表明使用华法林时孕产妇结局更好，血栓栓塞事件发生率在0%至10%之间，而使用肝素时为4%至48%。因此，得出的结论是，尽管华法林对胎儿的风险更大，但它是一种更持久的抗凝剂，孕产妇结局更好。尽管与以前的教导相反，胚胎病的风险并非口服抗凝的主要缺点。肝素一直效果较差，但可能因对胎儿结局更好而更受青睐。孕早期使用肝素可降低胎儿风险，但仍与不良的孕产妇结局相关。虽然照顾患有机械心脏瓣膜的孕妇的临床医生的重点可能是预防孕产妇血栓栓塞并发症，但许多女性最关心的是避免对未出生的孩子造成任何伤害——即使这会使她们自己的健康处于危险之中。因此，必须让患有机械心脏瓣膜的女性充分了解不同抗凝方法所涉及的风险，以便做出明智的决定。
