2012—2018年扬州市妇幼保健院产后静脉血栓的分析

任卫娟 张静 冯永 黄靖冰 肖敏 张慧妍

[摘要] 目的 探討产后静脉血栓的发生率、危险因素、发生时间、临床表现及诊断，避免过渡治疗。

方法 对2012年1月—2018年12月扬州大学附属医院扬州市妇幼保健院（以下简称“我院”）收治47 948名孕产妇中5例产后发生静脉血栓者的临床资料进行回顾性分析。按2015年4月英国皇家妇产科医师学会发布了关于降低妊娠期及产褥期静脉血栓栓塞疾病发生风险的诊疗指南中标准进行评分，并且比较患者分娩前、血栓发现时凝血功能的差异。同时与我院2018年晚期妊娠无并发症及合并症的正常孕妇6525名的分娩前凝血功能进行比较。

结果 5例患者均经综合性医院及我院彩色多普勒超声或CT肺动脉造影确诊，深静脉血栓3例，浅静脉血栓2例，深静脉血栓中1例肺栓塞。近6年发生率为（1.04～1.07）/万。5例患者均发生在产后1周内，5例患者中1例危险因素评分为4分，1例患者危险因素评分为3分，3例患者危险因素评分为1分。有下肢疼痛症状患者4例。5例患者分娩前、血栓发现时凝血功能比较，差异无统计学意义（P > 0.05），但与6525名正常孕妇的分娩前凝血功能比较，5例患者分娩前凝血酶原时间、凝血酶时间短于正常孕妇（P < 0.05），活化部分凝血酶原时间、国际标准化比值、纤维蛋白原、D-二聚体比较，差异无统计学意义（P > 0.05）。经抗凝治疗，5例患者均痊愈。

结论 产后静脉血栓发病率低，分娩前PT、TT明显缩短及分娩后出现下肢疼痛症状，警惕静脉血栓的发生，一旦发生及早治疗。

[关键词] 静脉血栓症;浅静脉栓塞;深静脉血栓;肺栓塞;产后

[中图分类号] R473.71          [文献标识码] A          [文章编号] 1673-7210（2020）07（c）-0121-04

Analysis of postpartum venous thrombosis in Yangzhou Maternal and Child Gare Service Centre from 2012 to 2018

REN Weijuan1*   ZHANG Jing2*   FENG Yong3   HUANG Jingbing2   XIAO Min2   ZHANG Huiyan1

1.Department of Obstetrics and Gynecology， Wuxi Rich Women and Children′s Hospital， Jiangsu Province， Wuxi   214002， China; 2.Department of Obstetrics and Gynecology， Yangzhou Maternal and Child Care Service Centre， Affilated Hospital of Yangzhou University， Jiangsu Province， Yangzhou   225002， China; 3.Information Section， Yangzhou Maternal and Child Care Service Centre， Affilated Hospital of Yangzhou University， Jiangsu Province， Yangzhou   225002， China

[Abstract] Objective To investigate the incidence， risk factors， occurrence time， clinical manifestations and diagnosis of postpartum venous thrombosis， and to avoid overtreatment. Methods The clinical data of five cases of postpartum venous thrombosis in 47 948 pregnant women admitted to Yangzhou Maternal and Child Care Service Centre （hereinafter referred to as “our hospital”） from January 2012 to December 2018 were retrospectively analyzed. The score according to the criteria set out in the April 2015 Royal College of Obstetricians and Gynaecologists guidelines on reducing the risk of venous thromboembolism during pregnancy and puerperium， the differences in clotting function before delivery and at the time of thrombus discovery were compared. Meanwhile， the coagulation function was compared with that of 6525 normal pregnant women without complications and complications in the third trimester pregnancy in our hospital in 2018. Results All five cases were confirmed by color doppler ultrasonography or CT pulmonary angiography in general hospitals and our hospital， including three cases of deep vein thrombosis， two cases of superficial vein thrombosis， and one case of deep vein thrombosis. In recent six years， the incidence was （1.04-1.07）/10 000. All of the five cases occurred within one week after delivery. Among the five patients， one case had a risk factor score of four， one case had a risk factor score of three， and three cases had a risk factor score of one. Four cases had lower extremity pain symptoms. Comparison of coagulation function between the five patients before delivery and at the time of thrombosis discovery showed no statistically significant difference （P > 0.05）. However， compared with the coagulation function before delivery of 6525 normal pregnant women， the prothrombin time （PT） and thrombin time （TT） of five cases before delivery were shorter than that of normal pregnant women （P < 0.05）. There were no significant differences in activated partial prothrombin time， international standardized ratio， fibrinogen and D-dimer （P > 0.05）. After anticoagulant therapy， all the five cases recovered. Conclusion The incidence of postpartum venous thrombosis is low， PT and TT before delivery are shortened significantly and lower limb pain symptoms appear after delivery.

低分子肝素、肝素是产后的首选抗凝治疗，必要时可加用华法林，产后华法林对母乳喂养是安全的[2，20]。至于抗凝持续时间目前指南推荐至少到产后6周，停抗凝药物前，应由血管外科医师进行评估，以决定是否需要进一步治疗[21]。

综上所述，产后静脉血栓发病率低，但发生都有一定危险因素，目前尚不能提供良好的筛查指标。产妇出现下肢疼痛症状以及分娩前PT、TT明显缩短，产后形成静脉血栓明显增高。彩色多普勒超声是最简便的诊断方法，低分子肝素、肝素是产后的首选抗凝治疗。避免过渡治疗会造成患者经济负担及出血风险，国内需要进行流行病学数据分析，制订出诊疗指南或共识。

[参考文献]

[1]  朱燕，陈奕.妊娠相关血栓栓塞性疾病的风险评估及预防研究现状[J].中华医学杂志，2018，98（23）：1893-1896.

[2]  刘真，孙瑜.妊娠期及产褥期静脉血栓栓塞疾病诊治：2015英国皇家妇产科医师学会指南解读[J].中华围产医学杂志，2017，20（12）：841-845.

[3]  Royal College of Obstetricians and Gynaecologists. Thromboembolic Disease in Pregnancy and the Puerperium：Acute Management. Green-top Guideline No.37a[S/OL].（2015-04-30）[2017-07-15]. https：//www. rcog. org.uk/globalassets/ documents/guidelines/gtg-37b.pdf.

[4]  王晨，杨慧霞.2018年美国妇产科医师学会关于“妊娠期血栓栓塞症”的新推荐[J].中华围产医学杂志，2019， 22（2）：139-140.

[5]  Abdul SA，Tata LJ，Grainge MJ，et al. The incidence of first venous thromboembolism in and around pregnancy using linked primary and secondary care data：a population based cohort study from England and comparative meta-analysis [J]. PLoS One，2013，8（7）：e70310.

[6]  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-e7.

[7]  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.

[8]  Chan LY，Tam WH，Lau TK. Venous thromboembolism in pregnancy Chinese women [J]. Obstet Gynecol，2001，98（3）：471-475.

[9]  Abdul SA，Grainge MJ，West J，et al. Impact of risk factors on the timing of first postpartum venous thromboembolism：a population-based cohort study from England [J]. Blood，2014，124（18）：2872-2880.

[10]  Middeldorp S. Thrombosis in women：what are the knowledge gaps in 2013 [J]. J Thromb Haemost，2013，11（Suppl 1）：180-191.

[11]  Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. Green-Top Guideline No .37a [EB/OL]. London：RCOG.（2015-04-30）[2018-05-20]. https：//www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf.

[12]  D′Alton ME ，Friedman AM，Smiley RM，et al. National partnership for maternal safety：consensus bundle on venous thromboembolism [J]. Obstet Gynecol，2016，128（4）：688-698.

[13]  方婧，戴毅敏，顧宁，等.通过41例产科静脉血栓评价不同指南的推荐差异[J].中国妇幼健康研究，2019，30（8）：941-945.

[14]  Caprini JA. Risk assessment as a guide to thrombosis prophylaxis [J]. Curr Opin Pulm Med，2010，16（5）：448-452.

[15]  赵芳，刘佳宜，潘晓玉.妊娠相关性静脉血管栓塞性疾病6例分析及文献复习[J].中日友好医院学报，2018， 32（5）：259-262，266.

[16]  陈奕，朱燕.妊娠期及产褥期静脉血栓栓塞症的诊断与治疗[J].中华妇产科杂志，2018，53（9）：635-639.

[17]  邵素臣，俞昌明.彩色多普勒超声在下肢深静脉血栓诊断中的临床应用[J].医学影像学杂志，2017，27（4）：783-786.

[18]  徐建云，周梦林，何玉花，等.高龄产妇分娩前后D-二聚体水平变化特点及其临床意义[J].中华医学杂志，2019，99（35）：2768-2772.

[19]  李帅，吕时铭，汤杰英.浙江地区汉族孕产妇D-二聚体参考区间的建立及应用[J].中华检验医学杂志，2011，4（7）：580-585.

[20]  韦永刚，付德安.低分子肝素联合华法林治疗次大面积肺栓塞患者的临床观察[J].中国医学创新，2018，15（20）：54-58.

[21]  赵鹏，蔺莉，栾景源，等.妊娠及产褥期静脉血栓栓塞的危险因素评估及处理策略[J].中华围产医学杂志，2019， 22（6）：429-431.

（收稿日期：2019-10-29）