妊娠相关静脉血栓栓塞症风险评估模型研究进展

doi:10.12280/gjfckx.20220687

摘要/Abstract

摘要：

妊娠相关静脉血栓栓塞症（pregnancy associated venous thromboembolism，PA-VTE）包括妊娠期和产褥期发生的静脉系统的血栓形成疾病，由深静脉血栓形成（deep vein thrombosis，DVT）和肺栓塞（pulmonary embolism，PE）组成的PA-VTE是发达国家孕产妇发病和死亡的主要原因。采用高效、便捷的风险评估模型评估PA-VTE的发病风险并进行分级预防是目前多个国家推荐的主要措施，但由于各国医学水平、经济发展和传统习惯的不同，各国相继开发风险评估模型或根据实际情况对其他国家的风险评估模型进行改良，进而对妊娠期及产褥期VTE风险进行个体化评估，并实施相应的血栓预防策略。通过回顾国内外的PA-VTE风险评估模型，旨在为我国进一步建立孕产妇的VTE防治指南提供依据，为产科医务工作者制定出适合我国产科人群的VTE风险评估模型提供参考。

关键词: 妊娠, 静脉血栓栓塞, 比例危险度模型, 危险因素, 预防卫生服务

Abstract:

Pregnancy-associated venous thromboembolism (PA-VTE) consists of thrombotic diseases of the venous system occurring during pregnancy and puerperium, consisting of deep vein thrombosis (DVT) and pulmonary embolism(PE) is the leading cause of maternal morbidity and mortality in developed countries. The use of efficient and convenient risk assessment model to assess the risk of PA-VTE and carry out hierarchical prevention is the main measure recommended by many countries. But, due to the differences medical levels, economic development and traditional practices of different countries, many countries have successively developed PA-VTE risk assessment model or modified the risk assessment model in other countries according to the actual situation, so that to assess the risk of VTE during pregnancy and puerperium individually and implement corresponding thrombus prevention strategies. By reviewing the PA-VTE risk assessment model in China and abroad, this study aims to provide a basis for the further establishment of VTE prevention and treatment guidelines for pregnant women in China, and provide a reference for obstetric medical workers to formulate VTE risk assessment model suitable for the obstetric population in China.

Key words: Pregnancy, Venous thromboembolism, Proportional hazards models, Risk factors, Preventive health services

陈秋和, 张林, 任郁, 胡雅毅. 妊娠相关静脉血栓栓塞症风险评估模型研究进展[J]. 国际妇产科学杂志, 2023, 50(1): 74-81.

CHEN Qiu-he, ZHANG Lin, REN Yu, HU Ya-yi. Research Progress of Risk Assessment Models of Pregnancy Associated Venous Thromboembolism[J]. Journal of International Obstetrics and Gynecology, 2023, 50(1): 74-81.

图/表 1

参考文献 40

[1]	Zhang W, Shen J, Sun JL. Risk scores, prevention, and treatment of maternal venous thromboembolism[J]. World J Clin Cases, 2020, 8(11):2210-2218. doi: 10.12998/wjcc.v8.i11.2210. doi: 10.12998/wjcc.v8.i11.2210 pmid: 32548151
[2]	James AH. Thrombosis in pregnancy and maternal outcomes[J]. Birth Defects Res C Embryo Today, 2015, 105(3):159-166. doi: 10.1002/bdrc.21106. doi: 10.1002/bdrc.21106
[3]	Heit JA, Kobbervig CE, James AH, et al. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study[J]. Ann Intern Med, 2005, 143(10):697-706. doi: 10.7326/0003-4819-143-10-200511150-00006. doi: 10.7326/0003-4819-143-10-200511150-00006 pmid: 16287790
[4]	Kourlaba G, Relakis J, Kontodimas S, et al. A systematic review and meta-analysis of the epidemiology and burden of venous thromboembolism among pregnant women[J]. Int J Gynaecol Obstet, 2016, 132(1):4-10. doi: 10.1016/j.ijgo.2015.06.054. doi: 10.1016/j.ijgo.2015.06.054 pmid: 26489486
[5]	Bitsadze V, Khizroeva J, Elalamy I, et al. Venous thrombosis risk factors in pregnant women[J]. J Perinat Med, 2020 Oct 26:jpm-2020-0011. doi: 10.1515/jpm-2020-0011. doi: 10.1515/jpm-2020-0011
[6]	Friedman AM, Ananth CV. Obstetrical venous thromboembolism: Epidemiology and strategies for prophylaxis[J]. Semin Perinatol, 2016, 40(2):81-86. doi: 10.1053/j.semperi.2015.11.011. doi: 10.1053/j.semperi.2015.11.011 pmid: 26742600
[7]	Lindqvist PG, Kublikas M, Dahlbäck B. Individual risk assessment of thrombosis in pregnancy[J]. Acta Obstet Gynecol Scand, 2002, 81(5):412-416. doi: 10.1034/j.1600-0412.2002.810507.x. doi: 10.1034/j.1600-0412.2002.810507.x
[8]	Lindqvist PG, Hellgren M. Obstetric thromboprophylaxis: the Swedish guidelines[J]. Adv Hematol, 2011, 2011:157483. doi: 10.1155/2011/157483. doi: 10.1155/2011/157483
[9]	Lindqvist PG, Torsson J, Almqvist A, et al. Postpartum thromboembolism: severe events might be preventable using a new risk score model[J]. Vasc Health Risk Manag, 2008, 4(5):1081-1087. doi: 10.2147/vhrm.s2831. doi: 10.2147/vhrm.s2831 pmid: 19183756
[10]	Dargaud Y, Rugeri L, Ninet J, et al. Management of pregnant women with increased risk of venous thrombosis[J]. Int J Gynaecol Obstet, 2005, 90(3):203-207. doi: 10.1016/j.ijgo.2005.05.003. doi: 10.1016/j.ijgo.2005.05.003
[11]	Dargaud Y, Rugeri L, Vergnes MC, et al. A risk score for the management of pregnant women with increased risk of venous thromboembolism: a multicentre prospective study[J]. Br J Haematol, 2009, 145(6):825-835. doi: 10.1111/j.1365-2141.2009.07698.x. doi: 10.1111/j.1365-2141.2009.07698.x
[12]	Dargaud Y, Rugeri L, Fleury C, et al. Personalized thromboprophylaxis using a risk score for the management of pregnancies with high risk of thrombosis: a prospective clinical study[J]. J Thromb Haemost, 2017, 15(5):897-906. doi: 10.1111/jth.13660. doi: 10.1111/jth.13660 pmid: 28231636
[13]	Chauleur C, Gris JC, Laporte S, et al. Use of the Delphi method to facilitate antithrombotics prescription during pregnancy[J]. Thromb Res, 2010, 126(2):88-92. doi: 10.1016/j.thromres.2010.01.012. doi: 10.1016/j.thromres.2010.01.012 pmid: 20153880
[14]	Chauleur C, Quenet S, Varlet MN, et al. Feasibility of an easy-to-use risk score in the prevention of venous thromboembolism and placental vascular complications in pregnant women: a prospective cohort of 2736 women[J]. Thromb Res, 2008, 122(4):478-484. doi: 10.1016/j.thromres.2007.12.020. doi: 10.1016/j.thromres.2007.12.020 pmid: 18280547
[15]	Chauleur C, Gris JC, Laporte S, et al. Benefit of Risk Score-Guided Prophylaxis in Pregnant Women at Risk of Thrombotic Events: A Controlled Before-and-After Implementation Study[J]. Thromb Haemost, 2018, 118(9):1564-1571. doi: 10.1055/s-0038-1668524. doi: 10.1055/s-0038-1668524
[16]	Chau C, Campagna J, Vial M, et al. Use of a personalized iterative score to evaluate risk of venous thromboembolism during pregnancy and puerperium[J]. Int J Gynaecol Obstet, 2019, 144(3):277-282. doi: 10.1002/ijgo.12754. doi: 10.1002/ijgo.12754 pmid: 30578681
[17]	Testa S, Passamonti SM, Paoletti O, et al. The "Pregnancy Health-care Program" for the prevention of venous thromboembolism in pregnancy[J]. Intern Emerg Med, 2015, 10(2):129-134. doi: 10.1007/s11739-014-1111-6. doi: 10.1007/s11739-014-1111-6 pmid: 25078669
[18]	Schoenbeck D, Nicolle A, Newbegin K, et al. The use of a scoring system to guide thromboprophylaxis in a high-risk pregnant population[J]. Thrombosis, 2011, 2011:652796. doi: 10.1155/2011/652796. doi: 10.1155/2011/652796
[19]	Cantwell R, Clutton-Brock T, Cooper G, et al. Saving Mothers′ Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom[J]. BJOG, 2011, 118(Suppl 1):1-203. doi: 10.1111/j.1471-0528.2010.02847.x. doi: 10.1111/j.1471-0528.2010.02847.x
[20]	Royal College of Obstetricinas and Gynecologists. Reducing the risk of venous thromboembolism during pregnancy and the puerperium[EB/OL]. Green-top Guideline No.37a, 2015. https://scholar.google.com/scholar_lookup?title=Green-top+guideline+No.+37A&publication_ year=2015&.
[21]	刘彩云, 刘娇兰, 华海红. RCOG血栓风险评估模型在产妇静脉血栓栓塞症中的预防价值[J]. 国际生殖健康/计划生育杂志, 2016, 35(6):473-475.
[22]	Sultan AA, West J, Grainge MJ, et al. Development and validation of risk prediction model for venous thromboembolism in postpartum women: multinational cohort study[J]. BMJ, 2016, 355:i6253. doi: 10.1136/bmj.i6253. doi: 10.1136/bmj.i6253
[23]	Ban L, Abdul Sultan A, West J, et al. External validation of a model to predict women most at risk of postpartum venous thromboembolism: Maternity clot risk[J]. Thromb Res, 2021, 208:202-210. doi: 10.1016/j.thromres.2021.05.020. doi: 10.1016/j.thromres.2021.05.020 pmid: 34120750
[24]	Shang MM, Yan R, Wang XL, et al. Comparison of 2013 and 2009 versions of Caprini risk assessment models for predicting VTE in Chinese cancer patients: a retrospective study[J]. J Thromb Thrombolysis, 2020, 50(2):446-451. doi: 10.1007/s11239-020-02038-2. doi: 10.1007/s11239-020-02038-2
[25]	Cronin M, Dengler N, Krauss ES, et al. Completion of the Updated Caprini Risk Assessment Model (2013 Version)[J]. Clin Appl Thromb Hemost, 2019, 25:1076029619838052. doi: 10.1177/1076029619838052. doi: 10.1177/1076029619838052
[26]	Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J]. Chest, 2012, 141(2 Suppl):e227S-e277S. doi: 10.1378/chest.11-2297. doi: 10.1378/chest.11-2297
[27]	Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J]. Chest, 2012, 141(2 Suppl):e195S-e226S. doi: 10.1378/chest.11-2296. doi: 10.1378/chest.11-2296
[28]	Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J]. Chest, 2012, 141(2 Suppl):e278S-e325S. doi: 10.1378/chest.11-2404. doi: 10.1378/chest.11-2404
[29]	Tadesse TA, Kedir HM, Fentie AM, et al. Venous Thromboembolism Risk and Thromboprophylaxis Assessment in Surgical Patients Based on Caprini Risk Assessment Model[J]. Risk Manag Healthc Policy, 2020, 13:2545-2552. doi: 10.2147/RMHP.S272852. doi: 10.2147/RMHP.S272852
[30]	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. doi: 10.23736/S0392-9590.16.03765-2. doi: 10.23736/S0392-9590.16.03765-2 pmid: 27606807
[31]	黄思语, 李威, 殷艳, 等. RCOG及Caprini评估模型预测产科住院患者静脉血栓栓塞症风险的效果研究[J]. 中国病案, 2020, 21(8):93-95. doi: 10.3969/j.issn.1672-2566.2020.08.033. doi: 10.3969/j.issn.1672-2566.2020.08.033
[32]	Barbar S, Noventa F, Rossetto V, et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score[J]. J Thromb Haemost, 2010, 8(11):2450-2457. doi: 10.1111/j.1538-7836.2010.04044.x. doi: 10.1111/j.1538-7836.2010.04044.x pmid: 20738765
[33]	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. doi: 10.1097/AOG.0000000000001579. doi: 10.1097/AOG.0000000000001579 pmid: 27607857
[34]	Tran JP, Stribling SS, Ibezim UC, et al. Performance of Risk Assessment Models for Peripartum Thromboprophylaxis[J]. Reprod Sci, 2019, 26(9):1243-1248. doi: 10.1177/1933719118813197. doi: 10.1177/1933719118813197 pmid: 30486735
[35]	Queensland Clinical Guidelines. Venous thromboembolism (VTE) in pregnancy and the puerperium. Guideline MN20.9-V7-R25[EB/OL]. Queensland Health, 2020. http://www.health.qld.gov.au/qcg.
[36]	Autar R. Nursing assessment of clients at risk of deep vein thrombosis (DVT): the Autar DVT scale[J]. J Adv Nurs, 1996, 23(4):763-770. doi: 10.1111/j.1365-2648.1996.tb00049.x. doi: 10.1111/j.1365-2648.1996.tb00049.x pmid: 8675895
[37]	尹月娥, 周文娟, 方肖琼, 等. 产科静脉血栓风险评估表的信效度研究[J]. 护士进修杂志, 2017, 32(11):970-973. doi: 10.16821/j.cnki.hsjx.2017.11.003. doi: 10.16821/j.cnki.hsjx.2017.11.003
[38]	上海市母婴安全专家委员会, 上海市医学会围产医学专科分会, 上海市医学会妇产科专科分会产科学组, 等. 上海市产科静脉血栓栓塞症防治的专家共识[J]. 上海医学, 2020, 43(11):645-650. doi: 10.19842/j.cnki.issn.0253-9934.2020.11.001. doi: 10.19842/j.cnki.issn.0253-9934.2020.11.001
[39]	Chen Y, Dai Y, Song J, et al. Establishment of a risk assessment tool for pregnancy-associated venous thromboembolism and its clinical application: protocol for a prospective observational study in Beijing[J]. BMC Pregnancy Childbirth, 2019, 19(1):294. doi: 10.1186/s12884-019-2448-7. doi: 10.1186/s12884-019-2448-7
[40]	Zhang M, Liu M, Wang D, et al. Development of a risk assessment scale for perinatal venous thromboembolism in Chinese women using a Delphi-AHP approach[J]. BMC Pregnancy Childbirth, 2022, 22(1):426. doi: 10.1186/s12884-022-04700-4. doi: 10.1186/s12884-022-04700-4

风险因素	2015RCOG	2020昆士兰	2020上海专家共识
BMI	孕前BMI≥30 kg/m² 1分	当前BMI 30~39 kg/m² 1分	孕前BMI 28.0~34.9 kg/m² 1分
	孕前BMI≥40kg/m² 2分	当前BMI≥40 kg/m² 2分	孕前BMI≥35 kg/m² 2分
年龄	>35岁 1分	>35岁 1分	≥35岁 1分
IVF/ART	产前 1分	产前和产后 1分	产前 1分
VTE病史	VTE病史（与大手术相关的VTE史除外）4分	手术诱发的单一VTE 3分	既往或妊娠期新发的VTE（除外大手术后发生），复发性VTE（2次或以上）4分
	大手术后的VTE史 3分		大手术后的VTE史3分
高危易栓症	3分	未评分	3分
低危易栓症	1分	未评分	未评分
内科合并症	3分	未评分	3分
静脉曲张	大静脉曲张 1分	大静脉曲张1分	下肢静脉曲张 1分
孕前糖尿病	无	1分	1分
产时剖宫产	2分	3分	2分
子宫切除术	3分	3分	2分
产后出血	（>1 000 mL和/或输血） 1分	（>1 000 mL或输血） 1分	（≥1 000 mL和/或输血） 1分
产程延长	（>24 h）1分	（>24 h）1分	（≥24 h） 1分
卵巢过度刺激综合征	4分	未评分	4分
妊娠剧吐	3分	未评分	3分
手术史	妊娠期或产褥期手术（除外急性会阴修复）如阑尾切除术、绝育术 3分	任何手术（妊娠期或产后）	妊娠期或产褥期有外科手术史，除外会阴修复术。例如阑尾切除术、产后绝育术、骨折 3分
制动	卧床≥72 h 1分	卧床≥24 h 1分	卧床≥48 h 1分
脱水	1分	未评分	1分

风险因素	2015RCOG	2020昆士兰	2020上海专家共识
BMI	孕前BMI≥30 kg/m² 1分	当前BMI 30~39 kg/m² 1分	孕前BMI 28.0~34.9 kg/m² 1分
	孕前BMI≥40kg/m² 2分	当前BMI≥40 kg/m² 2分	孕前BMI≥35 kg/m² 2分
年龄	>35岁 1分	>35岁 1分	≥35岁 1分
IVF/ART	产前 1分	产前和产后 1分	产前 1分
VTE病史	VTE病史（与大手术相关的VTE史除外）4分	手术诱发的单一VTE 3分	既往或妊娠期新发的VTE（除外大手术后发生），复发性VTE（2次或以上）4分
	大手术后的VTE史 3分		大手术后的VTE史3分
高危易栓症	3分	未评分	3分
低危易栓症	1分	未评分	未评分
内科合并症	3分	未评分	3分
静脉曲张	大静脉曲张 1分	大静脉曲张1分	下肢静脉曲张 1分
孕前糖尿病	无	1分	1分
产时剖宫产	2分	3分	2分
子宫切除术	3分	3分	2分
产后出血	（>1 000 mL和/或输血） 1分	（>1 000 mL或输血） 1分	（≥1 000 mL和/或输血） 1分
产程延长	（>24 h）1分	（>24 h）1分	（≥24 h） 1分
卵巢过度刺激综合征	4分	未评分	4分
妊娠剧吐	3分	未评分	3分
手术史	妊娠期或产褥期手术（除外急性会阴修复）如阑尾切除术、绝育术 3分	任何手术（妊娠期或产后）	妊娠期或产褥期有外科手术史，除外会阴修复术。例如阑尾切除术、产后绝育术、骨折 3分
制动	卧床≥72 h 1分	卧床≥24 h 1分	卧床≥48 h 1分
脱水	1分	未评分	1分