Diagnostik und Therapie venöser Thromboembolien in der Schwangerschaft und Postpartalperiode

Zusammenfassung

Das Auftreten sowohl der tiefen Beinvenenthrombose als auch einer Lungenarterienembolie wird bereits durch physiologische Mechanismen in der Schwangerschaft und im Wochenbett begünstigt. Es kommt neben vorbestehenden Risikofaktoren zu transienten Erscheinungen, die das Risiko für venöse thromboembolische Erkrankungen erhöhen. Die Klinik von Thromboembolien ist oft unspezifisch. Erprobte Diagnosealgorithmen bestehen in der Schwangerschaft nicht. Aufgrund der klinischen Relevanz ist jedoch eine Diagnosesicherung unerlässlich. Die Anamnese, Klinik und Labordiagnostik sind wesentliche Bestandteile in der Diagnosefin-dung, können aber alleine eine venöse Thromboembolie nicht ausschließen. Eine apparative Beurteilung der betroffenen Venen durch die Sonographie ist dabei die Untersuchungsmethode der Wahl. Die vorliegende Arbeit beschreibt die Diagnostik und Therapie venöser Thromboembolien in der Schwangerschaft.

Schlüsselwörter

Thrombose - Lungenarterienembolie - Thromboembolie - Schwangerschaft

• Literatur

• 1 Greer IA. Thrombosis in pregnancy: maternal and fetal issues. Lancet 1999; 353 9160 1258-1265.
• 2 Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med 2008; 359 (19) 2025-2033.
• 3 Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton III LJ. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005; 143 (10) 697-706.
• 4 James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol 2006; 194 (05) 1311-1315.
• 5 Ginsberg JS, Brill-Edwards P, Burrows RF, Bona R, Prandoni P, Buller HR. et al. Venous thrombosis during pregnancy: leg and trimester of presentation. Thromb Haemost 1992; 67 (05) 519-520.
• 6 Macklon NS, Greer IA. The deep venous system in the puerperium: an ultrasound study. Br J Obstet Gynaecol 1997; 104 (02) 198-200.
• 7 Brenner B. Haemostatic changes in pregnancy. Thromb Res 2004; 114 (05) [phone].
• 8 Pabinger I, Grafenhofer H, Kaider A, Kyrle PA, Quehenberger P, Mannhalter C. et al. Risk of pregnancy-associated recurrent venous thromboembolism in women with a history of venous thrombosis. J Thromb Haemost 2005; 3 (05) 949-954.
• 9 Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 2001; 161 (01) 92-97.
• 10 Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG. et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998; 129 (12) 997-1005.
• 11 Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J. et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349 (13) 1227-1235.
• 12 O’Connor C, Moriarty J, Walsh J, Murray J, Coulter-Smith S, Boyd W. The application of a clinical risk stratification score may reduce unnecessary investigations for pulmonary embolism in pregnancy. J Matern Fetal Neonatal Med 2011; 24 (12) 1461-1464.
• 13 Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD. et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Am J Med 2006; 119 (12) 1048-1055.
• 14 Kline JA, Williams GW, Hernandez-Nino J. D-dimer concentrations in normal pregnancy: new diagnostic thresholds are needed. Clin Chem 2005; 51 (05) 825-829.
• 15 Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R. et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med 2004; 140 (08) 589-602.
• 16 Jeremiah ZA, Adias TC, Opiah M, George SP, Mgbere O, Essien EJ. Elevation in D-dimer concentrations is positively correlated with gestation in normal uncomplicated pregnancy. Int J Womens Health 2012; 4: 437-443.
• 17 Sivandarajah S. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4: current evidence does not support the use of a negative D-dimer to rule out suspected pulmonary embolism in pregnancy. Emerg Med J 2011; 28 (03) 245-246.
• 18 Chan WS, Lee A, Spencer FA, Chunilal S, Crowther M, Wu W. et al. D-dimer testing in pregnant patients: towards determining the next ’level’ in the diagnosis of deep vein thrombosis. J Thromb Haemost 2010; 8 (05) 1004-1011.
• 19 Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 2007; 116 (04) 427-433.
• 20 Elias A, Le Corff G, Bouvier JL, Benichou M, Serradimigni A. Value of real time B mode ultrasound imaging in the diagnosis of deep vein thrombosis of the lower limbs. Int Angiol 1987; 6 (02) 175-182.
• 21 Fraser DG, Moody AR, Morgan PS, Martel AL, Davidson I. Diagnosis of lower-limb deep venous thrombosis: a prospective blinded study of magnetic resonance direct thrombus imaging. Ann Intern Med 2002; 136 (02) 89-98.
• 22 Groves AM, Yates SJ, Win T, Kayani I, Gallagher FA, Syed R. et al. CT pulmonary angiography versus ventilation-perfusion scintigraphy in pregnancy: implications from a UK survey of doctors’ knowledge of radiation exposure. Radiology 2006; 240 (03) 765-770.
• 23 Winer-Muram HT, Boone JM, Brown HL, Jennings SG, Mabie WC, Lombardo GT. Pulmonary embolism in pregnant patients: fetal radiation dose with helical CT. Radiology 2002; 224 (02) 487-492.
• 24 Gilet AG, Dunkin JM, Fernandez TJ, Button TM, Budorick NE. Fetal radiation dose during gestation estimated on an anthropomorphic phantom for three generations of CT scanners. AJR Am J Roentgenol 2011; 196 (05) 1133-1137.
• 25 Stein PD, Chenevert TL, Fowler SE, Goodman LR, Gottschalk A, Hales CA. et al. Gadolinium-enhanced magnetic resonance angiography for pulmonary embolism: a multicenter prospective study (PIOPED III). Ann Intern Med 2010; 152 (07) 434-433.
• 26 Katzberg RW, McGahan JP. Science to practice: Will Gadolinium--enhanced MR imaging be useful in assessment of at-risk pregnancies?. Radiology 2011; 258 (02) 325-326.
• 27 Kahn SR. Post-thrombotic syndrome after deep venous thrombosis: risk factors, prevention, and therapeutic options. Clin Adv Hematol Oncol 2009; 7 (07) 433-435.
• 28 McColl MD, Ellison J, Greer IA, Tait RC, Walker ID. Prevalence of the post-thrombotic syndrome in young women with previous venous thromboembolism. Br J Haematol 2000; 108 (02) 272-274.
• 29 Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) e691S-e736S.
• 30 Greer IA, Nelson-Piercy C. Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood 2005; 106 (02) 401-407.
• 31 Junqueira DR, Carvalho M, Perini E. Heparin-induced thrombocytopenia: a review of concepts regarding a dangerous adverse drug reaction. Rev Assoc Med Bras 2013; 59 (02) 161-166.
• 32 Ginsberg JS, Chan WS, Bates SM, Kaatz S. Anticoagulation of pregnant women with mechanical heart valves. Arch Intern Med 2003; 163 (06) 694-698.
• 33 Schaefer C, Hannemann D, Meister R, Elefant E, Paulus W, Vial T. et al. Vitamin K antagonists and pregnancy outcome. A multi-centre prospective study. Thromb Haemost 2006; 95 (06) 949-957.
• 34 Buller HR, Prins MH, Lensin AW, Decousus H, Jacobson BF, Minar E. et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 2012; 366 (14) 1287-1297.
• 35 Bauersachs R, Berkowitz SD, Brenner B, Buller HR, Decousus H, Gallus AS. et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010; 363 (26) 2499-2510.
• 36 Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT. et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35 (01) 64-101.
• 37 Milford W, Chadha Y, Lust K. Use of a retrievable inferior vena cava filter in term pregnancy: case report and review of literature. Aust N Z J Obstet Gynaecol 2009; 49 (03) 331-333.
• 38 Trujillo-Santos J, Perea-Milla E, Jimenez-Puente A, Sanchez-Cantalejo E, del Toro J, Grau E. et al. Bed rest or ambulation in the initial treatment of patients with acute deep vein thrombosis or pulmonary embolism: findings from the RIETE registry. Chest 2005; 127 (05) 1631-1636.
• 39 Enden T, Haig Y, Klow NE, Slagsvold CE, Sandvik L, Ghanima W. et al. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet 2012; 379 9810 31-38.
• 40 Leonhardt G, Gaul C, Nietsch HH, Buerke M, Schleussner E. Thrombolytic therapy in pregnancy. J Thromb Thrombolysis 2006; 21 (03) 271-276.
• 41 Robertson L, Wu O, Langhorne P, Twaddle S, Clark P, Lowe GD. et al. Thrombophilia in pregnancy: a systematic review. Br J Haematol 2006; 132 (02) 171-196.
• 42 Nelson SM, Greer IA. Thrombophilia and the risk for venous thromboembolism during pregnancy, delivery, and puerperium. Obstet Gynecol Clin North Am 2006; 33 (03) 413-427.