клин рекомендации ВТЭО. Венозные осложнения во время беременности. Венозные осложнения во время беременности и послеродовом периоде. Акушерская тромбоэмболия
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Уровень убедительности рекомендаций С (уровень достоверности доказательств –4) • У женщин с двумя или более персистирующими факторами риска ( Приложение Г3) (кроме перенесенного ВТЭО или наличия тромбофилии высокого риска), следует 78 Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management. Green-top Guideline No. 37b. Royal College of Obstetricians and Gynaecologists (RCOG); April 2015 79 Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. Green-top guideline No. 37a. Royal College of Obstetricians and Gynaecologists (RCOG); April 2015. 40 применять НМГ в профилактических дозах, скорректированных в соответствие с массой тела на протяжении 10 дней после родов 80 [72,200–202]. Уровень убедительности рекомендаций C (уровень достоверности доказательств –4) • При наличии любого онкологического заболевания в активной стадии риск ВТЭО в послеродовом периоде расценивается как высокий, и рекомендована тромбопрофилактика НМГ минимум в течение 6 недель после родов [146,183]. Уровень убедительности рекомендаций C (уровень достоверности доказательств –5) • Тромбопрофилактика в послеродовом периоде проводится в зависимости от нозологии. В случае наличия протезированных клапанов и других заболеваний, требующих тромбопрофилактики вне беременности, показана терапия варфарином** в стандартном режиме, как до беременности. В случае необходимости назначения прямых оральных антитромботических средств это проводится после завершения лактации. Во время лактации показана тромбопрофилактика НМГ или варфарином** [146]. Уровень убедительности рекомендаций С (уровень достоверности доказательств –5) • НМГ рекомендованы для профилактики и лечения ВТЭО в послеродовом периоде. [34,146]. Уровень убедительности рекомендаций С (уровень достоверности доказательств – 5) Комментарий:Частота таких осложнений как кровотечение, гепарин-индуцированная тромбоцитопения (ГИТ), гепарин-ассоциированный остеопороз ниже у женщин, получающих НМГ по сравнению с НФГ** [60]. • Всем женщинам с наличием в анамнезе подтвержденного ВТЭО рекомендовано проводить тромбопрофилактику НМГ или варфарином** на протяжении по меньшей мере 6 недель после родов независимо от способа родоразрешения 81 [91,157]. Уровень убедительности рекомендаций С (уровень достоверности доказательств –5) Комментарий:использование варфарина** не рекомендовано у женщин с дефицитом протеина С или S в связи с риском развития варфарин-индуцированного некроза кожи [203]. • У женщин с наличием в анамнезе семейного ВТЭО у родственников первой линии родства до 50 лет и подтвержденной тромбофилией следует рекомендовать 6-недельную послеродовую тромбопрофилактику 82 [177–181]. 80 Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. Green-top guideline No. 37a. Royal College of Obstetricians and Gynaecologists (RCOG); April 2015. 81 Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. Green-top guideline No. 37a. Royal College of Obstetricians and Gynaecologists (RCOG); April 2015. 41 Уровень убедительности рекомендаций С (уровень достоверности доказательств –2) • У всех женщин после операции кесарева сечения следует проводить тромбопрофилактику НМГ на протяжении 10 дней после родов, за исключением тех, кому проведено плановое кесарево сечение без дополнительных факторов риска 83 [201,204,205]. Уровень убедительности рекомендаций C (уровень достоверности доказательств 42) Комментарий: Большинство женщин, у которых развиваются ВТЭО после кесарева сечения, имеют другие факторы риска, включающие беременность двойней, ожирение, тяжелую преэклампсию, повторное оперативное вмешательство, иммобилизацию и предлежание плаценты. Кесарево сечение является фактором риска смерти от ТЭЛА. Плановое кесарево сечение, по меньшей мере, удваивает риск послеродового ВТЭО по сравнению с вагинальным родоразрешением. Риск послеродового ВТЭО после экстренного кесарева сечения в два раза выше, чем после планового кесарева сечения, и в четыре раза больше, чем после вагинального родоразрешения [198,201]. • Послеродовую тромбопрофилактику рекомендовано проводить в течение 6 недель у женщин с высоким риском и в течение 10 дней у женщин со средним (промежуточным) риском ( Приложение Г4) [146,183,184]. Уровень убедительности рекомендаций C (уровень достоверности доказательств –5) • Терапию НМГ рекомендовано прекратить или временно отменить у женщин с кровотечением, тщательно оценив при этом баланс между риском развития кровотечения и тромбоза[206] Уровень убедительности рекомендаций С (уровень достоверности доказательств – 4) • Женщинам с наличием в анамнезе или имеющейся на данный момент аллергической реакцией на НМГ рекомендовано предложить альтернативный препарат или альтернативные методы профилактики [138]. Уровень убедительности рекомендаций С (уровень достоверности доказательств - 4) • У женщин с очень высоким риском тромбоза рекомендовано использовать гепарин натрия** при сроке незадолго до родов, и вскоре после родов, если присутствует 82 Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. Green-top guideline No. 37a. Royal College of Obstetricians and Gynaecologists (RCOG); April 2015. 83 Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management. Green-top Guideline No. 37b. Royal College of Obstetricians and Gynaecologists (RCOG); April 2015. 42 повышенный риск кровотечения или в случае, когда может потребоваться применение методов регионарной анестезии 84 ( Приложение А3.5)[34]. Уровень убедительности рекомендаций С (уровень достоверности доказательств – 5) • В случае применения гепарина натрия** после кесарева сечения (или другой операции) рекомендовано контролировать количество тромбоцитов перед началом терапии НФГ**, затем каждые 2–3 дня вплоть до прекращения терапии гепарином натрия**[146,207]. Уровень убедительности рекомендаций С (уровень достоверности доказательств –5) 6. Организация оказания медицинской помощи В соответствие с Приказом Минздрава России от 20.10.2020 N 1130н "Об утверждении Порядка оказания медицинской помощи по профилю "акушерство и гинекология" (Зарегистрировано в Минюсте России 12.11.2020 N 60869) пациентки, которым показаны антитромботические препараты во время беременности и в послеродовом периоде соответствуют критериям для определения этапности оказания медицинской помощи, консультирования и направления беременных женщин в акушерские стационары третьей А (Б) группы (уровня) (например: заболевания сердечно- сосудистой системы (ревматические и врожденные пороки сердца вне зависимости от степени недостаточности кровообращения, пролапс митрального клапана с гемодинамическими нарушениями, оперированные пороки сердца, аритмии, миокардиты, кардиомиопатии, хроническая артериальная гипертензия); тромбозы, тромбоэмболии и тромбофлебиты в анамнезе и при настоящей беременности; заболевания нервной системы (эпилепсия, рассеянный склероз, нарушения мозгового кровообращения, состояния после перенесенных ишемических и геморрагических инсультов) Всем беременным с диагностированным случаем острого тромбоза показана консультация врача-сердечно-сосудистого хирурга и госпитализация в стационар III уровня 85 84 Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. Green-top guideline No. 37a. Royal College of Obstetricians and Gynaecologists (RCOG); April 2015. 85 Приказ министерства здравоохранения об утверждении порядка медицинской помощи по профилю «акушерство и гинекология» №1130н от 12.11.2020г 43 Нахождение под амбулаторным наблюдением в течение не менее 2-х недель от момента постановки диагноза возможно только после заключения сосудистого хирурга 86 При оказании медицинской помощи необходимо учитывать приказ от 3 декабря 2007 г. N 736. Показано стационарное наблюдение и лечение беременных и родильниц с легочной тромбоэмболией тромбоэмболией в стационаре, в условиях отделения реанимации и интенсивной терапии 87, 88, 89 Об утверждении перечня медицинских показаний для искусственного прерывания беременности (в ред. Приказа Минздравсоцразвития РФ от 27.12.2011 N 1661н): тромбоэмболическая болезнь и тромбоэмболические осложнения (системные эмболии артерий головного мозга, рук, ног, почек, мезентериальных сосудов, а также ветвей легочной артерии) (I74, I74.2, I74.3, I74.8); пороки сердца с тромбоэмболическими осложнениями во время беременности или в анамнезе, а также при наличии тромба в полостях сердца (I74 I81 - I82 I51.3) 7. Дополнительная информация (в том числе факторы, влияющие на исход заболевания или состояния) Отсутствует. Критерии оценки качества медицинской помощи №п/п Критерии качества Оценка выполнения 1 Все женщины должны проходить документально фиксируемую Да/Нет 86 VTE in Pregnancy Guideline. SOGCVenous thromboembolism and antithrombotic therapy in pregnancy. J Obstet Gynaecol Canada (2014) 87 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society Journal (2020) 88 Российские клинические рекомендации по диагностике, лечению и профилактике венозных тромбоэмболических осложнений. Флебология 2014 89 Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. Green-top guideline No. 37a. Royal College of Obstetricians and Gynaecologists (RCOG); April 2015. 44 оценку факторов риска ВТЭО при первом посещении врача (на раннем сроке беременности или до беременности). 2 Все женщины должны проходить документально фиксируемую оценку факторов риска ВТЭО повторно - при родоразрешении и в послеродовом периоде. Да/Нет 3 Проведение скрининга на тромбофилии после эпизода ВТЭО рекомендовано назначать до наступления беременности, через 12 недель после эпизода ВТЭО вне антикоагулянтной и гормональной терапии. Да/Нет 4 При подозрении на ТЭЛА для диагностики ТГВ рекомендовано первоначально использовать ультразвуковое компрессионное дуплексное ангиосканирование как основной метод диагностики Да/Нет 5 НМГ является предпочтительным антитромботическим средством для профилактики и лечения ВТЭО во время беременности и в послеродовом периоде Да/Нет 6 При возникновении ВТЭО во время беременности рекомендовано курс лечения НМГ (при отсутствии осложнений при введении препарата) проводить с момента выявления показаний до завершения беременности и в течение 6 недель после родоразрешения. Да/Нет 7 Варфарин** не рекомендован для лечения и профилактики ВТЭО во время беременности (за исключением случаев с механическими клапанами сердца и высоким риском ВТЭО). Да/Нет 8 Рекомендуется стационарное наблюдение и лечение беременных с легочной тромбоэмболией Да/Нет СПИСОК ЛИТЕРАТУРЫ 1. Kohlhepp L.M. et al. Physiological changes during pregnancy // Anaesthesist. 2018. Vol. 67, № 5. P. 383–396. 2. Szecsi P.B. et al. 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