Epidemiologie, Risikofaktoren und Risikostratifizierung venöser Thromboembolien (VTE) in Schwangerschaft und Wochenbett

 

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Zusammenfassung

Venöse Thromboembolien (VTE) gehören zu den häufigsten Ursachen direkter Müttersterbefälle in den Industrieländern. Ihre Inzidenz hat in den letzten 20 Jahren signifikant zugenommen. Das absolute Risiko für VTE liegt in der Schwangerschaft zwischen 0,6–2,2/1000 Geburten, im Vergleich zu Nichtschwangeren ist das tägliche Risiko für VTE in der Schwangerschaft um das 7- bis 10-fache höher und im Wochenbett um das 15- bis 35-fache. Die Inzidenz an Lungenembolien (LE) ist während der ersten 6 Wochen nach der Geburt um das 15-fache höher als in der Schwangerschaft und bleibt bis zu 12 Wochen postpartum noch signifikant erhöht. Die fallbezogene Sterblichkeit der LE liegt zwischen 2,2–6,6%.

Grundlage der medikamentösen VTE-Prophylaxe ist eine sorgfältige Erfassung individueller Risikofaktoren und eine adäquate Risikostratifizierung. Zu unterscheiden sind präexistente mütterliche von transienten Schwangerschafts-spezifischen Risikofaktoren. Das höchste Risiko für VTE weisen Frauen mit vorangegangener VTE oder mit angeborenen Hochrisiko-Thrombophilien oder mit Antiphospholipid-Syndrom auf. Weitere bedeutende Schwangerschafts-spezifische Risikofaktoren antenatal sind das schwere ovarielle Hyperstimulationssyndrom, die Hyperemesis, größere Operationen, schwere Komorbidität (z. B. systemischer Lupus erythematodes), Hospitalisierung bei Frauen mit einem Body-Maß-Index>25 kg/m² und entzündliche Darmerkrankungen.

Herzerkrankungen, Totgeburt, systemische Infektionen, schwere postpartale Blutung in Kombination mit der Substitution von Erythrozytenkonzentraten/Gerinnungsfaktoren und/oder Operationen sowie die sekundäre Sectio sind die stärksten Risikofaktoren im Wochenbett.

Empfehlungen zu Risikostratifizierungen sind in aktuellen internationalen Leitlinien unterschiedlich. Nach der Leitlinie der Kanadischen Gesellschaft für Geburtshilfe und Gynäkologie 2014 (SOGC) wird eine medikamentöse VTE-Prophylaxe dann empfohlen, wenn das VTE-Risiko eines einzelnen oder mehrerer Risikofaktoren>1% beträgt. Die ACCP (American College of Chest Physicians)-Leitlinie 2012 bezieht sich ausschließlich auf eine Risiko-basierte VTE-Prophylaxe nach Sectio caesarea. Die jüngste RCOG (Royal College of Obstetricians and Gynaecologists)-Leitlinie No. 37a 2015 empfiehlt die Risikostratifizierung für VTE auf der Grundlage eines speziellen „risk scoring“-Systems und gewichtet die individuellen Risikofaktoren zwischen einem Punkt (niedriges Risiko) bis maximal 4 Punkte (sehr hohes Risiko).

Jede geburtshilfliche Klinik sollte über eine Checkliste wichtiger Risikofaktoren und über einen auf aktuellen Leitlinien basierenden Handlungsplan zur medikamentösen Thrombose-Prophylaxe verfügen.

Abstract

Venous thromboembolism (VTE) remains a leading cause of direct maternal deaths in the developed countries. The incidence of VTE has increased significantly during the past two decades. The absolute risk of VTE is estimated 0.6–2.2 per 1000 deliveries. Compared with age-matched non-pregnant women, the daily risk of VTE is increased 7- to 10-fold for antepartum VTE, but it is 15- to 35-fold for postpartum VTE. The incidence of pulmonary embolism (PE) during the first 6 weeks postpartum is nearly 15-fold higher compared to the incidence in pregnancy, and remains significantly increased up to 12 weeks postpartum. The case fatality rate of PE ranges from 2.2 to 6.6%.

The basis of VTE prevention is careful assessment of individual risk factors of VTE and proper risk stratification.

It is necessary to differentiate preexisting maternal from transient pregnancy-specific risk factors. Women with previous VTE or hereditary high-risk thrombophilias or with the antiphospholipid syndrome have the highest risk for VTE in pregnancy and the puerperium.Other most important pregnancy-specific risk factors in the antenatal period are severe ovarian hyperstimulation syndrome, hyperemesis, major surgery, severe comorbidities (e.g., systemic lupus erythematodes), hospitalization in women with a body mass index > 25 kg/m², and inflammatory bowel diseases.

Heart diseases, stillbirth, systemic infections, severe postpartum hemorrhage in combination with blood product replacement and/or surgery and emergency caesarean section are predominant risk factors in the postpartum period.

Recommendations for risk stratification vary among current international guidelines. According to the SOGC (Society of Obstetricians and Gynaecologists of Canada) 2014, pharmacologic VTE prophylaxis is recommended if the estimated absolute risk of one or multiple risk factors is greater than 1%.

The ACCP (American College of Chest Physicians) Guideline 2012 presents specific recommendations only for post-caesarean risk-factor-based prophylaxis.

The recent RCOG (Royal College of Obstetricians and Gynaecologists) Guideline No. 37a 2015 recommends risk stratification for VTE prophylaxis on the basis of a special risk scoring system weighting individual risk factors between one point (low risk) to a maximum of 4 points (very high risk).

A check list of important risk factors and a management plan for thromboprophylaxis based on current guidelines should be readily available in each obstetric unit.

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