Gebelikte Tromboembolik Hastalıklar
Özet
Gebelik ve lohusalık dönemleri, venöz tromboemboli (VTE) riskini 4-50 kat artıran önemli süreçlerdir ve derin ven trombozu (DVT), pulmoner emboliden (PE) üç kat daha sık görülür. PE, gelişmiş ülkelerdeki anne ölümlerinin yedinci sıradaki nedenidir. Postpartum dönemde VTE riski ilk altı haftada en yüksek seviyededir. Kalıtımsal trombofili, geçirilmiş VTE öyküsü, sezaryen doğum, obezite ve ileri anne yaşı başlıca risk faktörleri arasında yer alır. Gebelikte DVT tanısında proksimal ven kompresif ultrasonografi (CUS) yüksek duyarlılığa sahiptir. Şüpheli PE durumunda ise normal akciğer grafisini takiben ventilasyon/perfüzyon (V/Q) taraması veya bilgisayarlı tomografi pulmoner anjiyografi (BTPA) tercih edilir. Tedavide ve önlemede, plasentayı geçmeyen ve fetüs için güvenli olan düşük moleküler ağırlıklı heparin (DMAH) ve anfraksiyone heparin (AFH) öncelikli olarak kullanılır. Buna karşın, teratojenik etkileri ve veri yetersizliği nedeniyle varfarin ve direkt oral antikoagülanlar gebelikte kontrendikedir. Heparin tedavisi kanama, heparine bağlı trombositopeni (HIT), cilt nekrozu ve osteoporoz gibi ciddi komplikasyonlara yol açabilir. Doğum zamanı öngörülebiliyorsa, nöraksiyel anestezi sırasında spinal hematom riskini önlemek amacıyla DMAH tedavisi doğumdan en az 24 saat önce kesilmelidir. Antikoagülasyonun kontrendike olduğu durumlarda inferior vena kava filtreleri veya hayatı tehdit eden vakalarda trombolitik tedavi değerlendirilebilir.
Pregnancy and the postpartum period are critical processes that increase the risk of venous thromboembolism (VTE) by 4-50 times, with deep vein thrombosis (DVT) occurring three times more frequently than pulmonary embolism (PE). PE ranks as the seventh leading cause of maternal mortality in developed countries. In the postpartum period, the risk of VTE is highest during the first six weeks. Inherited thrombophilia, a history of previous VTE, cesarean delivery, obesity, and advanced maternal age are among the primary risk factors. Compression ultrasonography (CUS) of proximal veins yields high sensitivity in diagnosing DVT during pregnancy. For suspected PE, a ventilation/perfusion (V/Q) scan or computed tomography pulmonary angiography (CTPA) is preferred following a normal chest X-ray. Low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH), which do not cross the placenta and are safe for the fetus, are primarily utilized for treatment and prophylaxis. Conversely, warfarin and direct oral anticoagulants are contraindicated during pregnancy due to teratogenic effects and insufficient data. Heparin therapy may lead to severe complications such as bleeding, heparin-induced thrombocytopenia (HIT), skin necrosis, and osteoporosis. If the timing of delivery is predictable, LMWH therapy must be discontinued at least 24 hours prior to delivery to prevent the risk of spinal hematoma during neuraxial anesthesia. Inferior vena cava filters can be considered when anticoagulation is contraindicated, or thrombolytic therapy may be evaluated in life-threatening cases.
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