Профилактика и лечение венозной тромбоэмболии при беременности и в послеродовом периоде

Введение. Венозная тромбоэмболия (ВТЭ) является одной из ведущих причин материнской заболеваемости и смертности в перинатальном периоде в большинстве развитых стран. Во время беременности и после родов частота встречаемости ВТЭ возрастает в 4 и 14 раз соответственно.

Цель: провести анализ и систематизировать современные взгляды на факторы риска тромботических событий в период гестации, а также обсудить последние рекомендации по лечению и профилактике венозных тромбоэмболических осложнений (ВТЭО) при беременности и после родов c учетом баланса риска и пользы от назначения антикоагулянтов.

Материалы и методы. Библиографический поиск за последние 10 лет осуществляли в наукометрических базах данных РИНЦ, PubMed/MEDLINE, Embase. При формулировке стратегии поиска доказательной информации применяли метод PICO (англ. P = Patient; I = Intervention; C = Comparison; O = Outcome) и ключевые термины «венозный тромбоз/venous thromboembolism» и «беременность/pregnancy».

Результаты. К факторам риска относятся индивидуальный или семейный анамнез ВТЭ, наличие наследственной или приобретенной тромбофилии, некоторые сопутствующие заболевания или состояния (иммобилизация, избыточный вес, варикозная болезнь, гематологическая патология, аутоиммунные расстройства). При профилактическом назначении антикоагулянтов развитие ВТЭ можно предотвратить, однако до сих пор отсутствуют рандомизированные клинические исследования с высокой степенью доказательности в отношении различных подходов к тромбопрофилактике у беременных. Поскольку гепарины не проникают через плацентарный барьер, препаратами выбора для лечения ВТЭ у беременных являются низкомолекулярные гепарины (НМГ) в терапевтической дозировке с поправкой на массу тела. Приемлемы как однократный, так и двукратный суточный режим введения НМГ. Убедительные данные, указывающие на преимущества подбора дозы НМГ по уровню активности Xa фактора, отсутствуют. В случаях неосложненной ВТЭ не рекомендуется рутинное назначение беременным антагонистов витамина К, прямых ингибиторов тромбина или Xa фактора, фондапаринукса и данапароидов. В период лактации допустим переход с НМГ на прием варфарина. Антикоагулянтную терапию следует продолжать в течение 6 нед после родов, а ее общая продолжительность должна быть не менее 3 мес.

Заключение. Ведение беременных с ВТЭ является непростой задачей, эффективное решение которой предполагает дифференцированный подход с учетом актуальных рекомендаций и индивидуальных особенностей пациенток.

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