Переведите на понятный язык своему светочу в гинекологии рекомендации более 10 летней давности, похоже она была сильно занята сравнительно честным отъемом леек у доверчивых прихожанок и было невдомек провести повышение собств. квалификации:
Selective population screening: pregnancy
In addition to being associated with VTE in pregnancy, heritable thrombophilia has been linked to adverse pregnancy outcomes, including fetal loss, placental abruption, pre‐eclampsia and intrauterine growth retardation. Screening in pregnancy is appealing as it gives the opportunity to provide antithrombotic treatment to reduce the risk of these events in at‐risk women. However, the use of such a screening strategy is not supported on the basis of current knowledge. Wu et al,31 in a cost–benefit analysis, found that screening unselected women before pregnancy is not cost effective, at £81 436 per event prevented. This model included adverse pregnancy outcome as an event (thus the figure for DVT prevention alone is likely to be much higher) and assumed use of antepartum prophylaxis with heparin in all women who test positive.
In women who have had a previous VTE there is no clear benefit to thrombophilia testing before pregnancy. This is because the VTE recurrence rate in pregnancy is low, necessitating the exposure of a large number of women to heparin prophylaxis throughout pregnancy to prevent a single episode of VTE. In addition, the evidence does not suggest that identification of heritable thrombophilia can usefully influence management. Brill‐Edwards et al39 withheld antepartum prophylaxis in 125 women with a previous single episode of DVT. All women were given postpartum VTE prophylaxis for 6 weeks. Only 3 (2.4%) of these women had antepartum DVT recurrence. Of the 36 women whose prior event was considered idiopathic, 2 (5.5%) had antepartum recurrence, whereas only 1 (1.7%) of 59 women whose prior event was associated with a temporary risk factor had antepartum recurrence. Notably, there were also three postpartum recurrences despite prophylaxis (two in the idiopathic group and one in the temporary risk group). These data indicate that the risk of VTE recurrence in pregnancy is quite low. Furthermore, Pabinger et al40 observed 109 women who had previous VTE through 197 pregnancies without antepartum prophylaxis. They observed 8 (4.1%) antepartum recurrences. Of the 62 women, 4 (6.2%) who tested positive for thrombophilia had antepartum recurrence compared with 4 (10.2%) of 39 women who tested negative. Interestingly, most of the recurrences were in women whose previous VTE was provoked by the OCP (seven recurrences in the 72 women whose previous events were OCP related), whereas there was only one recurrence in the 37 women whose previous event was a non‐OCP temporary risk factor and no recurrence in the 15 women whose previous event was spontaneous.
Severe thrombophilias (eg antithrombin deficiency, homozygosity for factor V Leiden and V Leiden/prothrombin mutation double heterozygotes) may have a higher absolute risk of pregnancy‐associated thrombosis. Owing to their low prevalence, estimates of risk have been inconsistent. Although a VTE risk of 40% in pregnancy has been suggested in antithrombin‐deficient women,15,6 Friederich et al14 followed up 13 antithrombin‐deficient women through a total of 33 pregnancies and observed only one thrombotic event (3%). A recent study found that 3 of 19 (15.8%) women with homozygotic factor V Leiden and 2 of 50 (4%) women with double heterozygosity developed pregnancy‐associated venous thrombosis, although all but one of these events occurred postpartum.18 These at‐risk women cannot be efficiently identified without adopting a strategy of routine testing. Targeting tests to women with the strongest family histories of VTE is a possibility, but the cost effectiveness of such an approach has not been tested.
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Testing for thrombophilia: an evidence‐based approach
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