2025 年第 6 期 第 20 卷

不同抗凝方法下心脏机械瓣膜置换术后孕妇的胎儿和新生儿不良结局分析

Analysis of the adverse fetal/neonatal outcomes of pregnant women after mechanical heart valves replacement under different anticoagulation methods

作者：赵梓文董云李怡王继秋刘桂英

英文作者：Zhao Ziwen Dong Yun Li Yi Wang Jiqiu Liu Guiying

单位：首都医科大学附属北京安贞医院儿科，北京100029

英文单位：Department of Pediatrics Capital Medical University Beijing Anzhen Hospital Beijing 100029 China

关键词：心脏机械瓣膜；妊娠；抗凝方法；胎儿/新生儿；不良结局

英文关键词：Mechanicalheartvalves;Pregnancy;Anticoagulationmethod;Fetuses/neonates;Adverseoutcomes

• 摘要：

• 目的 分析不同抗凝方法下心脏机械瓣膜(MHVs)置换术后孕妇的胎儿/新生儿不良结局。方法 回顾性收集2015年12月至2023年12月首都医科大学附属北京安贞医院收治MHVs置换术后孕妇105例（137次妊娠）及其胎儿／新生儿资料，按照孕期抗凝方式分为3组：华法林组（96例次）、低分子肝素（LMWH）组（28例次）、序贯治疗组（13例次）。分析比较3组孕妇和胎儿/新生儿相关资料。结果 华法林组孕周小于LMWH组及序贯治疗组（P＜0.001），孕次多于LMWH组及序贯治疗组（P=0.045）。共活产56例，华法林组28例(29.2%)，LMWH组18例（64.3%），序贯治疗组10例（76.9%），华法林组活产率低于其余2组（P＜0.001）。3组死胎/自然流产率（P=0.549）、胎儿/新生儿畸形率（P=0.337）比较差异均无统计学意义。活产儿中早产儿7例，低出生体重儿5例，小于胎龄儿2例，新生儿窒息2例，呼吸衰竭6例，脓毒症3例，新生儿脑病3例，出血事件6例（消化道出血2例，颅内出血2例，头颅血肿1例，弥散性血管内凝血1例）。华法林组新生儿国际标准化比值（INR）（P=0.004）、凝血酶原时间（P=0.001）、活化部分凝血活酶时间（P=0.004）高于/长于其余2组。华法林组及序贯治疗组共有22例新生儿收入儿科病房，新生儿生后第1天INR明显高于其母亲分娩前24 h内INR［（2.5±1.5）比（1.5±0.6）］（P=0.008）。结论 孕期持续口服华法林的MHVs置换术后孕妇孕次更多，但活产率更低、孕周更小，其新生儿早期凝血功能差，更易受到华法林影响。应加强对育龄期MHVs置换术后妇女的产前咨询，并在三级医院进行多学科联合管理，尽量避免未计划妊娠。

• Objective Objective  to analyze the adverse fetal/neonatal outcomes of pregnant women after mechanical heart valves (MHVs) replacement under different anticoagulation methods . Methods Data of 105 pregnant women (137 pregnancies) and their fetuses/newborns after MHVs replacement in Beijing Anzhen Hospital, Capital Medical University from December 2015 to December 2023 were retrospectively collected. According to the anticoagulation mode during pregnancy, they were divided into three groups: warfarin group (96 cases), low molecular weight heparin (LMWH) group (28 cases), and sequential treatment group (13 cases). The relevant data of pregnant women and fetuses/newborns in the three groups were analyzed and compared. Results The gestational age of warfarin group was less than that of LMWH group and sequential treatment group (P<0.001), and the number of pregnancies was more than that of LMWH group and sequential treatment group (P=0.045). There were 56 live births in total, 28 cases (29.2%) in the warfarin group, 18 cases (64.3%) in the LMWH group, and 10 cases (76.9%) in the sequential treatment group. The live birth rate in the warfarin group was lower than that in the other two groups (P<0.001). There were no significant differences in the stillbirth/spontaneous abortion rate (P=0.549) and fetal/neonatal malformation rate (P=0.337) among the three groups. Among the live births, there were 7 premature infants, 5 low birth weight infants, 2 small for gestational age infants, 2 neonatal asphyxia, 6 respiratory failure, 3 sepsis, 3 neonatal encephalopathy, and 6 bleeding events (2 cases of gastrointestinal bleeding, 2 cases of intracranial hemorrhage, 1 case of cranial hematoma, and 1 case of disseminated intravascular coagulation). The international normalized ratio (INR) (P=0.004), prothrombin time (P=0.001) and activated partial thromboplastin time (P=0.004) of newborns in warfarin group were higher/longer than those in the other two groups. A total of 22 neonates in the warfarin group and sequential treatment group were admitted to the pediatric ward. The INR of neonates on the first day after birth was significantly higher than that of their mothers within 24 h before delivery ［(2.5±1.5) vs (1.5±0.6)］(P=0.008). Conclusions After MHVs replacement with continuous oral warfarin during pregnancy, pregnant women have more pregnancies, but the live birth rate is lower, the gestational age is smaller, and their early neonatal coagulation function is poor, which is more vulnerable to warfarin. Prenatal consultation for women after MHVs replacement in childbearing age should be strengthened, and multidisciplinary joint management should be carried out in tertiary hospitals to try to avoid unplanned pregnancy.