Medikamentöse Thromboembolie-Prophylaxe in Schwangerschaft und Wochenbett: neue Leitlinienempfehlungen & kritischer Leitlinienvergleich

Zusammenfassung

Venöse Thromboembolien (VTE) sind weltweit eine der häufigsten mütterlichen Todesursachen. Die steigende Zahl an Schwangeren mit Risikofaktoren hat zu einer signifikanten Zunahme der VTE-Inzidenz geführt. Mortalität und Morbidität infolge VTE sind potentiell vermeidbar, da mehr als 2/3 dieser Frauen identifizierbare Risikofaktoren aufweisen und von einer adäquaten VTE-Prophylaxe profitieren können. Die Eckpfeiler zur Prävention von VTE sind die individuelle und sorgfältige Erfassung von präexistenten und neu auftretenden/transienten Risikofaktoren in der Schwangerschaft, vor und nach der Geburt sowie eine risikoadaptierte medikamentöse Thromboembolie-Prophylaxe. Derzeitige Empfehlungen zur VTE-Prophylaxe basieren nur auf Konsensus-Statements und Expertenmeinungen. Es werden die vor kurzem publizierte AWMF-Leitlinie 003/001 und die Leitlinie Nr. 37a des Royal College of Obstetricians and Gynecologists (RCOG) diskutiert. Die RCOG-Leitlinie empfiehlt eine antenatale Thromboseprophylaxe bei Frauen mit vorangegangener VTE, Hochrisiko-Thrombophilien oder beim Vorliegen von≥4 Risikofaktoren ab Beginn der Schwangerschaft, bei 3 Risikofaktoren ab der 28. SSW. Nach der Geburt sollte bei mittlerem Risiko NMH über mindestens 10 Tage und bei hohem Risiko über 6 Wochen gegeben werden. Nach elektiver Sectio wird prophylaktisches NMH über 10 Tage nur bei zusätzlichen Risikofaktoren empfohlen, das gleiche Vorgehen gilt für alle Frauen mit sekundärer Sectio. Die Gabe von NMH sollte bei Beginn der Wehen, vaginalen Blutungen, vor geplanter Geburtseinleitung oder mindestens 12 Stunden vor einer elektiven Sectio abgesetzt werden, sie kann 4–6 Stunden nach vaginaler Geburt und 6–12 Stunden nach Sectio fortgesetzt werden, sofern kein erhöhtes Blutungsrisiko besteht. Die aktuellen Leitlinien empfehlen eine Körpergewichts-adaptierte Prophylaxe mit NMH.

Abstract

Venous thromboembolism (VTE) is one of the leading causes of maternal deaths worldwide. Due to the increasing number of pregnant women with risk factors, the incidence of VTE has risen over the past decades. Mortality and morbidity of VTE are potentially preventable, since more than two-thirds of these women have identifiable risk factors and may benefit from appropriate thromboprophylaxis. The cornerstones for prevention of VTE are the individual and careful assessment of preexisting and new-onset/transient risk factors during pregnancy as well as before and after delivery and a risk-stratified pharmacological thromboprophylaxis. Current recommendations for thromboprophylaxis must rely on consensus statements and expert opinions. The recently published German AWMF-Guideline 003/001 and the Green-top Guideline No. 37a from the Royal College of Obstetricians and Gynaecologists (RCOG) are discussed. The RCOG Guideline recommends antenatal thromboprophylaxis in women with previous VTE, high-risk thrombophilia or in the presence of ≥ 4 risk factors from the beginning of pregnancy, in women with 3 current risk factors from 28 weeks of gestation. After delivery women with intermediate risk should receive prophylactic LMWH for at least 10 days and women with high risk for 6 weeks postnatally. All women who have had an elective caesarean section and who have>1 additional risk factor should be given prophylactic NMH as well as all women who have had a caesarean section in labour or an emergency caesarean section. At the onset of labour, in case of any vaginal bleeding, prior to scheduled labour induction or at least 12 h before an elective caesarean section, antenatal LMWH prophylaxis should be discontinued. LMWH prophylaxis can be continued 4–6 h after vaginal delivery and 6–12 h after caesarean delivery when women do not have an increased risk of haemorrhage. Current guidelines recommend weight-based LMWH.

Schlüsselwörter

venöse Thromboembolie - aktuelle Leitlinien - Risikostratifizierung - ante- und postnatale Prophylaxe - niedermolekulares Heparin

Key words

venous thromboembolism - current guidelines - risk stratification - antenatal and postnatal prophylaxis - low molecular weight heparin

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