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疑似肺栓塞的妊娠期YEARS诊断流程
Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism


Liselotte M. van der Pol ... 心脑血管疾病 呼吸系统疾病 妇产科和儿科 • 2019.03.21
NEJM 动画解读

妊娠期疑似肺栓塞的诊断
相关阅读
• 改进疑似肺栓塞孕妇的分诊 • 减少肺栓塞中CT应用的安全简便方法

摘要


背景

肺栓塞是西方国家孕妇死亡的主要原因之一。由于D-二聚体检测的特异度和灵敏度低,因此所有疑似肺栓塞的孕妇都要接受计算机断层扫描(CT)肺动脉造影或通气-灌注扫描,而这两种检查方法使孕妇和胎儿受到辐射暴露。经调整后适合妊娠期的诊断流程可否使疑似肺栓塞的孕妇安全避免诊断性影像学检查仍不清楚。

 

方法

我们对疑似肺栓塞的孕妇进行了一项前瞻性研究,评估了YEARS诊断流程的三条标准(深静脉血栓形成的临床体征、咯血、最可能的诊断是肺栓塞),并测定了D-二聚体水平。如果三条标准均不符合并且D-二聚体水平低于1,000 ng/mL,或者如果符合三条标准中的一条或多条并且D-二聚体水平低于500 ng/mL,则肺栓塞被排除。为了使之适合妊娠期,对YEARS诊断流程所做的调整包括对有深静脉血栓形成症状的女性进行加压超声检查;如果结果为阳性(即存在血凝块),则不进行CT肺动脉造影检查。肺栓塞未被排除的所有患者均接受了CT肺动脉造影检查。主要结局为3个月时的静脉血栓栓塞发病率。次要结局为不需要使用CT肺动脉造影即可安全排除肺栓塞的患者比例。

 

结果

共有510名女性接受了筛选,其中12名女性(2.4%)被排除。基线时,20例患者(4.0%)被诊断为肺栓塞。随访期间,1例患者(0.21%;95%置信区间[CI],0.04%~1.2%)被诊断为腘窝深静脉血栓形成;无任何患者发生肺栓塞。195例患者(39%;95% CI,35%~44%)不需要CT肺动脉造影检查,因而避免了这项检查。这一诊断流程的效率在妊娠早期最高,在妊娠晚期最低;在妊娠早期和妊娠晚期开始参与本研究的患者中,分别有65%和32%避免了CT肺动脉造影检查。

 

结论

经调整后适合妊娠期的YEARS诊断流程安全排除了妊娠早中晚期的肺栓塞。有32%~65%的患者避免了CT肺动脉造影检查(由荷兰莱顿大学[Leiden University]医疗中心和参与本研究的另外17家医院资助;Artemis在Netherlands Trial Register注册号为NL5726)。





作者信息

Liselotte M. van der Pol, M.D., Cecile Tromeur, M.D., Ingrid M. Bistervels, M.D., Fionnuala Ni Ainle, M.D., Thomas van Bemmel, M.D., Laurent Bertoletti, M.D., Francis Couturaud, M.D., Yordi P.A. van Dooren, M.D., Antoine Elias, M.D., Laura M. Faber, M.D., Herman M.A. Hofstee, M.D., Tom van der Hulle, M.D., Marieke J.H.A. Kruip, M.D., Maxime Maignan, M.D., Albert T.A. Mairuhu, M.D., Saskia Middeldorp, M.D., Mathilde Nijkeuter, M.D., Pierre-Marie Roy, M.D., Olivier Sanchez, M.D., Jeannot Schmidt, M.D., Marije ten Wolde, M.D., Frederikus A. Klok, M.D., and Menno V. Huisman, M.D. for the Artemis Study Investigators*
From the Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden (L.M.P., T.H., F.A.K., M.V.H.), the Department of Internal Medicine, Haga Teaching Hospital (L.M.P., A.T.A.M.), and the Department of Internal Medicine, Haaglanden Medical Center (H.M.A.H.), the Department of Vascular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam (I.M.B., S.M.), the Department of Internal Medicine, Flevo Hospital, Almere (I.M.B., M.W.), the Department of Internal Medicine, Gelre Hospital, Apeldoorn (T.B.), the Department of Pulmonology, Groene Hart Hospital, Gouda (Y.P.A.D.), the Department of Internal Medicine, Red Cross Hospital, Beverwijk (L.M.F.), the Department of Hematology, Erasmus University Medical Center, Rotterdam (M.J.H.A.K.), and the Department of Internal Medicine, University Medical Center Utrecht, Utrecht (M.N.), all of which are part of the Dutch Thrombosis Network (DTN) — all in the Netherlands; the Department of Internal Medicine and Chest Diseases, Brest Hospital Center, Groupe d’Etude de Thrombose de Bretagne Occidentale, University of Brest, EA 3878, CIC-INSERM 1412, University of Brest, Brest (C.T., F.C.), Service de médecine vasculaire et thérapeutique, Centre Hospitalier Universitaire (CHU) Saint Etienne, INSERM CIC-1408, INSERM Unité 1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint Etienne (L.B.), the Department of Vascular Medicine, Sainte Musse Hospital, Toulon (A.E.), the Emergency Department, CHU Grenoble-Alpes, Hypoxy-Physiopathology laboratory HP2 INSERM 1042, Grenoble (M.M.), the Emergency Department, CHU d’Angers, UFR Santé, Université d’Angers, Institut Mitovasc, UMR CNRS 6015 UMR INSERM 1083, Angers (P.-M.R.), the Department of Pulmonary Disease and Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Université Paris Descartes, Faculté de Médecine, Université Sorbonne Paris Cité, INSERM UMR S 1140, Paris (O.S.), and the Emergency Department, CHU de Clermont-Ferrand, Clermont-Ferrand (J.S.), all of which are part of the French Clinical Research Infrastructure Network–Investigation Network on Venous Thrombo-Embolism (F-CRIN INNOVTE Network, Saint Etienne) — all in France; and the School of Medicine, University College Dublin, and the Department of Haematology, Rotunda Hospital Dublin, INViTE Network, Dublin (F.N.A.). Address reprint requests to Dr. Huisman at the Department of Thrombosis and Hemostasis, Leiden University Medical Center (LUMC), Rm. C7-68g, Albinusdreef 2, 2300 RC Leiden, the Netherlands, or at m.v.huisman@lumc.nl. A complete list of the Artemis Study Investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

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