GEBELİK VE KALITSAL TROMBOFİLİ

Year 2005, Volume: 6 Issue: 2, 43 - 50, 01.08.2005

Samet Kafkas Gürhan Kadıköylü

Abstract

Gebelikte ortaya çıkan venöz tromboembolizm (VTE) maternal mortalite ve morbiditeyi arttıran en önemlifaktörlerden birisidir. Gebelikle ilişkili VTE geçiren kadınların 2/3'ünde edinsel ve %30-50'sinde kalıtsaltrombofilik risk faktörü saptanmıştır. Gebelikte kalıtsal olarak ortaya çıkan en sık kalıtsal trombofili nedenlerifaktör-V Leiden (FV-L), protrombin G20210A ve metilentetrahidrofolat redüktaz gen mutasyonlarıdır. Kalıtsaltrombofilili gebelerde VTE yanı sıra plasental vasküler zedelenme, infarktüs ve fibrinoid nekroz nedeniyleablatio plasenta, yineleyen gebelik kayıpları, intrauterin fetal ölümler, intrauterin fetal gelişmegerilikleri(İUFGG) ve preeklampsi görülmektedir.Gebelikte kalıtsal trombofili tarama testleri gebelik ya da puerperium ile ilişkili VTE, birinci, ikinci trimestirdeortaya çıkan yineleyen gebelik kaybı ve intrauterin fetal ölüm olgularında gereklidir. Ancak şiddetli preeklampsi,İUFGG, ablatio placenta gibi gebelik komplikasyonlarında da önerilebilir. Bu testler özellikle doğumdan 3 aysonra yapılmalıdır.Gebelikte ortaya çıkan akut VTE tedavisinde unfraksiyone heparin (UFH) ya da düşük molekül ağırlıklıheparinler (DMAH) kullanılmalıdır. Her iki heparin de plasentaya geçmediği için gebelikte güvenlidir. En azUFH kadar etkili olan DMAH'in biyoyararlılığı daha fazla ve yan etkileri daha azdır.Gebelikte VTE rekürrensi %1-13 arasındadır. Antitrombin eksikliği ve VTE öyküsü olan tüm kalıtsal trombofililigebeler yüksek riskte kabul edilmekte ve agressif olarak antikoagulan proflaksisi önerilmektedir. VTE öyküsüolmayan heterozigot Protein C eksikliği, homozigot FV-L ve protrombin gen mutasyonlu ve AT eksikliğidışındaki kombine trombofilili gebeler ise orta risk gurubunda olup tromboproflaksi yapılmalıdır. HeterozigotPS eksikliği, FV-L, protrombin gen mutasyonları bulunan gebeler ise düşük risk altında olup tromboproflaksiönerilmemektedir. Ancak tromboz için ek bir risk faktörü bulunan, yineleyen bebek kaybı, intrauterin fetal ölüm,şiddetli preeklampsi, İUFGG gibi komplikasyon gelişen, dört saatten uzun sürecek uçak yolculuğuna çıkacakkalıtsal trombofilili gebelerde de tromboproflaksi yapılmalıdır. Tromboproflaksi DMAH ile gebelik boyunca vedoğumdan sonraki ilk altı hafta süresince uygulanmalıdır

Keywords

Kalıtsal trombofili, gebelik, venöz tromboembolizm

Pregnancy and Hereditary Thrombophilia

Abstract

Pregnancy-related venous thromboembolism (VTE) is one of the risk factors that increase maternal mortality and morbidity. Acquired and congenital thrombophilic risk factors were detected in 2/3 and 30-50% of women with VTE related pregnancy, respectively. The most common causes of pregnancy related VTE are factor-V Leiden (FV-L), prothrombin G20210A and methylenetetrahyrofolate reductase (MTHFR) gene mutations. In pregnant women with hereditary thrombophilia, both VTE and adverse pregnancy outcomes including pregnancy loss, placental abruption and intrauterine growth retardation (IUGR) can be seen. Screening tests for hereditary thrombophilia should be done in VTE related to pregnancy or puerperium ,  recurrent pregnancy loss in the first and second trimester and   intrauterine fetal death. Additionally, these screening tests should also be recommended in pregnancy related complications such as severe preeclampsia, IUGR and placental abruption. These tests should be done especially after three months of pregnancy. Both low molecular weight heparin (LMWH) and unfractionated heparin are the choice of treatment in pregnancy-related VTE. These heparins do not penetrate placenta, so they are safe.  Recurrence of VTE in pregnancy is 1-13 %. The pregnant women who have antithrombin deficiency and history of VTE with all types of congenital thrombophilia are accepted to be in high-risk group and aggressive thromboprophylaxis should be done in these subjects. Pregnant women who had no history of VTE with heterozygote protein C deficiency and homozygote FV-L and prothrombin gene mutations and combined thrombophilia excluding antithrombin deficiency are in moderate group and thromboprophylaxis should also be done. Heterozygote protein S  deficiency, FV-L, prothrombin gene mutations are in low-risk for VTE, so that thromboprophylaxis should not be recommended. However, thromboprophylaxis should be performed in severe preeclampsia, recurrent pregnancy loss, intrauterine fetal death and IUGR and also air travels more than four hours. Thromboprophylaxis with LMWH should be done during the pregnancy and the first six weeks following labor thereafter.

Keywords

Hereditary thrombophilia, pregnancy and venous thromboembolism

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