术前活化部分凝血活酶时间检测与产科手术患者术中出血的相关性研究
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摘要
目的明确术前活化部分凝血活酶时间检测对产科术中出血评估的价值。方法对2013年3月至2015年7月间的9 783位18岁以上产科手术患者进行回顾性分析。根据术前APTT值,患者临床情况及干预方法对患者进行分组,比较对照组1与组2之间的术中大出血率和失血量。结果在所有调查患者中,有163人的APTT值超出正常对照值10 s,62人的APTT值超出正常对照值的1.5倍。剩余的患者中,随机抽取了256人作为正常病历组。在APTT值延长的2个组中,患者在术中出现大出血的概率(31.7%vs 40.3%vs 0.78%,P<0.05)以及其失血量(1 935.0 mL vs 2 757.4 mL vs 380.2 mL,P<0.05)均大于正常病历组。而在这些患者中,胎盘早剥、胎盘植入、前置胎盘、异位妊娠破裂、妊娠肝内胆汁淤积等都是较常见术前并发症,且这些病症大都可以在术前通过影像学检查或其他检验手段确认,除开此类患者外,剩余的APTT延长患者的术中大出血概率与病历组相比(2.38%vs 0%vs 0.91%,P>0.05)未见升高,失血量(202.76 mLvs 228.09 mL vs 322.13 mL,P<0.05)甚至偏低。同时,对产科此类非大出血性APTT延长的患者,术前输入含凝血因子的血浆(FFP)并不会对其术中出血的预防和控制有任何帮助,与没输FFP的患者相比,其大出血概率(5.41%vs 4.17%,P>0.05)和失血量(173.16 mL vs 180.97 mL,P>0.05)无差异。结论对中国的产科患者来说,APTT检测是1个能够预测术中出血的筛查方法。不过,查体、临床表现、影像学检查仍是更优选的检查手段。如果能通过上述手段确认存在高出血风险,APTT检测对于术中出血的预测能力将明显减弱。
Objective To evaluate the value of activated partial thromboplastin time examined pre-surgery to predict hemorrhage during caesarean section.Methods A retrospective review of 9 783 over-eighteen patients recorded during March 2013 to July 2015 was performed. The rate of major bleeding and the mount of blood loss during surgeries were compared among groups of patients divided by the value of preoperative APTT, patient department, measures of intervention. Results Among the 9 783 patients, 163 were confirmed with elevated APTT by 10 seconds longer than the normal contrast, while 62 were confirmed as 1.5 times higher than that of the normal contrast. Another 256 patients were selected from the rest randomly as the control group. Both elevated APTT groups showed much higher rates of major bleeding(31.7% vs 40.3% vs 0.78%, P<0.05)and volumes of blood loss(1 935.0 mL vs 2 757.4 mL vs 380.2 mL, P<0.05) than the control group. Patients from the gynecology department demonstrated similar results. In the elevated APTT group, placental abruption, placental implantation, placenta praevia, ectopic pregnancy ruputure, intrahepatic cholestatsis of pregnancy and preoperative massive hemorrhage were the common causes for hospitalization, indicating close relationship with bleeding or factors deficiency and could be confirmed before surgery by physical/imaging examination. Other elevated APTT patients would no longer have higher rate of major bleeding(2.38% vs 0% vs 0.91%, P>0.05) and even lower mount of blood losing(202.76 mL vs 228.09 mL vs 322.13 mL, P<0.05). For these patients with non-hemorrhage elevated APTT, FFP transfusion before surgery would bring no improvement to surgical bleeding control compared with those Non-FFS received. The rate of major bleeding(5.41% vs 4.17%, P>0.05)and the mount of blood loss(173.16 mL vs 180.97 mL, P>0.05) were same between the groups of patients with or without FFP intervention.Conclusion For Chinese patients from obstetrics departments, APTT is a good screen test to predict surgical hemorrhage. Meanwhile physical examination, clinical manifestation and imaging examination still have higher priority, especially for obstetric patients, as APTT would become useless while patients with high bleeding risk confirmed by those mentioned above are excluded.
Objective To evaluate the value of activated partial thromboplastin time examined pre-surgery to predict hemorrhage during caesarean section.Methods A retrospective review of 9 783 over-eighteen patients recorded during March 2013 to July 2015 was performed. The rate of major bleeding and the mount of blood loss during surgeries were compared among groups of patients divided by the value of preoperative APTT, patient department, measures of intervention. Results Among the 9 783 patients, 163 were confirmed with elevated APTT by 10 seconds longer than the normal contrast, while 62 were confirmed as 1.5 times higher than that of the normal contrast. Another 256 patients were selected from the rest randomly as the control group. Both elevated APTT groups showed much higher rates of major bleeding(31.7% vs 40.3% vs 0.78%, P<0.05)and volumes of blood loss(1 935.0 mL vs 2 757.4 mL vs 380.2 mL, P<0.05) than the control group. Patients from the gynecology department demonstrated similar results. In the elevated APTT group, placental abruption, placental implantation, placenta praevia, ectopic pregnancy ruputure, intrahepatic cholestatsis of pregnancy and preoperative massive hemorrhage were the common causes for hospitalization, indicating close relationship with bleeding or factors deficiency and could be confirmed before surgery by physical/imaging examination. Other elevated APTT patients would no longer have higher rate of major bleeding(2.38% vs 0% vs 0.91%, P>0.05) and even lower mount of blood losing(202.76 mL vs 228.09 mL vs 322.13 mL, P<0.05). For these patients with non-hemorrhage elevated APTT, FFP transfusion before surgery would bring no improvement to surgical bleeding control compared with those Non-FFS received. The rate of major bleeding(5.41% vs 4.17%, P>0.05)and the mount of blood loss(173.16 mL vs 180.97 mL, P>0.05) were same between the groups of patients with or without FFP intervention.Conclusion For Chinese patients from obstetrics departments, APTT is a good screen test to predict surgical hemorrhage. Meanwhile physical examination, clinical manifestation and imaging examination still have higher priority, especially for obstetric patients, as APTT would become useless while patients with high bleeding risk confirmed by those mentioned above are excluded.
引文
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[9] Weiling S,Qian C,Wei W,et al.Research of the efficiency of different lupus anticoagulant assays.Chinese Medical Journal,2015,95(34):2760-2765.
[10] Almesbah F,Mandiwanza T,Kaliaperumal C,et al.Routine preoperative blood testing in pediatric neurosurgery.J Neurosurg Pediatr,2013,12(6):615-621.
[11] Asaf T,Reuveni H,Yermiahu T,et al.The need for routine pre-operative coagulation screening tests (prothrombin time PT/partial thromboplastin time PTT) for healthy children undergoing elective tonsillectomy and/or adenoidectomy.Int J Pediatr Otorhinolaryngol,2001,61(3):217-222.
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[13] Stirling Y,Woolf L,North WR,et al.Haemostasis in normal pregnancy.Thrombosis and haemostasis,1984,52(2):176-182.
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[15] Bateman BT,Berman MF,Riley LE,et al.The epidemiology of postpartum hemorrhage in a large,nationwide sample of deliveries.Anesthesia and analgesia,2010.110(5):1368-1373.
[16] Sebire NJ,Jolly M,Harris JP,et al.Maternal obesity and pregnancy outcome:a study of 287,213 pregnancies in London.International journal of obesity and related metabolic disorders:journal of the International Association for the Study of Obesity,2001,25(8):1175-1182.
[17] Al-Zirqi I,Vangen S,Forsen L,et al.Prevalence and risk factors of severe obstetric haemorrhage.BJOG:an international journal of obstetrics and gynaecology,2008,115(10):1265-1272.
[18] Sosa CG,Althabe F,Belizan JM,et al.Risk factors for postpartum hemorrhage in vaginal deliveries in a Latin-American population.Obstetrics and gynecology,2009,113(6):1313-1319.
[19] Kramer MS,Rouleau J,Baskett TF,et al.Amniotic-fluid embolism and medical induction of labour:a retrospective,population-based cohort study.Lancet(London,England),2006,368(9545):1444-1448.
[20] Abenhaim HA,Azoulay L,Kramer MS,et al.Incidence and risk factors of amniotic fluid embolisms:a population-based study on 3 million births in the United States.American journal of obstetrics and gynecology,2008,199(1):49.e1-8.
[21] Knight M,Tuffnell D,Brocklehurst P,et al.Incidence and risk factors for amniotic-fluid embolism.Obstetrics and gynecology,2010,115(5):910-917.
[22] De SV,Chiusolo P,Paciaroni K,et al.Epidemiology of factor V Leiden:clinical implications.Seminars in Thrombosis & Hemostasis,1998,24(4):367-379.
[23] Chau KY,Yuen ST,Ng TH,et al.An autopsy study of pulmonary thromboembolism in Hong Kong Chinese.Pathology,1991,23(3):181-184.
[24] Nandi P,Wong KP,Wei WI,et al.Incidence of postoperative deep vein thrombosis in Hong Kong Chinese.British Journal of Surgery,1980,67(4):251-253.
[25] Tso SC,Wong V,Chan V,et al.Deep Vein Thrombosis and Changes in Coagulation and Fibrinolysis after Gynaecological Operations in Chinese:the Effect of Oral Contraceptives and Malignant Disease.British journal of haematology,1980,46(4):603-612.
[26] Shen YJ,Yao JF,Brar SS,et al.Racial/Ethnic Differences in the Risk of Intracranial Hemorrhage Among Patients With Atrial Fibrillation.Journal of the American College of Cardiology,2007,50(4):309-315.
[2] 中华医学会编.妇产科学分册-临床诊疗指南.北京:人民医学出版社,2012.
[3] Kamal AH,Tefferi A,Pruthi RK.How to Interpret and Pursue an Abnormal Prothrombin Time,Activated Partial Thromboplastin Time,and Bleeding Time in Adults.Mayo Clinic Proceedings,2007,82(7):864-873.
[4] 中华人民共和国卫生部医政司编.全国临床检验操作规程,4版,南京:东南大学出版社,2015.
[5] Hogshire LC,Patel MS,Edward Rivera MD,et al.Evidence review:Periprocedural use of blood products.Journal of Hospital Medicine An Official Publication of the Society of Hospital Medicine,2013,8(11):647-652.
[6] Holland LL,Brooks JP.Toward rational fresh frozen plasma transfusion:The effect of plasma transfusion on coagulation test results.American Journal of Clinical Pathology,2006(126):133-139.
[7] Thomas D,Wee M,Clyburn P,et al.Blood transfusion and the anaesthetist:management of massive haemorrhage.Anaesthesia,2010,65(11):1153-1161.
[8] Levy JH,Szlam F,Wolberg AS,et al.Clinical Use of the Activated Partial Thromboplastin Time and Prothrombin Time for Screening:A Review of the Literature and Current Guidelines for Testing.Clinics in Laboratory Medicine,2014,34(3):453-477.
[9] Weiling S,Qian C,Wei W,et al.Research of the efficiency of different lupus anticoagulant assays.Chinese Medical Journal,2015,95(34):2760-2765.
[10] Almesbah F,Mandiwanza T,Kaliaperumal C,et al.Routine preoperative blood testing in pediatric neurosurgery.J Neurosurg Pediatr,2013,12(6):615-621.
[11] Asaf T,Reuveni H,Yermiahu T,et al.The need for routine pre-operative coagulation screening tests (prothrombin time PT/partial thromboplastin time PTT) for healthy children undergoing elective tonsillectomy and/or adenoidectomy.Int J Pediatr Otorhinolaryngol,2001,61(3):217-222.
[12] van Veen JJ,Spahn DR,Makris M.Routine preoperative coagulation tests:an outdated practice?Br J Anaesth,2011,106(1):1-3.
[13] Stirling Y,Woolf L,North WR,et al.Haemostasis in normal pregnancy.Thrombosis and haemostasis,1984,52(2):176-182.
[14] Francalanci I,Comeglio P,Liotta AA,et al.D-dimer concentrations during normal pregnancy,as measured by ELISA.Thrombosis research,1995,78(5):399 405.
[15] Bateman BT,Berman MF,Riley LE,et al.The epidemiology of postpartum hemorrhage in a large,nationwide sample of deliveries.Anesthesia and analgesia,2010.110(5):1368-1373.
[16] Sebire NJ,Jolly M,Harris JP,et al.Maternal obesity and pregnancy outcome:a study of 287,213 pregnancies in London.International journal of obesity and related metabolic disorders:journal of the International Association for the Study of Obesity,2001,25(8):1175-1182.
[17] Al-Zirqi I,Vangen S,Forsen L,et al.Prevalence and risk factors of severe obstetric haemorrhage.BJOG:an international journal of obstetrics and gynaecology,2008,115(10):1265-1272.
[18] Sosa CG,Althabe F,Belizan JM,et al.Risk factors for postpartum hemorrhage in vaginal deliveries in a Latin-American population.Obstetrics and gynecology,2009,113(6):1313-1319.
[19] Kramer MS,Rouleau J,Baskett TF,et al.Amniotic-fluid embolism and medical induction of labour:a retrospective,population-based cohort study.Lancet(London,England),2006,368(9545):1444-1448.
[20] Abenhaim HA,Azoulay L,Kramer MS,et al.Incidence and risk factors of amniotic fluid embolisms:a population-based study on 3 million births in the United States.American journal of obstetrics and gynecology,2008,199(1):49.e1-8.
[21] Knight M,Tuffnell D,Brocklehurst P,et al.Incidence and risk factors for amniotic-fluid embolism.Obstetrics and gynecology,2010,115(5):910-917.
[22] De SV,Chiusolo P,Paciaroni K,et al.Epidemiology of factor V Leiden:clinical implications.Seminars in Thrombosis & Hemostasis,1998,24(4):367-379.
[23] Chau KY,Yuen ST,Ng TH,et al.An autopsy study of pulmonary thromboembolism in Hong Kong Chinese.Pathology,1991,23(3):181-184.
[24] Nandi P,Wong KP,Wei WI,et al.Incidence of postoperative deep vein thrombosis in Hong Kong Chinese.British Journal of Surgery,1980,67(4):251-253.
[25] Tso SC,Wong V,Chan V,et al.Deep Vein Thrombosis and Changes in Coagulation and Fibrinolysis after Gynaecological Operations in Chinese:the Effect of Oral Contraceptives and Malignant Disease.British journal of haematology,1980,46(4):603-612.
[26] Shen YJ,Yao JF,Brar SS,et al.Racial/Ethnic Differences in the Risk of Intracranial Hemorrhage Among Patients With Atrial Fibrillation.Journal of the American College of Cardiology,2007,50(4):309-315.