探讨妊娠早中期肺栓塞的临床表现、诊断、治疗方案的选择及母婴结局。

根据北京大学深圳医院收治的1例及国内外文献报道的18例妊娠20周前肺栓塞的临床资料，对其治疗方案及母婴结局进行回顾性分析。

本例患者26岁，妊娠18^＋2周，因"胸闷15 h"于2022年4月28日收入北京大学深圳医院呼吸科，CT肺动脉血管造影提示急性大面积肺栓塞，给予肝素抗凝治疗，4月30日晨考虑病情稳定，改用依诺肝素钠抗凝治疗，当日夜间再次出现胸闷、呼吸困难、肺动脉压增高，急诊行介入下取栓＋溶栓治疗，术后因并发严重抗凝血酶Ⅲ缺乏(活性24%)出现肝素抵抗，经输注新鲜冰冻血浆、调整普通肝素剂量并桥接华法林后好转出院。该孕妇于2022年9月26日(妊娠39^＋5周)入院待产，9月28日放置宫颈扩张球囊＋静脉滴注催产素引产，最终经阴道分娩一健康活婴。PubMed检索文献报道的18例妊娠20周以内肺栓塞孕妇及本例孕妇，临床表现有呼吸困难(13/19)、胸痛/胸闷(9/19)、晕厥/昏迷(3/19)。19例肺栓塞孕妇行胸部CT、CT肺动脉造影或肺通气/灌注扫描诊断16例，行经胸超声心动图2例，1例未提及检查方法。其中14例患者在溶栓或手术前接受肝素或低分子肝素治疗。3例行肺栓塞切除术，10例行全身溶栓治疗，6例使用导管导向治疗。

妊娠期肺栓塞最常见的临床表现为呼吸困难及胸痛，主要依靠CT肺动脉血管造影进行诊断。治疗应遵循个体化原则，由多学科团队共同决策。对于血流动力学不稳定或高危患者，导管导向治疗因其高效率和相对较低的出血风险，可作为优先考虑的再通策略。规范的抗凝管理与围产期规划是获得良好母婴结局的关键。

To explore the clinical manifestations, diagnosis, treatment options, and maternal and infant outcomes of pulmonary embolism in early and middle pregnancy.

Based on the clinical data of 1 case admitted to Peking University Shenzhen Hospital and 18 cases reported in domestic and international literature of pulmonary embolism before 20 weeks of gestation, the treatment plans and maternal and infant outcomes were retrospectively analyzed.

The patient was a 26-year-old woman at 18^{+ 2} weeks of gestation, admitted to the Department of Respiratory Medicine, Peking University Shenzhen Hospital on April 28, 2022, with a complaint of " chest distress for 15 hours". Chest CT pulmonary angiography suggested acute massive pulmonary embolism, and heparin was administered for anticoagulation. On the morning of April 30, the condition was considered stable, and the treatment was switched to enoxaparin sodium. However, that night, chest distress and dyspnea recurred with increased pulmonary artery pressure. Emergency interventional thrombectomy and thrombolysis were performed. After the procedure, severe antithrombin Ⅲ deficiency (activity 24%) complicated by heparin resistance occurred. After infusion of fresh frozen plasma, adjustment of unfractionated heparin dosage, and bridging with warfarin, the patient improved and was discharged. The pregnant woman was admitted for delivery at 39^{+ 5} weeks of gestation on September 26, 2022. On September 28, a cervical dilation balloon was placed followed by intravenous oxytocin for induction of labor, and she eventually delivered a healthy live infant vaginally. A total of 18 cases of pregnant women with pulmonary embolism within 20 weeks of gestation were identified from the PubMed literature. Together with the present case, the clinical manifestations in the 19 cases were as follows: dyspnea (13/19), chest pain/chest tightness (9/19), syncope/unconsciousness (3/19). Among these 19 patients, 16 were diagnosed by chest CT, CT pulmonary angiography, or lung ventilation/perfusion scan, 2 by transthoracic echocardiography, and 1 did not mention the examination method. Of these, 14 patients received heparin or low-molecular-weight heparin before thrombolysis or surgery. Three cases underwent pulmonary embolectomy, 10 received systemic thrombolysis, and 6 received catheter-directed therapy.

Common clinical manifestations of pulmonary embolism in pregnancy include dyspnea and chest pain, and diagnosis mainly relies on CT pulmonary artery angiography. Treatment should follow the principle of individualization and be decided by a multidisciplinary team. For patients with hemodynamic instability or high risk, catheter-directed therapy can be considered as a priority reperfusion strategy because of its high efficiency and relatively low bleeding risk. Standard anticoagulant management and perinatal planning are key to achieving good maternal and infant outcomes.