瓣膜置换术后妊娠患者抗凝治疗中的个体化决策与实践反思

Individualized Decision-Making for Anticoagulation Upon Pregnancy After Valve Replacement: A Clinical Reflection

关键词:  临床药师  心脏瓣膜置换术  低分子肝素  华法林

Key words:  clinical pharmacist  heart valve replacement  low molecular weight heparin  warfarin

摘要:

目的 通过一例机械瓣膜置换术后妊娠多次发生胎死宫内的病例，探讨临床药师在复杂抗凝管理中的角色与挑战。方法 以该患者的抗凝治疗过程为实例，围绕华法林转换时机、INR控制范围、低分子肝素剂量调整及监测频率等矛盾点展开讨论。结果 针对患者实际情况与指南推荐不一致的情况，临床药师需结合循证医学证据与个体化风险评估，协助制定合理用药方案。结论 临床药师应在多学科协作中发挥核心作用，通过动态评估、分层干预、全程监护的个体化抗凝管理模式，为类似复杂病例的临床实践提供参考。

Abstract:

OBJECTIVE To explore the role and challenges of clinical pharmacists in complex anticoagulation management through a case of multiple intrauterine fetal deaths in a pregnant patient after mechanical valve replacement. METHODS Using the anticoagulation therapy process of this patient as an example, key contradictions were discussed, including the timing of warfarin transition, INR target range, dosage adjustment of low-molecular-weight heparin, and monitoring frequency. RESULTS In situations where the patient’s actual condition is inconsistent with guideline recommendations, clinical pharmacists should integrate evidence-based medicine with individualized risk assessment to assist in formulating appropriate medication strategies. CONCLUSION Clinical pharmacists should play a central role in multidisciplinary collaboration and adopt an individualized anticoagulation management model characterized by dynamic evaluation, stratified intervention, and whole-process monitoring, thereby providing a reference for the clinical practice of similar complex cases.