1
|
Howley MM, Fisher SC, Van Zutphen AR, Papadopoulos EA, Patel J, Lin AE, Browne ML. Maternal exposure to heparin products and risk of birth defects in the National Birth Defects Prevention Study. Birth Defects Res 2023; 115:133-144. [PMID: 36458698 DOI: 10.1002/bdr2.2074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/14/2022] [Accepted: 07/21/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Heparin and low-molecular-weight heparin are the preferred anticoagulants during pregnancy as they do not cross the placenta. Although research on the safety of heparin products has been reassuring, previous studies have considered birth defects as a single outcome or by larger organ system and have not examined associations with specific birth defects. METHODS We analyzed data from the National Birth Defects Prevention Study, a multisite, population-based case-control study from 1997 to 2011. We used unconditional logistic regression with Firth's penalized likelihood to calculate adjusted odds ratios (ORs) and profile likelihood 95% confidence intervals (CIs) for defects with at least five exposed cases. For defects with 3-4 exposed cases, we estimated crude ORs and exact 95% CIs. RESULTS Of the 42,743 women in our analysis, 117 (0.4%) case and 44 (0.4%) control mothers reported using a heparin product in early pregnancy. The adjusted ORs ranged from 0.9 to 3.9 and were elevated for anorectal atresia (OR = 2.0, 95% CI = 0.8-4.3), longitudinal limb deficiency (3.5, 1.3-7.8), transverse limb deficiency (1.8, 0.6-4.3), atrioventricular septal defect (3.9, 1.4-9.0), and secundum atrial septal defect (2.2, 1.2-3.8). CONCLUSIONS We observed elevated associations for some birth defects, although heparin is a rare exposure, which limited our ability to evaluate many associations. Future studies that can explore specific birth defects and adequately control for confounding by indication are needed. Given that women with an indication for heparin products during pregnancy often need to take medication, one must remain mindful of the underlying risk of a birth defect that exists regardless of medication use.
Collapse
Affiliation(s)
- Meredith M Howley
- Birth Defects Registry, New York State Department of Health, Albany, New York, USA
| | - Sarah C Fisher
- Birth Defects Registry, New York State Department of Health, Albany, New York, USA
| | - Alissa R Van Zutphen
- Birth Defects Registry, New York State Department of Health, Albany, New York, USA.,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York, USA
| | - Eleni A Papadopoulos
- Birth Defects Registry, New York State Department of Health, Albany, New York, USA
| | - Jenil Patel
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, Texas, USA.,Arkansas Center for Birth Defects Research and Prevention, Fay W. Boozman College of Public Health, University of Arkansas for Medical Science, Little Rock, Arkansas, USA
| | - Angela E Lin
- Medical Genetics Unit, Department of Pediatrics, MassGeneral Hospital for Children, Boston, Massachusetts, USA
| | - Marilyn L Browne
- Birth Defects Registry, New York State Department of Health, Albany, New York, USA.,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York, USA
| | | |
Collapse
|
2
|
Jakobsen C, Larsen JB, Fuglsang J, Hvas AM. Mechanical Heart Valves, Pregnancy, and Bleeding: A Systematic Review and Meta-Analysis. Semin Thromb Hemost 2022. [PMID: 36174605 DOI: 10.1055/s-0042-1756707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Anticoagulant therapy is essential in pregnant women with mechanical heart valves to prevent valve thrombosis. The risk of bleeding complications in these patients has not gained much attention. This systematic review and meta-analysis investigate the prevalence of bleeding peri-partum and post-partum in women with mechanical heart valves and also investigate whether bleeding risk differed across anticoagulant regimens or according to delivery mode. The present study was conducted according to The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Studies reporting bleeding prevalence in pregnant women with mechanical heart valves receiving anticoagulant therapy were identified through PubMed and Embase on December 08, 2021. Data on bleeding complications, delivery mode, and anticoagulation therapy were extracted. A total of 37 studies were included, reporting 423 bleeding complications in 2,508 pregnancies. A meta-analysis calculated a pooled prevalence of 0.13 (95% confidence interval [CI]: 0.09-0.18) bleeding episodes per pregnancy across anticoagulant regimens. The combination of unfractionated heparin (UFH) and vitamin K antagonist (VKA) and single VKA therapy showed the lowest risk of bleeding (8 and 12%). Unexpectedly, the highest risk of bleeding was found in women receiving a combination of low-molecular-weight-heparin (LMWH) and VKA (33%) or mono-therapy with LMWH (22%). However, this could be dose related. No difference in bleeding was found between caesarean section versus vaginal delivery (p = 0.08). In conclusion, bleeding episodes are common during pregnancy in women with mechanical heart valves receiving anticoagulant therapy. A combination of UFH and VKA or VKA monotherapy showed the lowest risk of bleeding.
Collapse
Affiliation(s)
- Carina Jakobsen
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus C, Denmark
| | - Julie Brogaard Larsen
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus C, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Jens Fuglsang
- Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus C, Denmark
| | | |
Collapse
|
3
|
Nadeem S, Khilji SA, Ali F, Jalal A. Continued use of Warfarin in lower dose has safe maternal and neonatal outcomes in pregnant women with Prosthetic Heart Valves. Pak J Med Sci 2021; 37:933-938. [PMID: 34290762 PMCID: PMC8281195 DOI: 10.12669/pjms.37.4.3924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/18/2021] [Accepted: 03/18/2021] [Indexed: 11/15/2022] Open
Abstract
Background and Objective: There has been concerns regarding the safety of Warfarin in pregnant females due to its teratogenic potential. At the same time warfarin provides best anticoagulation in patients with prosthetic valves. Various dosage regimes have been tried to strike a balance between safety of mother and the avoidance of congenital anomalies in the newborn. This study was conducted to observe the effect of Warfarin in pregnant mothers taking different doses of warfarin, and their neonatal outcome, in our outdoor patients. Methods: This is a cross sectional observational study conducted at the Faisalabad Institute of Cardiology. The pregnant mothers taking warfarin for prosthetic valve replacement who presented to our specialized clinic between November 2016 to April 2017 were included in the study. These included a total of 75 females between the age of 20-35 years. To compare the dose related effect of warfarin, two groups of the patients were formed. One group comprised of patients taking warfarin ≤5mg while the other group consisted of those who were taking >5mg of warfarin daily. These patients were followed till their delivery. The information was collected about the maternal and fetal outcomes. The maternal outcomes including mode of delivery/miscarriage, peripartum bleeding and any valve related thromboembolic complications. The fetal outcomes included birth weight, maturity, embryopathy and congenital anomaly in the baby. Results: Patient’s mean age was 29.25±3.75 years. The mitral valve replacement was present in 60% patients (n=45) while 25.3% patients (n=19) had aortic valve replacement and 14.7% patients (n=11) had double valve replacement. In this group 30 patients (40%) had taken <5 mg warfarin and 45 patients (60%) had received >5 mg warfarin medicine. Miscarriages, cesarean sections, low birth weight and prematurity were more common in patients receiving warfarin >5 mg with p-values 0.005, 0.046, 0.01 and 0.033 respectively. No case of fetal embryopathy was found in both groups. Conclusion: No case of embryopathy was found in each group which signifies that warfarin in lower doses is safe anticoagulant in patients with prosthetic valve replacements.
Collapse
Affiliation(s)
- Shafaq Nadeem
- Shafaq Nadeem, FCPS. Consultant of Gynecology & Obstetrics The Clinic for Women with Cardiac Diseases, Department of Cardiac Surgery, Faisalabad Institute of Cardiology, Faisalabad, Pakistan
| | - Shabaz Ahmad Khilji
- Shahbaz Ahmad Khilji, FCPS. Associate Professor Department of Cardiac Surgery, Faisalabad Institute of Cardiology, Faisalabad, Pakistan
| | - Faisal Ali
- Faisal Ali, Dip Card. Consultant Cardiologist, Department of Cardiology, Faisalabad Institute of Cardiology, Faisalabad, Pakistan
| | - Anjum Jalal
- Anjum Jalal, FRCS-CTh. Professor of Cardiac Surgery, Executive Director, Faisalabad Institute of Cardiology, Faisalabad, Pakistan
| |
Collapse
|
4
|
Movahedi M, Motamedi M, Sajjadieh A, Bahrami P, Saeedi M, Saeedi M. Pregnancy outcome in women with mechanical prosthetic heart valvesat their first trimester of pregnancy treated with unfractionated heparin (UFH) or enoxaparin: A randomized clinical trial. J Cardiovasc Thorac Res 2020; 12:209-213. [PMID: 33123327 PMCID: PMC7581847 DOI: 10.34172/jcvtr.2020.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/03/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction: Pregnancy increases the risks of thromboembolism for the mother and fetus in patients with mechanical heart valves. The results of some studies have indicated that low molecular weight heparin (LMWH), in comparison with unfractionated heparin (UFH), leads to a lower incidence rate of thrombocytopenia and a decrease in bleeding. Methods: The present randomized clinical trial involved 31 pregnant women with mechanical heart valves at their first trimester (0-14 weeks) of pregnancy. To perform the study, the patients were divided into two groups, i.e. group A (LMWH group-16 patients) and group B (UFH group-15 patients). The birth weight, mode of delivery, and gestational age at birth as well as the maternal and fetal complications were compared between the two groups. Results: The mean age of mothers in the UFH and LMWH groups was 32.67±9.11 and 31.50±5.81years, respectively (P value > 0.05). Although the rate of maternal and fetal complications was higher in the UFH group as compared with the LMWH group, the observed difference was not significant (P value > 0.05). Conclusion: LMWH can be regarded as a safer therapy for both the mother and fetus due to its lower number of refill prescriptions and fewer changes in the blood level.
Collapse
Affiliation(s)
- Minoo Movahedi
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Motamedi
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amirreza Sajjadieh
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parvin Bahrami
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahmood Saeedi
- Department of Cardiac Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Milad Saeedi
- Department of General Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
5
|
Güner A, Kalçık M, Gürsoy MO, Gündüz S, Astarcıoğlu MA, Bayam E, Kalkan S, Yesin M, Karakoyun S, Özkan M. Comparison of Different Anticoagulation Regimens Regarding Maternal and Fetal Outcomes in Pregnant Patients With Mechanical Prosthetic Heart Valves (from the Multicenter ANATOLIA-PREG Registry). Am J Cardiol 2020; 127:113-119. [PMID: 32375999 DOI: 10.1016/j.amjcard.2020.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 01/22/2023]
Abstract
Mechanical prosthetic heart valves (MPHVs) are highly thrombogenic, and a pregnancy-induced procoagulant status increases the risk of MPHV thrombosis. Despite numerous case reports, 2 major registries and meta-analyses/systematic reviews, optimal anticoagulation therapy during pregnancy remains controversial. The goal of this study was to evaluate different anticoagulation regimens in pregnant patients with MPHVs. The outcomes of anticoagulation regimens were assessed retrospectively in pregnant women (110 women; 155 pregnancies) with MPHVs. The study population was divided into 5 groups according to anticoagulation regimens used; high-dose warfarin (>5 mg/d) throughout pregnancy (group 1), low-dose warfarin (≤5 mg/d) throughout pregnancy (group 2), low molecular weight heparin (LMWH) throughout pregnancy (group 3), first trimester LMWH, 2nd and 3rd trimester warfarin (group 4), first 2 trimester LMWH, and 3rd trimester warfarin (group 5). Of 155 pregnancies, 55 (35%) resulted in fetal loss; whereas 41 (27%) cases with abortion (miscarriage and therapeutic) and 14 (9%) stillbirths occurred. The comparison of the groups showed that the whole abortion rates including therapeutic abortion were significantly higher in Group 1, and lower in groups 3 and 5 (p <0.001). However, miscarriage rates were similar between the groups. A total of 53 pregnancies (34%) suffered from prosthetic valves thrombosis (PVT) during pregnancy or in the postpartum period. Group 2 had significantly lower rates of PVT than the other groups (p <0.001). In conclusion, the current data suggests that there is no optimal therapy, and that all managements have advantages and disadvantages. Low-dose warfarin (≤5 mg/day) regimen with therapeutic international normalized ratio levels may provide effective maternal protection throughout pregnancy with acceptable fetal outcomes.
Collapse
Affiliation(s)
- Ahmet Güner
- Department of Cardiology, Koşuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey.
| | - Macit Kalçık
- Department of Cardiology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Mustafa Ozan Gürsoy
- Department of Cardiology, Izmir Katip Çelebi University, Atatürk Training and Research Hospital, Izmir, Turkey
| | - Sabahattin Gündüz
- Department of Cardiology, Koşuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Ali Astarcıoğlu
- Department of Cardiology, Dumlupinar University, Kutahya Evliya Celebi Education and Research Hospital, Dumlupinar, Turkey
| | - Emrah Bayam
- Department of Cardiology, Koşuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Semih Kalkan
- Department of Cardiology, Koşuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Mahmut Yesin
- Department of Cardiology, Faculty of Medicine, Kars Kafkas University, Kars, Turkey
| | - Süleyman Karakoyun
- Department of Cardiology, Faculty of Medicine, Kars Kafkas University, Kars, Turkey
| | - Mehmet Özkan
- Department of Cardiology, Koşuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey; Faculty of Health Sciences, Ardahan University, Ardahan, Turkey
| |
Collapse
|
6
|
Abstract
Women who are pregnant or in the postpartum period have a fourfold to fivefold increased risk of thromboembolism compared with nonpregnant women (). Approximately 80% of thromboembolic events in pregnancy are venous (), with a prevalence of 0.5-2.0 per 1,000 pregnant women (). Venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the United States, accounting for 9.3% of all maternal deaths ().The prevalence and severity of this condition during pregnancy and the peripartum period warrant special consideration of management and therapy. Such therapy includes the treatment of acute thrombotic events and prophylaxis for those at increased risk of thrombotic events. The purpose of this document is to provide information regarding the risk factors, diagnosis, management, and prevention of thromboembolism, particularly VTE in pregnancy. This Practice Bulletin has been revised to reflect updated guidance regarding screening for thromboembolism risk and management of anticoagulation around the time of delivery.
Collapse
|
7
|
Abstract
Inherited thrombophilias are associated with an increased risk of venous thromboembolism and have been linked to adverse outcomes in pregnancy. However, there is limited evidence to guide screening for and management of these conditions in pregnancy. The purpose of this document is to review common thrombophilias and their association with maternal venous thromboembolism risk and adverse pregnancy outcomes, indications for screening to detect these conditions, and management options in pregnancy. This Practice Bulletin has been revised to provide additional information on recommendations for candidates for thrombophilia evaluation, updated consensus guidelines regarding the need for prophylaxis in women with an inherited thrombophilia during pregnancy and the postpartum period, and discussion of new published consensus guidelines from the Society for Obstetric Anesthesia and Perinatology addressing thromboprophylaxis and neuraxial anesthetic considerations in the obstetric population.
Collapse
|
8
|
Outcomes and Long-term Effects of Pregnancy in Women With Biologic and Mechanical Valve Prostheses. Am J Cardiol 2018; 122:1738-1744. [PMID: 30449326 DOI: 10.1016/j.amjcard.2018.07.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/19/2018] [Accepted: 07/23/2018] [Indexed: 11/20/2022]
Abstract
The optimal choice of prosthetic heart valve for women of child-bearing age is not well established. We conducted this retrospective cohort study to compare pregnancy outcomes and maternal mortality and morbidity, including long-term valve reoperation, between women with biologic and mechanical valve replacements. Women ≤50 years of age with prosthetic heart valve implantation and subsequent pregnancy in California, New Jersey, and New York State between 1990 to 2015 were identified using mandatory state inpatient databases. Average follow-up time was 9.4 years (SD 6.7 years). Of 11,930 women who underwent 14,017 valve replacements, pregnancies in 417 women with 241 biologic valves, and 217 mechanical valves were identified. Women with mechanical prostheses experienced significantly higher rates of pregnancy loss, with almost 2/3 of pregnancies ending in either spontaneous or induced abortion, and hemorrhage and thromboembolic events during delivery. Delivery was a significant risk factor for reoperation for both biologic (hazard ratio 2.5, 95% confidence interval 1.6 to 3.8 after time-dependent propensity matching) and mechanical (hazard ratio 2.3, 95% confidence interval 1.3 to 4.1 after time-dependent propensity matching) prostheses. Half of reoperations in women with mechanical valves who experienced pregnancy occurred within 1 year after delivery, and most were associated with mitral valve thrombosis. In conclusion, pregnancy accelerates time to reoperation for both biologic and mechanical prostheses. Mechanical valves are at particular risk for near-term valve failure after delivery, and compared with bioprostheses, are associated with higher rates of adverse events during pregnancy.
Collapse
|
9
|
Anticoagulation therapy in pregnant women with mechanical heart valve. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:38-44. [PMID: 32082709 DOI: 10.5606/tgkdc.dergisi.2018.15016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/03/2017] [Indexed: 11/21/2022]
Abstract
Background This study aims to investigate the effects of various anticoagulant regimens on prosthetic valve-related complications and pregnancy outcomes including feto-maternal mortality and morbidity, and to identify the most optimal anticoagulation therapy regimen. Methods Anticoagulant therapy regimens for pregnant women who underwent mechanical heart valve replacement between January 1990 and December 2015 was analyzed retrospectively. Seventy-two pregnancies among 57 patients after mechanical heart valve replacement were reviewed, and four different regimens were identified and evaluated during different trimesters of pregnancy. Results Forty of 72 pregnancies resulted in healthy newborns; 35 (48.6%) healthy neonates, four (5.6%) premature births, and one (1.4%) low birth weight. Eighteen (25%) therapeutic and 12 (16.7%) spontaneous abortions, as well as two (2.8%) stillbirths occurred. Seven valve thromboses developed during pregnancy or the postpartum period. Bleeding occurred in six patients (10.5%) and peripheral embolism also occurred in six patients (10.5%). No maternal mortalities were recorded. Conclusion Although there is no consensus on the most optimal anticoagulant regimen during pregnancy, substituting warfarin with dose-adjusted unfractionated heparin or low-molecularweight heparin seems suitable to prevent teratogenicity and a high abortion rate in the first trimester. Low-molecular-weight heparin is practical to use and can be monitored reliably, resulting in successful pregnancy outcomes. However, warfarin throughout pregnancy ≤5 mg per day may be an alternative choice, if the risk of embryopathy is accepted by the pregnant woman.
Collapse
|
10
|
Devis P, Knuttinen MG. Deep venous thrombosis in pregnancy: incidence, pathogenesis and endovascular management. Cardiovasc Diagn Ther 2017; 7:S309-S319. [PMID: 29399535 DOI: 10.21037/cdt.2017.10.08] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Deep venous thrombosis (DVT) during pregnancy is associated with high mortality, morbidity, and costs. Pulmonary embolism (PE), its most feared complication, is the leading cause of maternal death in the developed world. DVT can also result in long-term complications that include postthrombotic syndrome (PTS) adding to its morbidity. Women are up to 5 times more likely to develop DVT when pregnant. The current standard of care for this condition is anticoagulation. This review discusses the epidemiology, pathogenesis, prophylaxis and diagnosis of DVT during pregnancy, and then focuses on endovascular treatment modalities. Inferior vena cava (IVC) filter placement and pharmacomechanical catheter directed thrombolysis (PCDT) in the pregnant patient are discussed, as well as patient selection criteria, and complications.
Collapse
Affiliation(s)
- Paola Devis
- Department of Medical Imaging, Division of Interventional Radiology, The University of Arizona, Banner University Medical Center, Tucson, AZ, USA
| | - M Grace Knuttinen
- Department of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
11
|
Steinberg ZL, Dominguez-Islas CP, Otto CM, Stout KK, Krieger EV. Maternal and Fetal Outcomes of Anticoagulation in Pregnant Women With Mechanical Heart Valves. J Am Coll Cardiol 2017; 69:2681-2691. [PMID: 28571631 PMCID: PMC5457289 DOI: 10.1016/j.jacc.2017.03.605] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/26/2017] [Accepted: 03/28/2017] [Indexed: 01/18/2023]
Abstract
Background Anticoagulation for mechanical heart valves during pregnancy is essential to prevent thromboembolic events. Each regimen has drawbacks with regard to maternal or fetal risk. Objectives This meta-analysis sought to estimate and compare the risk of adverse maternal and fetal outcomes in pregnant women with mechanical heart valves who received different methods of anticoagulation. Methods Studies were identified using a Medline search including all publications up to June 5, 2016. Study inclusion required reporting of maternal death, thromboembolism, and valve failure, and/or fetal spontaneous abortion, death, and congenital defects in pregnant women treated with any of the following: 1) a vitamin K antagonist (VKA) throughout pregnancy; 2) low-molecular-weight heparin (LMWH) throughout pregnancy; 3) LMWH for the first trimester, followed by a VKA (LMWH and VKA); or 4) unfractionated heparin for the first trimester, followed by a VKA (UFH and VKA). Results A total of 800 pregnancies from 18 publications were included. Composite maternal risk was lowest with VKA (5%), compared with LMWH (16%; ratio of averaged risk [RAR]: 3.2; 95% confidence interval [CI]: 1.5 to 7.5), LMWH and VKA (16%; RAR: 3.1; 95% CI: 1.2 to 7.5), or UFH and VKA (16%; RAR: 3.1; 95% CI: 1.5 to 7.1). Composite fetal risk was lowest with LMWH (13%; RAR: 0.3; 95% CI: 0.1 to 0.8), compared with VKA (39%), LMWH and VKA (23%), or UFH and VKA (34%). No significant difference in fetal risk was observed between women taking ≤5 mg daily warfarin and those with an LMWH regimen (RAR: 0.9; 95% CI: 0.3 to 2.4). Conclusions VKA treatment was associated with the lowest risk of adverse maternal outcomes, whereas the use of LMWH throughout pregnancy was associated with the lowest risk of adverse fetal outcomes. Fetal risk was similar between women taking ≤5 mg warfarin daily and women treated with LMWH.
Collapse
Affiliation(s)
- Zachary L Steinberg
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Clara P Dominguez-Islas
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Karen K Stout
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Eric V Krieger
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
12
|
Canobbio MM, Warnes CA, Aboulhosn J, Connolly HM, Khanna A, Koos BJ, Mital S, Rose C, Silversides C, Stout K. Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2017; 135:e50-e87. [PMID: 28082385 DOI: 10.1161/cir.0000000000000458] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Today, most female children born with congenital heart disease will reach childbearing age. For many women with complex congenital heart disease, carrying a pregnancy carries a moderate to high risk for both the mother and her fetus. Many such women, however, do not have access to adult congenital heart disease tertiary centers with experienced reproductive programs. Therefore, it is important that all practitioners who will be managing these women have current information not only on preconception counseling and diagnostic evaluation to determine maternal and fetal risk but also on how to manage them once they are pregnant and when to refer them to a regional center with expertise in pregnancy management.
Collapse
|
13
|
Anticoagulation Regimens During Pregnancy in Patients With Mechanical Heart Valves: A Systematic Review and Meta-analysis. Can J Cardiol 2016; 32:1248.e1-1248.e9. [DOI: 10.1016/j.cjca.2015.11.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 10/30/2015] [Accepted: 11/04/2015] [Indexed: 11/24/2022] Open
|
14
|
Khader KAAM, Saad AS, Abdelshafy M. Pregnancy Outcome in Women with Mechanical Prosthetic Heart Valves Treated with Unfractionated Heparin (UFH) or Enoxaparin. J Obstet Gynaecol India 2016; 66:321-6. [PMID: 27486276 PMCID: PMC4958066 DOI: 10.1007/s13224-015-0678-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 02/16/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE This study was carried out to determine the maternal (including thromboembolic and hemorrhagic complications) and fetal outcomes (including miscarriage, stillbirth, baby death, and live birth) in women with mechanical heart valves managed with therapeutic doses of unfractionated heparin (UFH) versus enoxaparin during pregnancy. METHODS This is a prospective comparative, nonrandomized study. Pregnant women with mechanical heart valves presenting to high-risk pregnancy unit of Benha University Hospital, Egypt were treated with UFH 15,000 U/12 h versus enoxaparin (Clexane) 1 mg/kg SC/12 h during pregnancy and the results were analyzed. RESULTS 40 pregnant women were included in the study. In 20 pregnant women, anticoagulation was with UFH, and 20 pregnant women received enoxaparin. One (3 %) thrombotic complication occurred with enoxaparin treatment. Noncompliance or subtherapeutic levels contributed to this outcome in this case. Antenatal hemorrhage occurred in 4 (10 %) and postpartum hemorrhagic complications in 5 (12.5 %) pregnancies. Of the 32 pregnant women who continued after 20 weeks' gestation, 100 % (17/17) of the women taking predominantly UFH had a surviving infant compared with 93 % (14/15) of the women taking primarily enoxaparin (p = 0.25). One intrauterine fetal death occurred in the enoxaparin group. There was no significant difference in the live birth rates between the two groups (p = 0.31). CONCLUSIONS Compliance with therapeutic dose of UFH during pregnancy in women with mechanical heart valves is associated with a low risk of valve thrombosis and good fetal outcomes, but meticulous monitoring is essential.
Collapse
Affiliation(s)
- Khalid Abd Aziz Mohamad Khader
- Benha Faculty of Medicine and Benha University Hospital, Benha University, Egypt, El Qulyobia Governorate, El Sadat Street, Benha City, Egypt
| | - Ahmed Samy Saad
- Benha Faculty of Medicine and Benha University Hospital, Benha University, Egypt, El Qulyobia Governorate, El Sadat Street, Benha City, Egypt
| | - Mohammed Abdelshafy
- Benha Faculty of Medicine and Benha University Hospital, Benha University, Egypt, El Qulyobia Governorate, El Sadat Street, Benha City, Egypt
| |
Collapse
|
15
|
|
16
|
Akhtar RP, Abid AR, Zafar H, Cheema MA, Khan JS. Anticoagulation in Pregnancy with Mechanical Heart Valves: 10-Year Experience. Asian Cardiovasc Thorac Ann 2016; 15:497-501. [DOI: 10.1177/021849230701500610] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Anticoagulation in pregnancy was evaluated in 33 women with a mechanical heart valve prosthesis who had 53 pregnancies between 1994 and 2006. Their mean age at valve operation was 24.4 ± 5.4 years, and 22 (67%) had isolated mitral valve disease. Of these patients, 22 had a single pregnancy, 5 had 2 pregnancies, 3 had 3, and 3 had 4. In 43 pregnancies, the patients took warfarin throughout; in the other 10, heparin was used in the first trimester followed by warfarin until the last 15 days. Mean international normalized ratio and warfarin levels before, during, and after pregnancy were similar. Complications occurred in 3 (6%) women who had thrombosed valves: 2 (20%) in the heparin group and 1 (2%) who had warfarin only. Live births resulted from 37 (70%) pregnancies. There were significantly more abortions in the heparin group (6; 60%) than the warfarin group (8; 19%). Hemorrhage requiring transfusion occurred in 2 (5%) patients in the warfarin group. All live births resulted in healthy babies. It was concluded that anticoagulation with warfarin is safe during pregnancy in women with mechanical heart valves.
Collapse
Affiliation(s)
| | - Abdul R Abid
- Department of Cardiology, Punjab Institute of Cardiology, Lahore, Pakistan
| | | | | | | |
Collapse
|
17
|
van Hagen IM, Roos-Hesselink JW, Ruys TPE, Merz WM, Goland S, Gabriel H, Lelonek M, Trojnarska O, Al Mahmeed WA, Balint HO, Ashour Z, Baumgartner H, Boersma E, Johnson MR, Hall R. Pregnancy in Women With a Mechanical Heart Valve: Data of the European Society of Cardiology Registry of Pregnancy and Cardiac Disease (ROPAC). Circulation 2015; 132:132-42. [PMID: 26100109 DOI: 10.1161/circulationaha.115.015242] [Citation(s) in RCA: 204] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 05/01/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Pregnant women with a mechanical heart valve (MHV) are at a heightened risk of a thrombotic event, and their absolute need for adequate anticoagulation puts them at considerable risk of bleeding and, with some anticoagulants, fetotoxicity. METHODS AND RESULTS Within the prospective, observational, contemporary, worldwide Registry of Pregnancy and Cardiac disease (ROPAC), we describe the pregnancy outcome of 212 patients with an MHV. We compare them with 134 patients with a tissue heart valve and 2620 other patients without a prosthetic valve. Maternal mortality occurred in 1.4% of the patients with an MHV, in 1.5% of patients with a tissue heart valve (P=1.000), and in 0.2% of patients without a prosthetic valve (P=0.025). Mechanical valve thrombosis complicated pregnancy in 10 patients with an MHV (4.7%). In 5 of these patients, the valve thrombosis occurred in the first trimester, and all 5 patients had been switched to some form of heparin. Hemorrhagic events occurred in 23.1% of patients with an MHV, in 5.1% of patients with a tissue heart valve (P<0.001), and in 4.9% of patients without a prosthetic valve (P<0.001). Only 58% of the patients with an MHV had a pregnancy free of serious adverse events compared with 79% of patients with a tissue heart valve (P<0.001) and 78% of patients without a prosthetic valve (P<0.001). Vitamin K antagonist use in the first trimester compared with heparin was associated with a higher rate of miscarriage (28.6% versus 9.2%; P<0.001) and late fetal death (7.1% versus 0.7%; P=0.016). CONCLUSIONS Women with an MHV have only a 58% chance of experiencing an uncomplicated pregnancy with a live birth. The markedly increased mortality and morbidity warrant extensive prepregnancy counseling and centralization of care.
Collapse
Affiliation(s)
- Iris M van Hagen
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Jolien W Roos-Hesselink
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
| | - Titia P E Ruys
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Waltraut M Merz
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Sorel Goland
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Harald Gabriel
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Malgorzata Lelonek
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Olga Trojnarska
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Wael Abdulrahman Al Mahmeed
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Hajnalka Olga Balint
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Zeinab Ashour
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Helmut Baumgartner
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Eric Boersma
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Mark R Johnson
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Roger Hall
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | | |
Collapse
|
18
|
Berresheim M, Wilkie J, Nerenberg KA, Ibrahim Q, Bungard TJ. A case series of LMWH use in pregnancy: Should trough anti-Xa levels guide dosing? Thromb Res 2014; 134:1234-40. [DOI: 10.1016/j.thromres.2014.09.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 09/11/2014] [Accepted: 09/23/2014] [Indexed: 11/25/2022]
|
19
|
|
20
|
Tounsi A, Abid D, Louati D, Mallek S, Akrout M, Abid L, Abdennadher M, Frikha I, Chaabene K, Hentati M, Kammoun S. Anticoagulation in Pregnant Women with Mechanical Heart Valve Prostheses: 25-Year Experience at a Tertiary Care Hospital in a Developing Country. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/wjcd.2014.46037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
21
|
Chugh R. Management of Pregnancy in Women With Repaired CHD or After the Fontan Procedure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:646-62. [DOI: 10.1007/s11936-013-0263-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
22
|
Conti E, Zezza L, Ralli E, Comito C, Sada L, Passerini J, Caserta D, Rubattu S, Autore C, Moscarini M, Volpe M. Pulmonary embolism in pregnancy. J Thromb Thrombolysis 2013; 37:251-70. [DOI: 10.1007/s11239-013-0941-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
23
|
|
24
|
Castellano JM, Narayan RL, Vaishnava P, Fuster V. Anticoagulation during pregnancy in patients with a prosthetic heart valve. Nat Rev Cardiol 2012; 9:415-24. [DOI: 10.1038/nrcardio.2012.69] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
25
|
Mazibuko B, Ramnarain H, Moodley J. An audit of pregnant women with prosthetic heart valves at a tertiary hospital in South Africa: a five-year experience. Cardiovasc J Afr 2012; 23:216-21. [PMID: 22614667 PMCID: PMC3721885 DOI: 10.5830/cvja-2012-022] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 03/06/2012] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Cardiac disease in pregnancy is a common problem in under-resourced countries and a significant cause of maternal morbidity and mortality. A large proportion of patients with cardiac disease have prosthetic mechanical heart valve replacements, warranting prophylactic anticoagulation. AIM To evaluate obstetric outcomes in women with prosthetic heart valves in an under-resourced country. METHODS A retrospective chart review was performed of 61 pregnant patients with prosthetic valve prostheses referred to our tertiary hospital over a five-year period. RESULTS Sixty-one (6%) of 1 021 pregnant women with A diagnosis of cardiac disease had prosthetic heart valves. Fifty-nine had mechanical valves and were on prophylactic anticoagulation therapy, three had stopped their medication prior to pregnancy and two had bioprosthetic valves. There were forty-one (67%) live births, two (3%) early neonatal deaths, 12 (20%) miscarriages and six (10%) stillbirths. Maternal complications included mitral valve thrombosis (n = 4), atrial fibrillation (n = 8), infective endocarditis (n = 6), caesarean section wound haematomas (n = 7), broad ligament haematoma (n = 1) and warfarin embryopathy (n = 4). Haemorrhagic complications occurred in five patients and all five required blood transfusions. CONCLUSION Prophylactic anticoagulation with warfarin in patients with mechanical heart valve prostheses was associated with high rates of maternal and neonatal complications, including significant foetal wastage in the first and early second trimesters of pregnancy. Health professionals providing care for pregnant women with prosthetic heart valves must consistently advise on family planning matters, adherence to anticoagulation regimes and consider the use of prophylactic anticoagulant regimens other than warfarin, particularly during the first trimester of pregnancy.
Collapse
Affiliation(s)
- B Mazibuko
- Department of Obstetrics and Gynaecology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | | |
Collapse
|
26
|
Mechanical valve prosthesis and anticoagulation regimens in pregnancy: a tertiary centre experience. Eur J Obstet Gynecol Reprod Biol 2011; 159:320-3. [DOI: 10.1016/j.ejogrb.2011.09.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Revised: 07/15/2011] [Accepted: 09/01/2011] [Indexed: 10/17/2022]
|
27
|
Bian C, Wei Q, Liu X. Influence of heart-valve replacement of warfarin anticoagulant therapy on perinatal outcomes. Arch Gynecol Obstet 2011; 285:347-51. [DOI: 10.1007/s00404-011-1962-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Accepted: 06/20/2011] [Indexed: 10/18/2022]
|
28
|
McLintock C. Anticoagulant therapy in pregnant women with mechanical prosthetic heart valves: no easy option. Thromb Res 2011; 127 Suppl 3:S56-60. [DOI: 10.1016/s0049-3848(11)70016-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
29
|
|
30
|
Asano R, Nakano K, Kodera K, Murai N, Sasaki A, Ikeda M, Kataoka G, Yamaguchi A, Domoto S, Takeuchi Y. Premeditated reoperation after mitral valve replacement with a Starr-Edwards ball valve for young women who desire to bear a child: report of two cases. Surg Today 2009; 39:717-20. [PMID: 19639442 DOI: 10.1007/s00595-008-3882-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 10/06/2008] [Indexed: 11/27/2022]
Abstract
There are many difficulties for young women with a Starr-Edwards ball valve who want to attempt pregnancy. There is no consensus regarding whether they should maintain anticoagulation therapy throughout pregnancy with the risk of a thromboembolism or to undergo a reoperation with bioprosthetic heart valves, followed by a third operation when the valve deteriorates. This report presents two cases of young women who underwent mitral valve replacement (MVR) with Starr-Edwards ball valves (model 6120: 1M) during their childhood. Although they did not have any cardiac symptoms, transthoracic echocardiography and cardiac catheterization data demonstrated that both the patients had asymptomatic mild relative mitral stenosis. They both wished to bear a child. After the patients and their family provided thorough informed consent, redo MVRs were preformed safely with biological prostheses. The presence of significant pannus formation along the strut and sewing ring of the excised valves could also have a positive impact on the decision to undergo reoperation.
Collapse
Affiliation(s)
- Ryota Asano
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Medical Center East, Arakawa-ku, Tokyo, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Abstract
The purpose of this review is to summarize the epidemiology of venous thromboembolism (VTE) in pregnancy and describe strategies used to prevent and treat it. The main reason for the increased risk of VTE in pregnancy is hypercoagulability. The hypercoagulability of pregnancy, which has likely evolved to protect women from the bleeding challenges of miscarriage and childbirth, is present as early as the first trimester and so is the increased risk of VTE. Other risk factors include a history of thrombosis, inherited and acquired thrombophilia, certain medical conditions, and complications of pregnancy and childbirth. Candidates for anticoagulation are women with a current thrombosis, a history of thrombosis, thrombophilia, and a history of poor pregnancy outcome, or postpartum risk factors for VTE. For fetal reasons, the preferred agents for anticoagulation in pregnancy are heparins. There are no large trials of anticoagulants in pregnancy and recommendations are based on case series and the opinion of experts. Nonetheless, anticoagulants are believed to improve the outcome of pregnancy for women who have or have had VTE.
Collapse
Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27710, USA.
| |
Collapse
|
32
|
Fetal outcomes of critically ill pregnant women admitted to the intensive care unit for nonobstetric causes. Crit Care Med 2008; 36:2746-51. [PMID: 18828192 DOI: 10.1097/ccm.0b013e318186b615] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The outcome of the fetus in critically ill mothers has been briefly reported as a part of descriptive studies focusing on maternal risk factors for admission to the intensive care unit. We evaluated the risk factors for adverse fetal outcomes in critically ill pregnant women admitted to the intensive care unit for nonobstetrical reasons. DESIGN Retrospective cohort study of all critically ill pregnant patients >18 yr; admitted to four (medical, surgical, trauma, and mixed medical-surgical) intensive care units at the Mayo Clinic in Rochester, MN; during the period of January 1995 to December 2005. Only pregnant women admitted to the intensive care unit in the antepartum period for nonobstetrical indications were included. Main predictors for fetal outcomes included: maternal comorbidities, obstetrical history, intensive care unit interventions, and intensive care unit complications. Fetal outcomes were defined as spontaneous abortions, neonatal mortality, fetal deaths, admission to the neonatal intensive care unit, neonatal intensive care unit length of stay, and neonatal intensive care unit complications. RESULTS A total of 153 adult women (>18 yr) with a diagnosis of pregnancy were admitted to the intensive care unit, of whom 93 pregnant women met the inclusion criteria. Median maternal age was 26 yr (interquartile range 22-33) and median gestational age was 25 wk (interquartile range 8-33). The median maternal Acute Physiologic and Chronic Health Evaluation III score was 27 (interquartile range 17-38). There were 32 fetal losses; 18 were spontaneous abortions and 14 were fetal deaths. Ten neonates required neonatal intensive care unit admission, five for respiratory distress syndrome; and only one neonate died. The median neonatal intensive care unit length of stay was 34 days (interquartile range 15-87). After multivariable logistic regression analysis, the risk factors associated with fetal loss were: presence of maternal shock, odds ratio 6.85 (95% confidence interval 1.16-58, p = 0.04); maternal transfusion of blood products, odds ratio 7.24 (95% confidence interval 1.4-49, p = 0.02); and gestational age, odds ratio 1.2 for every gestational week below 37 wk (95% confidence interval 1.1-1.3, p < 0.001). CONCLUSIONS Nonobstetrical critical illness in pregnant women significantly affects fetal and neonatal outcomes. Maternal shock, maternal requirement of allogenic blood product transfusion and lower gestational age were associated with an increased risk of fetal loss.
Collapse
|
33
|
Bates SM, Greer IA, Pabinger I, Sofaer S, Hirsh J. Venous thromboembolism, thrombophilia, antithrombotic therapy, and pregnancy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:844S-886S. [PMID: 18574280 DOI: 10.1378/chest.08-0761] [Citation(s) in RCA: 609] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This article discusses the management of venous thromboembolism (VTE) and thrombophilia, as well as the use of antithrombotic agents, during pregnancy and is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that benefits do, or do not, outweigh risks, burden, and costs. Grade 2 recommendations are weaker and imply that the magnitude of the benefits and risks, burden, and costs are less certain. Support for recommendations may come from high-quality, moderate-quality or low-quality studies; labeled, respectively, A, B, and C. Among the key recommendations in this chapter are the following: for pregnant women, in general, we recommend that vitamin K antagonists should be substituted with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) [Grade 1A], except perhaps in women with mechanical heart valves. For pregnant patients, we suggest LMWH over UFH for the prevention and treatment of VTE (Grade 2C). For pregnant women with acute VTE, we recommend that subcutaneous LMWH or UFH should be continued throughout pregnancy (Grade 1B) and suggest that anticoagulants should be continued for at least 6 weeks postpartum (for a total minimum duration of therapy of 6 months) [Grade 2C]. For pregnant patients with a single prior episode of VTE associated with a transient risk factor that is no longer present and no thrombophilia, we recommend clinical surveillance antepartum and anticoagulant prophylaxis postpartum (Grade 1C). For other pregnant women with a history of a single prior episode of VTE who are not receiving long-term anticoagulant therapy, we recommend one of the following, rather than routine care or full-dose anticoagulation: antepartum prophylactic LMWH/UFH or intermediate-dose LMWH/UFH or clinical surveillance throughout pregnancy plus postpartum anticoagulants (Grade 1C). For such patients with a higher risk thrombophilia, in addition to postpartum prophylaxis, we suggest antepartum prophylactic or intermediate-dose LMWH or prophylactic or intermediate-dose UFH, rather than clinical surveillance (Grade 2C). We suggest that pregnant women with multiple episodes of VTE who are not receiving long-term anticoagulants receive antepartum prophylactic, intermediate-dose, or adjusted-dose LMWH or intermediate or adjusted-dose UFH, followed by postpartum anticoagulants (Grade 2C). For those pregnant women with prior VTE who are receiving long-term anticoagulants, we recommend LMWH or UFH throughout pregnancy (either adjusted-dose LMWH or UFH, 75% of adjusted-dose LMWH, or intermediate-dose LMWH) followed by resumption of long-term anticoagulants postpartum (Grade 1C). We suggest both antepartum and postpartum prophylaxis for pregnant women with no prior history of VTE but antithrombin deficiency (Grade 2C). For all other pregnant women with thrombophilia but no prior VTE, we suggest antepartum clinical surveillance or prophylactic LMWH or UFH, plus postpartum anticoagulants, rather than routine care (Grade 2C). For women with recurrent early pregnancy loss or unexplained late pregnancy loss, we recommend screening for antiphospholipid antibodies (APLAs) [Grade 1A]. For women with these pregnancy complications who test positive for APLAs and have no history of venous or arterial thrombosis, we recommend antepartum administration of prophylactic or intermediate-dose UFH or prophylactic LMWH combined with aspirin (Grade 1B). We recommend that the decision about anticoagulant management during pregnancy for pregnant women with mechanical heart valves include an assessment of additional risk factors for thromboembolism including valve type, position, and history of thromboembolism (Grade 1C). While patient values and preferences are important for all decisions regarding antithrombotic therapy in pregnancy, this is particularly so for women with mechanical heart valves. For these women, we recommend either adjusted-dose bid LMWH throughout pregnancy (Grade 1C), adjusted-dose UFH throughout pregnancy (Grade 1C), or one of these two regimens until the thirteenth week with warfarin substitution until close to delivery before restarting LMWH or UFH) [Grade 1C]. However, if a pregnant woman with a mechanical heart valve is judged to be at very high risk of thromboembolism and there are concerns about the efficacy and safety of LMWH or UFH as dosed above, we suggest vitamin K antagonists throughout pregnancy with replacement by UFH or LMWH close to delivery, after a thorough discussion of the potential risks and benefits of this approach (Grade 2C).
Collapse
Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Henderson Research Centre, Hamilton, ON, Canada.
| | - Ian A Greer
- Hull York Medical School, The University of York, York, UK
| | - Ingrid Pabinger
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Jack Hirsh
- Henderson Research Centre, Hamilton, ON, Canada
| |
Collapse
|
34
|
Abstract
Normal pregnancy is accompanied by an increase in clotting factors. The resulting hypercoagulable state has likely evolved to protect women from hemorrhage at the time of miscarriage and childbirth. During pregnancy, women are 4 times more likely to suffer from venous thromboembolism (VTE) compared with when they are not pregnant. Relative to pregnancy, the risk postpartum is even higher. The incidence of VTE is approximately 2 per 1,000 births, and VTE accounts for 1 death per 100,000 births, or approximately 10% of all maternal deaths. The most important risk factors during pregnancy are thrombophilia and a history of thrombosis. A history of thrombosis increases the risk for VTE to 2% to 12%. Thrombophilia increases not only the risk for maternal thrombosis but also the risk of poor pregnancy outcome. Despite the increased risk for thrombosis during pregnancy and the postpartum period, most women do not require anticoagulation. Those who do require anticoagulation include women with current VTE, women on lifelong anticoagulation, and many women with thrombophilia or a history of thrombosis. Recommended options for anticoagulation in pregnancy are limited to heparins, which do not cross the placenta. Low-molecular-weight heparin (LMWH) is preferred over unfractionated heparin because LMWH has a longer half-life and is presumed to have fewer side effects. The longer half-life is a disadvantage around the time of delivery, when unfractionated heparin, with its shorter half-life, is easier to manage. For women who develop or are at high risk for heparin-induced thrombocytopenia or severe cutaneous reactions, fondaparinux is probably the agent of choice. Women who do not require lifelong anticoagulation, but require anticoagulation during pregnancy, will still require anticoagulation for the first 6 weeks postpartum.
Collapse
Affiliation(s)
- Andra H James
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina 27710, USA.
| |
Collapse
|
35
|
Chugh R. Management of pregnancy in women with palliated and unpalliated congenital heart defects. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2007; 9:414-27. [PMID: 17897571 DOI: 10.1007/s11936-007-0062-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Medical advancements have made it possible for more women with congenital heart defects (CHDs) to carry successful pregnancies. Most CHD surgeries or interventions are palliative with persistent residua and sequelae exacerbated by the physiologic stresses of pregnancy. Preconception assessment, a tailored multidisciplinary approach during pregnancy, and a planned, elective delivery followed by careful postpartum monitoring may improve outcomes. Teratogenic medications should be stopped and changed to safer alternatives. Major hemodynamic changes in pregnancy, labor, and delivery may aggravate the underlying cardiovascular defects. Interventions or surgeries, when anticipated, should be performed before pregnancy. Antibiotic prophylaxis is indicated for nearly all palliated and unpalliated defects.
Collapse
Affiliation(s)
- Reema Chugh
- Adult Congenital Heart Disease and Heart Disease in Pregnancy, Kaiser Foundation Hospitals, Department of Cardiology, 13652 Cantara Street, Area 308, Panorama City, CA 91402, USA.
| |
Collapse
|
36
|
Abstract
Fifteen to 25% of thromboembolic events in pregnancy are recurrent events. Women with a history of thrombosis have a three- to fourfold increased risk of recurrence when they are pregnant compared with when they are not. The risks are even higher postpartum. The rate of recurrent venous thromboembolic events without anticoagulation is 2.4% to 12.2%, whereas the rate with anticoagulation is 0% to 2.4%. Because the rates of recurrent thromboembolism can be reduced with anticoagulation, women with a history of thrombosis who are not on lifelong anticoagulation will likely require anticoagulation during pregnancy, or at least during the postpartum period. Women who are already on lifelong warfarin for the prevention of recurrent venous thromboembolism should be counseled about the teratogenic effects of warfarin and offered the opportunity to be converted to heparin before conception. During pregnancy, low-molecular-weight heparin, with fewer side effects and a longer half-life, is generally preferred over unfractionated heparin. Unfractionated heparin with its shorter half-life is generally preferred around the time of delivery. Women on antiplatelet medication for prevention of arterial thromboembolism may be converted to low-dose aspirin after conception and supplemented with low-dose heparin or low-molecular-weight heparin during pregnancy. Because current recommendations rely on case series and expert opinion, additional studies including randomized trials might enhance our ability to prevent recurrent thromboembolism in pregnancy.
Collapse
Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27710, USA.
| | | | | | | |
Collapse
|
37
|
Kawamata K, Neki R, Yamanaka K, Endo S, Fukuda H, Ikeda T, Douchi T. Risks and pregnancy outcome in women with prosthetic mechanical heart valve replacement. Circ J 2007; 71:211-3. [PMID: 17251669 DOI: 10.1253/circj.71.211] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pregnancy after mechanical heart valve replacement is highly risky for both mother and child because of the aggravation of maternal heart function and adverse effects of anticoagulation therapy. In Japan, however, the risks and pregnancy outcomes in women with prosthetic mechanical heart valve replacement remain to be elucidated. METHODS AND RESULTS In the present study 16 pregnancies in 12 women with prosthetic mechanical heart valve replacement were identified between 1983 and 2005. At 6-13 weeks of gestational age, warfarin, an anticoagulant agent, was changed to heparin and administration was continuously adjusted according to the activated partial thromboplastin time level up to the time of delivery. Major maternal complications and pregnancy outcomes were retrospectively investigated. The valve replaced was mitral (n=7), tricuspid (n=7), and aortic (n=2). Eight (50%) of 16 had cesarean live births. One case was delivered at full term, and 7 cases were delivered preterm (26-36 weeks) because of maternal indications. Two babies died in the neonatal period. Therapeutic abortion was performed in 3 cases, 4 cases ended in early miscarriage, and 1 case ended in intrauterine fetal death (30 weeks). Three mothers developed valve (mitral, tricuspid, aortic) thrombosis. There was 1 maternal death from heart failure. CONCLUSIONS Pregnancy after mechanical heart valve replacement requires strict control of coagulation. Special attention should be paid to the occurrence of complications during anticoagulation therapy.
Collapse
Affiliation(s)
- Kazuya Kawamata
- Department of Perinatology, National Cardiovascular Center, Suita, Japan.
| | | | | | | | | | | | | |
Collapse
|
38
|
Lee JH, Park NH, Keum DY, Choi SY, Kwon KY, Cho CH. Low molecular weight heparin treatment in pregnant women with a mechanical heart valve prosthesis. J Korean Med Sci 2007; 22:258-61. [PMID: 17449934 PMCID: PMC2693592 DOI: 10.3346/jkms.2007.22.2.258] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
No definitive recommendation is available concerning optimal antithrombotic therapy in pregnant women with a mechanical heart valve. The purpose of the current study was to evaluate the clinical results of nadroparin treatment with respect to pregnancy outcome and maternal complications. From 1997 to 2005, 31 pregnancies were reviewed in 25 women. Nadroparin (7,500 U, twice daily) was used in 23 pregnancies between 6 and 12 weeks of gestation and close-to-term only, and coumarin derivatives were used with aspirin at other times. Eight pregnant women treated with coumarin derivatives throughout pregnancy were compared to evaluate the safety and efficacy of nadroparin. No maternal death or bleeding complication occurred in either of the two groups, and frequencies of maternal thromboembolism including valve thrombosis (8.7% vs. 12.5%, p>0.05) were similar. However, the frequencies of live born (91.3% vs. 50%, p=0.01) and healthy babies (90.4% vs. 25%, p<0.01) were significantly higher, and the fetal loss rate was significantly lower (8.7% vs. 50%, p=0.01) in the nadroparin-treated group. Regarding the efficacy and safety of antithrombotic treatment in pregnant women with prosthetic heart valves, nadroparin treatment during the first trimester is an acceptable regimen and produces better results than coumarin derivatives.
Collapse
Affiliation(s)
- Jae Hoon Lee
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Nam Hee Park
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Dong Yoon Keum
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sae Young Choi
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Ki Young Kwon
- Division of Hematology, Department of Internal Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chi Heum Cho
- Department of Gynecology and Obstetrics, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| |
Collapse
|
39
|
|
40
|
James AH, Brancazio LR, Gehrig TR, Wang A, Ortel TL. Low-molecular-weight heparin for thromboprophylaxis in pregnant women with mechanical heart valves. J Matern Fetal Neonatal Med 2006; 19:543-9. [PMID: 16966122 DOI: 10.1080/14767050600886666] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pregnancy in a woman with a mechanical heart valve is a life-threatening situation. Due to the inability of unfractionated heparin to prevent valvular thromboses, warfarin or other vitamin K antagonists have been the preferred anticoagulants for the mother. They are, however, potentially harmful to the fetus. With the advent of low-molecular-weight heparins, clinicians were hopeful for an alternative that was safe for the fetus, but more effective than unfractionated heparin, which carries a 29-33% risk of life-threatening thromboses and a 7-15% chance of mortality. Unfortunately, fatal thromboses have occurred with low-molecular-weight heparin as well. METHODS We searched the MEDLINE database and other sources to identify cases of the use of low-molecular-weight heparin for thromboprophylaxis in women with mechanical heart valves. RESULTS We found 73 cases and added three of our own for a total of 76. There were 17 thrombotic events (22%). Thirteen were valve thromboses, two were strokes, and two were myocardial infarctions. There were three deaths (4%). CONCLUSIONS While pregnant women with mechanical heart valves who receive low-molecular-weight heparin for thromboprophylaxis are at extremely high risk of life-threatening thromboses, there is no evidence that low-molecular-weight heparin is inferior to unfractionated heparin.
Collapse
Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27710, USA.
| | | | | | | | | |
Collapse
|
41
|
Huh J, Bakaeen F. Heart valve replacement: which valve for which patient? Curr Cardiol Rep 2006; 8:109-16. [PMID: 16524537 DOI: 10.1007/s11886-006-0021-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The ideal heart valve substitute would show no deterioration or thrombogenicity, offer no resistance to blood flow, and be easy to implant. However, such a valve does not exist and we must accept compromises in some of these qualities based on our patients' needs. In selection of cardiac valve prosthesis, valve-related factors such as durability, thrombogenicity, and fluid dynamics should be carefully matched to patient-related factors such as age, size, life expectancy, comorbidities, plans for pregnancy, and lifestyle. In addition, surgeon- or operation-related factors should be considered. Technical aspects of implantation, ease of reoperation, and operative mortalities may tip the risk and benefit balance in a particular direction. We review currently available heart valve prostheses and the clinical factors that are involved in selection of a heart valve substitute.
Collapse
Affiliation(s)
- Joseph Huh
- Michael E. DeBakey Veterans Affairs Medical Center (112), 2002 Holcombe Boulevard, Houston, TX 77030, USA.
| | | |
Collapse
|
42
|
Abstract
UNLABELLED Pregnancy is a hypercoagulable state that increases the risk of thromboembolic events. These risks may be further increased in the presence of an acquired or inherited thrombophilia. Thrombophilias have been associated with both maternal and fetal complications. The use of anticoagulants during pregnancy may reduce the risk of maternal thromboses as well as the risk of adverse pregnancy outcomes. The choice of an anticoagulant requires consideration of maternal risks, potential for teratogenicity, the underlying condition necessitating the treatment, and cost. This review examines the options for anticoagulation, the clinical situations that may warrant such treatment, and factors to be considered at delivery and during the postpartum period. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to describe the roles of acquired and inherited thrombophilia in furthering the hypercoagulable state of pregnancy, identify the potential consequences of using anticoagulants during pregnancy, and summarize the treatment options when anticoagulation is required during pregnancy.
Collapse
Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina 27710, USA.
| | | | | |
Collapse
|