Anticoagulation for the Pregnant Patient with a Mechanical Heart Valve, No Perfect Therapy: Review of Guidelines for Anticoagulation in the Pregnant Patient

Peripartum Pharmacotherapy: A Pharmacist's Guide

Complications throughout the peripartum period may be caused by preexisting conditions or pregnancy-induced conditions and may alter pharmacotherapy management. Pharmacotherapy management during late pregnancy and delivery requires careful consideration due to changing hormones, hemodynamic status, and pharmacokinetics, and concerns for potential maternal and/or fetal morbidity. Increased maternal and fetal monitoring are often required and may lead to therapy changes. Pharmacists, as key members of the interprofessional team, can contribute essential perspective to the management of postpartum pharmacotherapy through assessment and recommendation of appropriate and judicious use of medications.

Coagulation conundrum in obstetric anesthesia with COVID-19

Coronavirus disease (COVID-19) pandemic is an unprecedented public health calamity that has caused an immense setback to maternal health services in developing countries. In addition to morbidity and mortality caused by COVID-19 disease in parturient directly, the indirect adverse impact of lockdown imposed during pandemic causing loss of follow-up of patients with coexisting illness is significant. There are no standard protocols to manage COVID-19 patients with comorbid medical illness, who are not optimized during antenatal visits. We report an interesting case of an antenatal patient with COVID-19, with prosthetic aortic valve on warfarin with elevated International Normalized Ratio (INR) and severe pre-eclampsia, posted for emergency cesarean section.

Mitral valve thrombosis in term pregnancy: A case report and review of the literature

OBJECTIVE

With this case report would like to emphasize the complexity that involves the management of pregnant women with mechanical heart valves. In that sense, an adequate interdisciplinary management of this potentially serious pathology is required for maternal and fetal well-being.

CASE REPORT

A 32-year-old primipara, with a mechanical mitral valve replacement, was admitted to our emergency department at 37⁺¹ weeks of gestation with acute dyspnea and presyncope. The patient was diagnosed with mechanical mitral valve thrombosis and, due to the appearance of hemodynamic instability, the patient underwent an uncomplicated emergency caesarean section and subsequent prosthetic mitral valve replacement. The patient was discharged six days after surgery, without any obstetric complication and with normal valve function.

CONCLUSION

This case report shows that, despite strict control and optimal anticoagulation regimen, pregnant women with mechanical heart valves still have a high risk of developing valve thrombosis.

State of the Art Management of Mechanical Heart Valves During Pregnancy

PURPOSE OF THE REVIEW

To review the management of women with mechanical heart valves during pregnancy, from preconception counseling through delivery with a summary of the latest guidelines.

RECENT FINDINGS

The hypercoagulability of pregnancy combined with the imperfect choices of anticoagulant agents contribute to a high risk of complications in pregnant women with mechanical heart valves. Valve thrombosis remains a major concern, much of which occurs during the first trimester transition to heparin-based products. The safest method of anticoagulation, with the best balance of maternal and fetal risk, is use of low-dose vitamin K antagonists, but only if therapeutic anticoagulation can be achieved with warfarin doses of ≤ 5 mg/day. Management of mechanical heart valves in pregnancy remains fraught with difficult decisions involving balancing of maternal and fetal risks as well as a high risk of maternal and fetal complications. Preconception counseling and planning is imperative. A risk-benefit discussion with the patient will help guide the choice of anticoagulation and outline the plan for safe delivery options. A multidisciplinary approach to management is advisable with close follow-up and care in a tertiary center.