Haemorrhage and other complications in pregnant women on anticoagulation for mechanical heart valves: a prospective observational cohort study

Abstract

Objective: To document maternal and foetal morbidity and mortality in anticoagulated, pregnant patients with mechanical heart valves until 42 days postpartum. Methods: In a tertiary single-centre, prospective cohort, 178 consecutive patients at the cardiac-obstetric clinic were screened for warfarin use between 1 July 2010 and 31 December 2015. Of 33 pregnancies identified, 29 were included. Patients received intravenous unfractionated heparin from six to 12 weeks' gestation and peripartum, and warfarin from 12 to 36 weeks. Maternal outcomes including death, major haemorrhage and thrombosis, and foetal outcomes were documented. Results: There were two maternal deaths, five returns to theatre post-delivery, eight patients transfused, six major haemorrhages, one case of infective endocarditis and three ischaemic strokes. Ten pregnancies had poor foetal outcomes (six miscarriages, three terminations, one early neonatal death). Twenty patients required more than 30 days' hospitalisation, and 15 required three or more admissions. HIV positivity was associated with surgical delivery (p = 0.0017). Conclusions: Complication rates were high despite centralised care.

Mechanical Heart Valves, Pregnancy, and Bleeding: A Systematic Review and Meta-Analysis

“…1 Separate data on major bleeding could be found in six studies. 1 18 22 26 32 33 In these studies, 68 bleeding episodes in 490 women (13.9%) were noted. Two studies also included minor bleeding, 22 33 but the definition of minor bleeding was not clearly stated.…”

“…1 18 22 26 32 33 In these studies, 68 bleeding episodes in 490 women (13.9%) were noted. Two studies also included minor bleeding, 22 33 but the definition of minor bleeding was not clearly stated. The remaining 20 studies did not define bleeding complications 3 6 8 10 12 13 17 18 19 21 23 24 25 27 30 31 35 37 40 41 42 and can therefore cover both minor and/or major bleedings.…”

“…After duplicate removal, 247 studies were identified through database search and screened by title and abstract. A total of 37 studies were finally included 1 2 3 5 8 10 12 13 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 ( Table 1 ). In 22 of the included studies, data were retrospectively collected, 6 10 12 13 17 18 19 20 21 23 24 25 26 28 32 36 37 38 40 41 42 43 44 whereas 15 studies collected data prospectively.…”

“…5 29 43 44 Other studies defined major bleeding as a blood loss requiring transfusion. 2 5 26 29 33 Finally, some studies defined major bleeding as a decrease in hemoglobin of 0.62 mmol/L 1 29 33 or end-organ damage. 1 Separate data on major bleeding could be found in six studies.…”

“…The studies described five different anticoagulant regimens: VKA throughout the pregnancy 1 2 3 5 8 12 13 17 18 19 21 23 24 26 30 32 34 35 36 37 38 40 43 44 ; LMWH throughout the pregnancy 1 2 5 6 12 17 18 22 25 26 27 29 31 32 36 42 43 44 ; UFH throughout the pregnancy 1 13 17 19 21 25 27 36 38 41 ; combination therapy with either LMWH and VKA 2 12 18 20 25 26 32 36 44 ; or UFH and VKA. 3 8 10 12 13 19 20 21 25 28 30 33 35 36 37 43 Acros...…”