Low molecular weight heparin for the prophylaxis of thromboembolism in women with prosthetic mechanical heart valves during pregnancy

Oran, Betül; Lee-Parritz, Aviva; Ansell, Jack

doi:10.1160/th04-06-0337

Cited by 133 publications

(36 citation statements)

References 35 publications

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“…49,50,[332][333][334][335][336][337][338][339][340] In a systematic review of observational studies between 1966 and 1997 that reported on outcomes with various anticoagulant regimens in pregnant women with mechanical prosthetic valves, the regimen associated with the lowest risk of valve thrombosis/systemic embolism was the use of vitamin K antagonists throughout pregnancy (3.9%). 49 The use of UFH in the fi rst trimester and near term was associated with a higher risk of valve thrombosis (9.2%).…”

Section: Anticoagulant Management Of Mechanical Prosthetic Valves In mentioning

confidence: 99%

“…332 Another systematic review of LMWH use in pregnant women with mechanical prosthetic heart valves that used slightly different eligibility criteria found that valve thrombosis occurred in seven of 81 pregnancies (8.6%; 95% CI, 2.5%-14.8%), and the overall thromboembolic rate was 10 of 81 pregnancies (12.4%; 95% CI, 5.2%-19.5%). 333 However, nine of the 10 patients with thromboembolic complications received a fi xed dose of LMWH, and in two of these, a fi xed low dose was used. Among 51 pregnancies in which anti-Xa LMWH levels were monitored and doses adjusted according to the result, only one patient was reported to have experienced a thromboembolic complication.…”

Section: E725smentioning

confidence: 99%

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VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy

Bates

Greer

Middeldorp

et al. 2012

Chest

1,310

591

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Summary of RecommendationsNote on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded. Abbreviations: APLA 5 antiphospholipid antibody; aPPT 5 activated partial thromboplastin time; HIT 5 heparin-induced thrombocytopenia; INR 5 international normalized ratio; LMWH 5 low-molecular-weight heparin; NNT 5 number needed to treat; PE 5 pulmonary embolism; RR 5 risk ratio; UFH 5 unfractionated heparin

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Section: Anticoagulant Management Of Mechanical Prosthetic Valves In mentioning

confidence: 99%

Section: E725smentioning

confidence: 99%

VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy

Bates

Greer

Middeldorp

et al. 2012

Chest

1,310

591

View full text Add to dashboard Cite

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“…4 In another review, Oran et al found an overall incidence of valve thrombosis of 8.64% (8/81) and the overall TE rate 12.35% (10/81). 5 However, 9 of these 10 patients received a fixed dose of LMWH, and in 2 of these a low fixed dose was used. Among 51 pregnancies where antiXa levels were monitored, only one patient was reported to have had TE.…”

Section: Introductionmentioning

confidence: 99%

Use of high intensity adjusted dose low molecular weight heparin in women with mechanical heart valves during pregnancy: a single-center experience

Quinn¹,

Klemperer²,

Brooks³

et al. 2009

Haematologica

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Brief Report IntroductionProvision of safe and effective anticoagulation for pregnant women with mechanical heart valves is a challenging management problem. All current anticoagulation regimens are associated with maternal thromboembolism (TE) and/or bleeding. Vitamin K antagonist (VKA) therapy throughout pregnancy results in the lowest observed risk of TE (3.9%). However, VKA use is associated with fetal anomaly rates of 6.4%, fetal death of 12% and neurodevelopmental problems.1,2 The rate of TE with unfractionated heparin (UFH) is high at 25% if used throughout pregnancy and 9% if used for the first trimester. 1 Therapeutic dose LMWH is an attractive alternative to VKAs and UFH. However, in the HIP-CAT study which compared enoxaparin with sequential UFH and warfarin in pregnant women with mechanical valves, 2/7 women receiving therapeutic dose enoxaparin 1 mg/kg 12 hourly developed fatal valve thrombosis. 3 The incidence of TE using LMWH in this setting is not known because of the limited data available, but James et al. found an overall TE rate of 22% and a maternal mortality of 4%. 4 In another review, Oran et al. found an overall incidence of valve thrombosis of 8.64% (8/81) and the overall TE rate 12.35% (10/81).5 However, 9 of these 10 patients received a fixed dose of LMWH, and in 2 of these a low fixed dose was used. Among 51 pregnancies where antiXa levels were monitored, only one patient was reported to have had TE. The American College of Chest Physicians (ACCP) advises that there are insufficient data for definitive recommendations on how best to anticoagulate women with mechanical valves in pregnancy, in view of concerns for fetal well-being with warfarin therapy and the possible poorer efficacy of subcutaneous UFH and LMWH in preventing maternal TE. 6 Recommendations have included adjusted dose LMWH throughout pregnancy to keep a 4 h post-dose anti-Xa level of 1.0-1.2 IU/mL although updated ACCP guidelines recommend adjusted dose LMWH to achieve the manufacturer's peak anti-Xa level 4 h post subcutaneous injection (approximately 1.0 IU/mL) with consideration of LDA in women with prosthetic heart valves at particularly high risk of thrombosis. 7Against this background, we conducted a prospective audit of our experience with the use of our dose-adjusted regimen of high intensity LMWH in pregnant women with mechanical heart valves, and documented TE and bleeding complications, pregnancy outcome, as well as anti-Xa levels throughout their pregnancies. Design and MethodsAll pregnancies in women with mechanical heart valves between 2001 and 2007 who received LMWH were included. The use of standard dose low molecular weight heparin (LMWH) to anticoagulate women with mechanical valves in pregnancy is associated with morbidity and mortality. We conducted a prospective audit of the use of adjusted dose high intensity LMWH in 12 pregnancies in 11 women with prosthetic heart valves. LMWH ± low-dose aspirin was started at therapeutic-dose with monitoring of anti-Xa levels to achieve a target level of 1.0-1.2 ...

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“…[3,[17][18][19][20] Tüm gebelik boyunca DMAH kullanıldığında herhangi bir tromboembolik komplikasyon oranı %12.3 kapak trombozu oranı ise %8.6 olarak bildirilirken, [17] bir başka çalışmada maternal tromboembolik olay oranı %4 [18] olarak bildirilmiştir. Saeed ve ark.…”

Section: Discussionunclassified

Clinical outcomes of pregnant women with mechanical heart valves

Küçüker¹

2014

Turk Gogus Kalp Dama

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Amaç: Bu çalışmada, mekanik kalp kapağı olan kadın hastaların gebelik öyküleri sorgulanarak, bu hastalara ideal yaklaşım stratejisi konusunda bir sonuca ulaşılması amaçlandı.Ça lış m a pla nı: Doğurganlık yaşında mekanik kalp kapağı takılmış olan 63 kadın hasta (ort. yaş 36.8 yıl; dağılım 22-48 yıl) çalışmaya dahil edildi. Kapak ameliyatı sonrası gebelik öyküleri sorgulandı. Yirmi dört hastada toplam 36 gebelik tespit edildi. Kendiliğinden veya medikal düşük, ölü doğum, canlı doğum, embriyopati, mekanik kapak trombozu veya herhangi bir tromboembolik olay kaydedildi. Bu hastalardaki gebelik süreci ve kullanılan antikoagülan ilaçlar ayrıntılı olarak sorgulandı. Bul gu lar:Toplam 36 gebeliğin klinik sonuçları şöyleydi: 10 canlı doğum (9 sağlıklı ve 1 varfarin embriyopatisi), ilk trimesterde gelişen 24 düşük (19 medikal düşük, 5 kendiliğinden düşük) ve iki ölü doğum. Düşük molekül ağırlıklı heparin (DMAH) kullanan üç hastada mekanik kalp kapağı trombozu nedeniyle acil ameliyat gerekli oldu. Bu hastalar tıbbi tahliye ve ölü doğum ile sağ kaldı. Sağlıklı doğum yapan hastalardan dördü gebelik boyunca DMAH; beşi ilk trimesterde DMAH, 12-36 haftalar arası varfarin, sonrasında doğuma kadar DMAH kullanmıştı. İlk trimesterde ≥5 mg varfarin kullanan bir hastada varfarin embriyopatisi gelişti.So nuç:Bu pilot çalışma sonuçları, mekanik kalp kapağı olan hastalarda ilginç olarak yüksek sayıda gebelik oluştuğunu ortaya koymaktadır. Mekanik kalp kapağı olan gebe kadınlara uygulanan genel yaklaşımın gebeliğin sonlandırılmasının olduğu görülmektedir; ancak sağlıklı doğumlar da mümkündür. Gebeliğini devam ettirmek isteyen kadınlarda kullanılan antikoagülasyon rejimleri ve sonuçları farklılık göstermekle beraber, birinin diğerine üstünlüğünü gösterecek bir bulguya henüz ulaşılamamıştır. Ancak, bu çalışma halen devam etmekte olan bir çalışma olup, daha fazla sayıda hasta ile görüşülerek, daha net ve güvenilir bir bilgiye ulaşılması amaçlanmaktadır.Anah tar söz cük ler: Antikoagülasyon; mekanik kalp kapağı; gebelik.Background:This study aims to investigate the pregnancy histories of women with mechanical heart valves and to establish a conclusion for an optimal management strategy for these patients.

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Low molecular weight heparin for the prophylaxis of thromboembolism in women with prosthetic mechanical heart valves during pregnancy

Cited by 133 publications

References 35 publications

VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy

VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy

Use of high intensity adjusted dose low molecular weight heparin in women with mechanical heart valves during pregnancy: a single-center experience

Clinical outcomes of pregnant women with mechanical heart valves

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