Maternal and Fetal Outcomes in Pregnant Women with a Prosthetic Mechanical Heart Valve

Abstract

BACKGROUNDPregnancy is associated with several cardiocirculatory changes that can significantly impact underlying cardiac disease. These changes include an increase in cardiac output, sodium, and water retention leading to blood volume expansion, and reductions in systemic vascular resistance and systemic blood pressure. In addition, pregnancy results in a hypercoagulable state that increases the risk of thromboembolic complications.OBJECTIVESThe aim of this study is to assess the maternal and fetal outcomes of pregnant women with mechanical prosthetic heart valves (PHVs).METHODSThis is a prospective observational study that included 100 pregnant patients with cardiac mechanical valve prostheses on anticoagulant therapy. The main maternal outcomes included thromboembolic or hemorrhagic complications, prosthetic valve thrombosis, and acute decompensated heart failure. Fetal outcomes included miscarriage, fetal death, live birth, small-for-gestational age, and warfarin embryopathy. The relationship between the following were observed: – Maternal and fetal complications and the site of the replaced valve (mitral, aortic, or double)– Maternal and fetal complications and warfarin dosage (≤5 mg, >5 mg)– Maternal and fetal complications and the type of anticoagulation administered during the first trimesterRESULTSThis study included 60 patients (60%) with mitral valve replacement (MVR), 22 patients (22%) with aortic valve replacement (AVR), and 18 patients (18%) with double valve replacement (DVR). A total of 65 patients (65%) received >5 mg of oral anticoagulant (warfarin), 33 patients (33%) received ≤5 mg of warfarin, and 2 patients (2%) received low-molecular-weight heparin (LMWH; enoxaparin sodium) throughout the pregnancy. A total of 17 patients (17%) received oral anticoagulant (warfarin) during the first trimester: 9 patients received a daily warfarin dose of >5 mg while the remaining 8 patients received a daily dose of ≤5 mg. Twenty-eight patients (28%) received subcutaneous (SC) heparin calcium and 53 patients (53%) received SC LMWH (enoxaparin sodium). Prosthetic valve thrombosis occurred more frequently in patients with MVR (P = 0.008). Postpartum hemorrhage was more common in patients with aortic valve prostheses than in patients with mitral valve prostheses (P = 0.005). The incidence of perinatal death was higher in patients with AVR (P = 0.014). The incidence of live birth was higher in patients with DVR (P = 0.012). The incidence of postpartum hemorrhage was higher in patients who received a daily dose of >5 mg of warfarin than in patients who received ≤5 mg of warfarin (P = 0.05). The incidence of spontaneous abortion was also higher in patients receiving >5 mg of warfarin (P ≤ 0.001), while the incidence of live births was higher in patients receiving ≤5 mg of warfarin (P = 0.008). There was a statistically significant difference between the anticoagulant received during the first trimester and cardiac outcomes. Specifically, patients on heparin developed more heart failure (P = 0.008), arrhythmias (P =...

Maternal and fetal outcome among pregnant women following open heart surgery

“…12 However, there were 3% maternal deaths which is higher with this current study. 12 Shannon et al also reported a maternal mortality rate of 1-4% with prosthetic heart valves who required anticoagulation therapy. 13 But Hagen et al reported that, women with a prosthetic heart valve had 58% chance of experiencing an uncomplicated pregnancy and the maternal mortality rate is 1.4%.…”

“…11 Ayad et al observed that, 15% patients developed heart failure and prosthetic valve thrombosis was in 8%of patients. 12 However, there were 3% maternal deaths which is higher with this current study. 12 Shannon et al also reported a maternal mortality rate of 1-4% with prosthetic heart valves who required anticoagulation therapy.…”

“…14 Ayad et al observed in their study that, 52% pregnancies ended in healthy live births with prosthetic heart valve and 29% terminated in abortion. 12 However, only 2% infants were born with congenital anomalies. Our results are in concordance with Ashour et al study, who also found that 56% pregnancies resulted in healthy births.…”

Comparison of anticoagulation regimens for pregnant women with prosthetic heart valves: A meta‐analysis of prospective studies

“…Warfarin appears to offer the best protection against thromboembolic complications, but the risk of its teratogenic effect is the concern of the clinicians. Some reports indicate that the administration of warfarin is relatively safe during pregnancy if adequate anticoagulation can be achieved at doses of 5 mg or less . Hassouna conducted a systematic review and meta‐analysis to evaluate the merit of warfarin dose not exceeding 5 mg/d; 494 eligible pregnancies reported in 11 studies were included in the meta‐analysis.…”

Infective endocarditis in pregnant women

“…[22] от-метили ИЭ ИК у одной (1%) женщины, а S. Ayad и соавт. [23] при наблюдении состояния такого же числа беремен-ных -у 2 (2%). Тем не менее отсутствие первичной кла-панной патологии и благополучный анамнез не исключа-ют вероятность инфекционного поражения эндокарда во время беременности [24].…”