Pregnancy in Patients After Valve Replacement

Abstract

This report is based on information obtainedfrom a questionnaire sent to major cardiac centres in the United Kingdom. This produced details of 39 pregnancies in 34 patients after valve replacement. The 39 pregnancies gave rise to 30 healthy babies. The small size of the series probably reflects both the increasing rarity ofyoung women with rheumatic heart disease in this country and the cautious attitude of their cardiologists. This makes it likely that these women represented the best end of the spectrum of cardiacfunction after valve replacement.Twenty-four pregnancies in 20 women who were not given anticoagulants produced 23 healthy babies and 1 spontaneous abortion. This group comprised 6 patients with free aortic homografts, 1 patient with a freefascia lata aortic valve, 2 with a Starr Edwards aortic valve, 7 with mounted mitral homografts, 1 with a fascia lata mitral valve, 1 with a Beall tricuspid prosthesis, 1 with a combined mitral homograft and Starr Edwards aortic prosthesis, and 1 with mitral and aortic frame-mounted fascia lata valves. There were no maternal deaths or thromboembolic complications in this group which included 5 patients who were in atrial fibrillation.Fifteen pregnancies in 14 women who received anticoagulants gave rise to 7 healthy babies. The fetal losses were one stillbirth, one intrauterine death at 34 weeks, and 3 spontaneous abortions; one surviving child has hydrocephalus as a result of blood clot and there were 2 maternal deaths. This group included 13 patients with Starr Edwards valves, 11 mitral and 2 aortic. A patient with a Hammersmith mitral valve was the only one to have been treated with heparin and her valve thrombosed. One patient with a mounted mitral homograft had a cerebral embolus. Nine of these patients were in atrialfibrillation.In 3 additional patients the valve replacement was carried out during pregnancy. Two of the patients survived operation. In one of these who was treated with warfarin the pregnancy gave rise to a congenitally malforned baby who died in the neonatal period. The baby born to the mother who did not receive anticoagulants has a hare-lip and talipes.Women with artificial valves can tolerate the haemodynamic load of pregnancy well, but there is an increased fetal wastage in patients taking oral anticoagulants. This is probably largely attributable to fetal haemorrhage but there is also a risk of malformation caused by a teratogenic effect of warfarin. Experience gained in non-pregnant patients suggests that withholding anticoagulants in pregnant patients with prosthetic valves would usually be undesirable but warfarin should be avoided. The advantages of biological valves were apparent in this series.Although rheumatic heart disease has become rare of child-bearing age who have had valve replaceamong our indigenous youth, its prevalence in many ments. These women need to know the risks of parts of the world remains unchanged and the pregnancy and the chances of having a healthy increasing frequency with which artificial valves are baby, but p...

Outcome of pregnancy in women with valve prostheses.

“…Most of the women in this study with a bioprosthesis went through pregnancy successfully without anticoagulant treatment. The fetal outcome was excellent and our data for this group do not differ from the normal population.6 This accords with previous reports.3 [7][8][9] The outcome was only slightly less favourable for the babies of mothers with mechanical valves. The difference did not reach statistical significance, except for prematurity.…”

Near fatal puerperal thrombosis on Bjork-Shiley mitral valve prosthesis.

“…Our patient received low doses of heparin and this undoubtedly predisposed to prosthetic valve malfunction, but thrombus formation had probably begun even while adequate levels of warfarin were being maintained. This reinforces the impression gained from the review of Oakley and Doherty (1976) that biological valves are the prostheses of choice for women who wish to become pregnant, and that, in any other situation, meticulous control of anticoagulation is required.…”

“…The case reported here illustrates a young lt. An electrowoman with good myocardial function whose , a QRS axis of desire to obtain a healthy infant at term, and also to depression and allow breast feeding, almost caused her death. y film showed Oakley and Doherty (1976) have reviewed exly, thrombosis perience of pregnancies in patients with valve prosin echocardio-theses in the United Kingdom, and biological valves (Fig. 2), and a are clearly preferable.…”

“…The most favourable outcome for fetus and mother is associated with biological valves which do not require lifelong anticoagulation (Oakley and Doherty, 1976). Coumarin anticoagulants in pregnant patients with non-biological valves may result in fetal malformation and haemorrhagic complications (Pettifor and Benson, 1975).…”

Cardiac disease in pregnancy

“…Cardiopulmonary bypass is associated with an increased risk to the fetus but no increased risk to the mother. One consequence of the increasing safety of heart valve replacement has been an increase in the number of young people with prosthetic heart valves (Oakley and Doherty, 1976). Whenever possible, 0032-5473/79/0500-0315$02.00 © 1979 The Fellowship of Postgraduate Medicine biological valves are to be preferred for women of child-bearing age, but if for any reason such a valve is not available then long-term anticoagulant therapy will be necessary.…”