The Choices of Anticoagulants in Pregnant Women with Metallic Prosthetic Heart Valves and the Fetal Outcome

Abstract Background: Patients with mechanical valve prostheses are at high risk for thromboembolic events and mortality increases during pregnancy. The most effective anticoagulation for the mother is achieved with oral anticoagulants which may be associated with embryopathy in the baby. Heparin does not cross the placental barrier and does not cause em-bryopathy. All forms of unfractionated heparin are associated with a higher rate of maternal complications and death. This study attempted to find the fetal outcome in pregnant women with prosthetic heart valve and comparing between warfarin, heparin or heparin warfarin heparin regimens throughout pregnancy and the best choice between them. Aim of Study: To determine fetal outcomes, true incidence and the clinical impact of warfarin embryopathy and to make sensible recommendations for other future pregnancies as regard the better choice of the anticoagulant regimen. Patients and Methods: This study is case series, interven-tional prospective study which was done on pregnant women with metallic prosthetic heart valves. These women were presented to Kasr El-Aini Cairo University Hospital in the high risk pregnancy unit over duration of three years (from the first of January 2013 to the end of December 2015). including (112 women (119 pregnancies) with mechanical prosthetic heart valve; mean age was (29.13±5.3 years old), evaluating the pregnancy out come as regard; spontaneous abortion, therapeutic abortion due to congenital anomalies, intrauterine fetal death IUFD, neonatal deaths, preterm delivery babies, and low birth weight babies. Results: The anticoagulation regimens used from the 1st trimester in women with prosthetic metallic heart valves once they get pregnant were as following; (71/119) of pregnancies were on (heparin-warfarin-heparin) regimen, (20/119) preg-nancies were on heparin regimen, and 28/119 pregnancies were on oral anticoagulant (warfarin). Pregnancy outcomes of 119 pregnancies were as following, (57/119) resulted in full term babies, which were higher with (heparin-warfarin-heparin) (47/71) (66.2%) p-value (0.001). The total live births were higher with (heparin-warfarin-heparin) (59/71) (83%), lower with heparin (10/20) (50%) and least with warfarin (13/28) (46.4%) p-value (0.002). Heparin and warfarin regimens were associated with high missed abortion in the first trimester as diagnosed by ultrasound (40%) (35.7%), however due to congenital anomalies which was associated with war-farin dose more than 5mg and therapeutic abortion which was done after that, the rate of abortion with warfarin was (42.9%) with significant p-value (0.001). Preterm labor higher with warfarin regimen (25%) with significant p-value (0.009). Neonatal deaths were higher with warfarin regimen (10.7%) especially when warfarin dose was more than 5mg with significant p-value (0.045). Conclusion: Women with prosthetic heart valves liable to have high rate of fetal complications either due to antico-agulation treatment during pregnancy or due to cardiovascular impairment which also increase during pregnancy. However the regimen of (heparin-warfarin-heparin) seems to have the highest living birth than both heparin alone and warfarin alone. Both heparin and warfarin regimens were associated with high missed abortion in the first trimester as diagnosed by ultrasound, also neonatal deaths were higher with warfarin regimen especially when warfarin dose was more than 5mg.