The Choices of Anticoagulants and their Effects on Pregnant Women with Metallic Prosthetic Heart Valves

Abstract Background: The management of a pregnant woman who has a metallic prosthetic heart valve requires important con-siderations especially for maintaining anticoagulation treatment and this represents a real challenge for the medical staff. Patients with mechanical valve prostheses are at high risk for thromboembolic events, valve thrombosis and mortality increases during pregnancy. Aim of Study: This study attempted to find the maternal outcome in pregnant women with prosthetic heart valve as regard to the choices of regimens of anticoagulation and comparing between warfarin and heparin regimens throughout pregnancy and the better choices of the anticoagulant treatment. Patients and Methods: This study is case series, interven-tional 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). The anticoagulation regimens used from the 1 st 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) pregnancies were on heparin regimen, and 28/119 pregnancies were on oral anticoagulant (warfarin). Results: The regimen (heparin warfarin heparin) has less maternal complications (31%) than warfarin (64.3%) and heparin (45%), however both (heparin warfarin heparin) regimen and (heparin) regimen were not protective against thrombotic complications which were (5.6%) (5%) respective-ly. Postpartum hemorrhage (PPH) was higher in cases used warfarin regimen (28.6%) with significant p-value (0.047), Women with prosthetic heart valveswere liable to have high rate of fetal complications (52.1 %) either due to anticoagulation treatment during pregnancy or due to cardiovascular impair-ment which also increase during pregnancy. Howeverthe regimen of (heparin-warfarin-heparin) seems to have the highest living birth rate (59/71) (83%) than both heparin alone (10/20) (50%) and warfarin alone (13/28) (46.4%) with significant p-value (0.002).
Conclusion: A mechanical heart valve is intended to replace a diseased heart valve with its prosthetic equivalent. The number of the pregnant women with metallic prosthetic valve increases and this necessities the need for proper follow-up of them, with concentration on the choices of anticoagulants to prevent valve thrombosis and follow-up of the mother and the fetus. Warfarin is the most protective anticoagulant for the mother, but mostly associated with lower live birth rate.