Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature.

نویسندگان

  • W S Chan
  • S Anand
  • J S Ginsberg
چکیده

BACKGROUND The management of women with prosthetic heart valves during pregnancy poses a particular challenge as there are no available controlled clinical trials to provide guidelines for effective antithrombotic therapy. Oral anticoagulants such as warfarin sodium cause fetal embryopathy; subcutaneous administration of heparin sodium has been reported to be ineffective in preventing thromboembolic complications. OBJECTIVE To identify the risks of maternal and fetal complications in women with mechanical heart valves treated with different anticoagulation regimens during pregnancy. METHODS We performed a systematic review of the literature to determine pooled estimates of maternal and fetal risks associated with the 3 commonly used approaches: (1) oral anticoagulants (OA) throughout pregnancy, (2) replacing OA with heparin in the first trimester (from 6-12 weeks' gestation), and (3) heparin use throughout pregnancy. Fetal outcomes included spontaneous abortions and fetopathic effects, and maternal outcomes were major bleeding, thromboembolic complications, and death. RESULTS The use of OA throughout pregnancy is associated with warfarin embryopathy in 6.4% (95% confidence interval [CI], 4.6%-8.9%) of livebirths. The substitution of heparin at or prior to 6 weeks, and continued until 12 weeks, eliminated this risk. Overall risks for fetal wastage (spontaneous abortion, stillbirths, and neonatal deaths) were similar in women treated with OA throughout, compared with women treated with heparin in the first trimester. Maternal mortality was 2.9% (95% CI, 1.9%-4.2%). Maj or bleeding events occurred in 2.5% (95% CI, 1.7%-3.5%) of all pregnancies, most at the time of delivery. The regimen associated with the lowest risk of valve thrombosis (3.9%; 95% CI, 2.9-5.9%) was the use of OA throughout; using heparin only between 6 and 12 weeks' gestation was associated with an increased risk of valve thrombosis (9.2%; 95% CI, 5.9%-13.9%). CONCLUSIONS Thromboembolic prophylaxis of women with mechanical heart valves during pregnancy is best achieved with OA; however, this increases the risk of fetal embryopathy. Substituting OA with heparin between 6 and 12 weeks reduces the risk of fetopathic effects, but with an increased risk of thromboembolic complications. The use of low-dose heparin is definitely inadequate; the use of adjusted-dose heparin warrants aggressive monitoring and appropriate dose adjustment. Large prospective trials to determine the best regimen for these women are needed.

برای دانلود متن کامل این مقاله و بیش از 32 میلیون مقاله دیگر ابتدا ثبت نام کنید

ثبت نام

اگر عضو سایت هستید لطفا وارد حساب کاربری خود شوید

منابع مشابه

An audit of pregnant women with prosthetic heart valves at a tertiary hospital in South Africa: a five-year experience

BACKGROUND Cardiac disease in pregnancy is a common problem in under-resourced countries and a significant cause of maternal morbidity and mortality. A large proportion of patients with cardiac disease have prosthetic mechanical heart valve replacements, warranting prophylactic anticoagulation. AIM To evaluate obstetric outcomes in women with prosthetic heart valves in an under-resourced coun...

متن کامل

Pregnancy Outcome with Intracytoplasmic Sperm Injection Method in a Woman with Prosthetic Heart Valves

There is an increased risk of thromboembolism, anticoagulant-related hemorrhage, fetal-wastage and congestive cardiac failure in pregnant women with mechanical heart valves. In order to have a good outcome, the care of such patients must necessarily be multidisciplinary and in a well- equipped centre with adequate support services .One such patient who had mechanical mitral and aortic valves re...

متن کامل

Recommendations for the anticoagulation of pregnant patients with mechanical heart valves.

BACKGROUND The management of pregnant patients with mechanical heart valves remains challenging because there are no large randomised studies to provide guidelines for effective anticoagulant therapy. Both vitamin K antagonists and heparins may be associated with maternal and foetal adverse events. METHOD The Southern African Society of Thrombosis and Haemostasis reviewed available literature...

متن کامل

Antithrombotic Management of Patients with Prosthetic Heart Valves.

Valvular heart disease is a major public health issue. The prevalence of valvular heart disease is expected to increase due to an aging population. Valve dysfunction manifests as valve stenosis, regurgitation, or both, due to various etiologies. Valve repair and replacement are the main treatment options for severe valve dysfunction. Valve replacement is achieved by using either a mechanical or...

متن کامل

Anticoagulation in pregnant women with prosthetic heart valves.

The combination of heart disease and pregnancy can present a formidable challenge to the clinician entrusted to care for both the mother and fetus. Since most data is retrospective, a definitive prognosis for such a patient may be difficult to obtain. Nevertheless, certain cardiac conditions carry greater risks of maternal mortality than do others. However, even for certain preexisting conditio...

متن کامل

ذخیره در منابع من


  با ذخیره ی این منبع در منابع من، دسترسی به آن را برای استفاده های بعدی آسان تر کنید

برای دانلود متن کامل این مقاله و بیش از 32 میلیون مقاله دیگر ابتدا ثبت نام کنید

ثبت نام

اگر عضو سایت هستید لطفا وارد حساب کاربری خود شوید

عنوان ژورنال:
  • Archives of internal medicine

دوره 160 2  شماره 

صفحات  -

تاریخ انتشار 2000