Anticoagulation in Pregnant Women with Mechanical Heart Valve Prostheses: 25-Year Experience at a Tertiary Care Hospital in a Developing Country

Ahmed Tounsi, Dorra Abid, Doulira Louati, Souad Mallek, Malek Akrout, Leila Abid, Mohamed Abdennadher, Imed Frikha, Kais Chaabene, Mourad Hentati, Samir Kammoun

Cardiology Department, Hedi Chaker Hospital, Sfax, Tunisia.
Department of Cardiovascular Surgery, Habib Bourguiba Hospital, Sfax, Tunisia.
Obstetrics and Gynecology Department, Hedi Chaker Hospital, Sfax, Tunisia.

DOI: 10.4236/wjcd.2014.46037                

Abstract

The aim of this retrospective study was to compare the different anticoagulation regimens used in pregnant women with prosthetic heart valves. We reviewed 86 pregnancies in 57 women from 1987 to 2011. The patients were divided into two groups: group A (39 pregnancies) had oral acenocoumarol throughout pregnancy; and in group B (47 pregnancies), acenocoumarol was replaced by subcutaneous heparin during the first trimester. Both groups received heparin at the time of delivery. The valves replaced were mitral (59.65%), aortic (12.28%), or both (28.07%). 74 pregnancies (86.04%) resulted in live births, 9 (10.46%) had stillbirths, 1 (1.16%) had spontaneous abortion and 2 (2.32%) underwent therapeutic abortions. The live birth rate was higher in women on heparin (87.23%) compared with those on acenocoumarol (84.61%). No malformations appeared in the 74 newborns, except for one case of hydrocephalus. There was one maternal death due to acute mitral valvular thrombosis while on heparin in the first trimester. Hemorrhagic complications occurred in 13 patients in the postpartum period, 4 of whom required transfusion. No anticoagulant regimen can be said to be entirely safe for use during pregnancy as there is a degree of risk with each regimen. Heparin does not offer a clear advantage over oral anticoagulation in the pregnancy outcome.

Keywords

Anticoagulation, Pregnancy, Mechanical Heart Valve Prostheses, Maternal Complications, Heparin, Acenocoumarol

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Schafer, A.I. (1985) The Hypercoagulable States. Annals of Internal Medicine, 102, 814-828. http://dx.doi.org/10.7326/0003-4819-102-6-814
[2]	Vitale, N., De Feo, M., De Santo, L.S., Pollice, A., Tedesco, N. and Cotrufo, M. (1999) Dose-Dependent Fetal Complications of Warfarin in Pregnant Women with Mechanical Heart Valves. Journal of the American College of Cardiology, 33, 1637-1641. http://dx.doi.org/10.1016/S0735-1097(99)00044-3
[3]	Chan, W.S., Anand, S. and Ginsberg, J.S. (2000) Anti-coagulation of Pregnant Women with Mechanical Heart Valves: A Systematic Review of the Literature. Archives of Internal Medicine, 160, 191-196. http://dx.doi.org/10.1001/archinte.160.2.191
[4]	McLintock, C. (2011) Anti-coagulant Therapy in Pregnant Women with Mechanical Prosthetic Heart Valves: No Easy Option. Thrombosis Research, 127, S56-S60. http://dx.doi.org/10.1016/S0049-3848(11)70016-0
[5]	Sadler, L., McCowan, L., White, H., Stewart, L., Bracken, M. and North, R. (2000) Pregnancy Outcomes and Cardiac Complications in Women with Mechanical, Bioprosthetic and Homograft Valves. BJOG: An International Journal of Obstetrics & Gynaecology, 107, 245-253. http://dx.doi.org/10.1111/j.1471-0528.2000.tb11696.x
[6]	Hanania, G. (2001) Management of Anti-coagulants during Pregnancy. Heart, 86, 125-126. http://dx.doi.org/10.1136/heart.86.2.125
[7]	Vongpatanasin, W., Hullis, D.L. and Lange, R.A. (1996) Prosthetic Heart Valves. The New England Journal of Medicine, 335, 407-416. http://dx.doi.org/10.1056/NEJM199608083350607
[8]	Hirsh, J., Fuster, V., Ansell, J. and Halperin, J.L. (2003) American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy. Journal of the American College of Cardiology, 41, 1633-1652. http://dx.doi.org/10.1016/S0735-1097(03)00416-9
[9]	Baroletti, S.A. and Goldhaber, S.Z. (2006) Heparin-Induced Thrombocytopenia. Circulation, 22, e355-e356. http://dx.doi.org/10.1161/CIRCULATIONAHA.106.632653
[10]	Sbarouni, E. and Oakley, C.M. (1994) Outcome of Pregnancy in Women with Valve Prostheses. British Heart Journal, 71, 196-201. http://dx.doi.org/10.1136/hrt.71.2.196
[11]	Hall, J.G., Pauli, R.M. and Wilson, K.M. (1980) Maternal and fetal Sequelae and Anticoagulation during Pregnancy. The American Journal of Medicine, 68, 122-140. http://dx.doi.org/10.1016/0002-9343(80)90181-3
[12]	Ginsberg, J.S. and Hirsh, J. (1998) Use of Antithrombotic Agents during Pregnancy. Chest Journal, 114, 524S-530S. http://dx.doi.org/10.1378/chest.114.5_Supplement.524S
[13]	Nassar, A.H., Hobeika, E.M., Essamad, A.H.M., Taher, A., Khalil, A.M. and Usta, I.M. (2004) Pregnancy Outcome in Women with Prosthetic Heart Valves. American Journal of Obstetrics & Gynecology, 191, 1009-1013. http://dx.doi.org/10.1016/j.ajog.2004.05.064
[14]	Khamooshi, A.J., Kashfi, F., Hoseini, S., Tabatabaei, M.B., Javadpour, H. and Noohi, F. (2007) Anticoagulation for Prosthetic Heart Valves in Pregnancy. Is There an Answer? Asian Cardiovascular and Thoracic Annals, 15, 493-496. http://dx.doi.org/10.1177/021849230701500609
[15]	van Leeuwen, Y., Rosendaal, F.R. and van der Meer, F.J.M. (2008) The Relationship between Maintenance Dosages of Three Vitamin K Antagonists: Acenocoumarol, Warfarin and Phenprocoumon. Thrombosis Research, 123, 225-230. http://dx.doi.org/10.1016/j.thromres.2008.01.020
[16]	Salazar, E., Izaguirre, R., Verdejo, J.G., et al. (1996) Failure of Adjusted Doses of Subcutaneous Heparin to Prevent Thromboembolic Phenomena in Pregnant Patients with Mechanical Cardiac Valve Prostheses. Journal of the American College of Cardiology, 27, 1698-1703. http://dx.doi.org/10.1016/0735-1097(96)00072-1