Hostname: page-component-78c5997874-94fs2 Total loading time: 0 Render date: 2024-11-17T14:58:01.421Z Has data issue: false hasContentIssue false
  • English
  • Français

MECHANICAL HEART VALVES AND PREGNANCY

Part of: Bespoke shallow archive Weizmann

Published online by Cambridge University Press:  01 November 2007

CYNTHIA MAXWELL  and
MATHEW SERMER
CYNTHIA MAXWELL*
Affiliation:
Medical Disorders of Pregnancy Program, Division of Maternal Fetal Medicine, Mount Sinai Hospital, University of Toronto, Canada.
MATHEW SERMER
Affiliation:
Medical Disorders of Pregnancy Program, Division of Maternal Fetal Medicine, Mount Sinai Hospital, University of Toronto, Canada.
*
Cynthia Maxwell, Mount Sinai Hospital, Department of Obstetrics and Gynaecology, 600 University Avenue, Toronto ON, M5G 1X5Canada.
Get access Rights & Permissions [Opens in a new window]

Extract

Mechanical heart valves pose a particular challenge in pregnancy, as the primary agent used to prevent valve thrombosis, coumadin (warfarin), is a known teratogen. Alternatives to coumadin, such as unfractionated heparin (UFH) and low-molecular weight heparin (LMWH) are safer for the fetus, particularly during the first trimester of pregnancy, but expose the mother to potential valve failure. This review will examine these controversies and the complex literature regarding management in pregnancy.

Type
Research Article
Information
Fetal and Maternal Medicine Review , Volume 18 , Issue 4 , November 2007 , pp. 311 - 331
Copyright
Copyright © Cambridge University Press 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1Kardon, E. Prosthetic heart valves. 2007. eMedicine internet site. www.emedicine.com/emerg/topic797.htm.Google Scholar
2Goldsmith, I, Turpie, AGG, Lip, GYH. ABC of antithrombotic therapy. Valvuar heart disease and prosthetic heart valves. Br Med J 2002; 325: 1228–231.CrossRefGoogle Scholar
3Salem, DN, Stein, PD, Al-Ahmad, A, Bussey, HI, Horskotte, D, Miller, N et al. Antithrombotic therapy in valvular heart disease – native and prosthetic: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 457–82.CrossRefGoogle ScholarPubMed
4Baudet, EM, Puel, V, McBride, JT, Grimaud, JP, Roques, F, Clerc, F et al. Long-term results of valve replacement with the St. Jude Medical prosthesis. J Thorac Cardiovasc Surg 1995; 109: 858–70.CrossRefGoogle ScholarPubMed
5Bjork, VO, Henze, A. Management of thrombo-embolism after aortic valve replacement with the Bjork-Shiley tilting disc valve: medicamental prevention with dicumarol in comparison with dipyrimidamole-acetylsalicylic acid; surgical treatment of prosthetic thrombosis. Scand J Thorac Cardiovasc Surg 1975; 9: 183–91.CrossRefGoogle ScholarPubMed
6Cappelleri, JC, Fiore, LD, Brophy, MT, Deykin, D, Lau, J. Efficacy and safety of combined anticoagulant and antiplatelet therapy versus anticoagulant monotherapy after mechanical heart valve replacement: a meta analysis. Am Heart J 1995; 130: 547–52.CrossRefGoogle Scholar
7Born, D, Martinez, EE, Almeida, PAM, Santos, DV, Carvalho, ACC, Moron, AF. Pregnancy in patients with prosthetic heart valves: the effect of anticoagulation on mother, fetus and neonate. Am Heart J 1992; 124: 413–17.CrossRefGoogle ScholarPubMed
8Sbarouni, E, Oakley, CM. Outcome of pregnancy in women with valve prostheses. Br Heart J 1994; 71: 196–201.CrossRefGoogle ScholarPubMed
9Hanania, G, Thomas, D, Michel, PL, Garbarz, E, Age, C, Millair, A et al. Grossesses chez les porteuses de prostheses valvulaires: etude cooperative retrospective francaise (155 cas). [Pregnancy in patients with heart valve prosthesis. A French retrospective cooperative study (155 cases)] Arch Mal Coeur Vaiss 1994; 87: 429–37.Google ScholarPubMed
10Lee, CN, Wu, CC, Lin, PY, Hsieh, FJ, Chen, HY. Pregnancy following cardiac prosthetic valve replacement. Obstet Gynecol 1994; 83: 353–56.Google ScholarPubMed
11Denbow, CE, Matadial, L, Sivapragasam, S, Spencer, H. Pregnancy in patients after homograft cardiac valve replacement. Chest 1983; 83: 540–42.CrossRefGoogle ScholarPubMed
12Dore, A, Somerville, J. Pregnancy in patients with pulmonary autograft valve replacement. Eur Heart J 1997; 18: 1659–62.CrossRefGoogle ScholarPubMed
13Elkayam, U. Editorial comment. Pregnancy through a prosthetic heart valve. J Am Coll Card 1999; 33: 1642–45.Google ScholarPubMed
14McLeod, AG, Ellis, C. Prevention and treatment of venous thromboembolism in high risk situations in pregnancy. Fet Mat Med Rev 2005; 16: 151–70.CrossRefGoogle Scholar
15Ginsberg, JS, Brill-Edwards, P, Burrows, RF, Bona, R, Prandoni, P, Buller, HR et al. Venous thrombosis during pregnancy: leg and trimester of presentation. Thromb Haemost 1992; 67: 519–20.Google ScholarPubMed
16Gherman, RB, Goodwin, TM, Leung, B, Byrne, JD, Hethumumi, R, Montoro, M. Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy. Obstet Gynecol 1999; 94: 730–34.Google ScholarPubMed
17Ray, JG, Chan, WS. Deep vein thrombosis during pregnancy and the puerperium: a meta-analysis of the period of risk and the leg of presentation. Obstet Gynecol Surv 1999; 54: 265–71.CrossRefGoogle ScholarPubMed
18Ginsberg, JS, Hirsh, J, Turner, DC, Levine, MN, Burrows, R. Risks to the fetus of anticoagulant therapy during pregnancy. Thromb Haemost 1989; 61: 197–203.Google Scholar
19Hall, JAG, Paul, RM, Wilson, KM. Maternal and fetal sequelae of anticoagulation during pregnancy. Am J Med 1980; 68: 122–140.CrossRefGoogle ScholarPubMed
20Chan, WS, Anand, S, Ginsberg, JS. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. Arch Int Med 2000; 160: 191–96.CrossRefGoogle Scholar
21Robin, F, Lecuru, F, Desfeux, P, Boucaya, B, Taurelle, R. Anticoagualation therapy in pregnancy. Eur J Obstet Gynecol Reprod Biol 1999; 83: 171–77.CrossRefGoogle Scholar
22Shaul, WL, Hall, JG. Multiple congenital anomalies associated with oral anticoagulants. Am J Obstet Gynecol 1997; 127: 191–95.CrossRefGoogle Scholar
23Ginsberg, JS, Kowalchuk, G, Hirsh, J, Brill-Edwards, P, Burrows, R. Heparin therapy during pregnancy: risk to the fetus and mother. Arch Int Med 1989; 149: 2233–36.CrossRefGoogle Scholar
24Shapira, Y, Sagie, A, Battler, A. Low-molecular-weight heparin for the treatment of patients with mechanical heart valves. Clin Cardiol 2002; 25: 323–27.CrossRefGoogle ScholarPubMed
25Groce, JB. “Bridging” therapy with low molecular weight heparin in pregnant patients and patients with mechanical prosthetic heart valves. J Thromb Thrombolysis 2003; 16: 79–82.CrossRefGoogle ScholarPubMed
26Stein, PD, Alpert, JS, Bussey, HI, Dalen, JE, Turpie, AGG. Antithrombotic therapy in patients with mechanical and bioprosthetic heart valves. Chest 2001; 119: 220–27.CrossRefGoogle Scholar
27Montalescot, G, Polle, V, Collet, JP, Leprince, P, Bellanger, A, Gandjbakhch, I. Low molecular weight heparin after mechanical heart valve replacement. Circulation 2000; 1010: 1083–1086.CrossRefGoogle Scholar
28Maxwell, CV, Poppas, A, Dunn, E, Sermer, M. Pregnancy, mechanical heart valves and anticoagulation: Navigating the complexities of management during gestation. In: Rosene-Montella, K, Keely, EJ, Lee, RV, Barbour, LA (eds) From Medical Care of the Pregnant Patient, 2nd Edition. Philadelphia, American College of Physicians, 2007; 344–355.Google Scholar
29Bates, SM, Greer, IA, Hirsh, J, Ginsberg, JS. Conference on antithrombotic and thrombolytic therapy use of antithrombotic agents during pregnancy – The seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 627–44.CrossRefGoogle ScholarPubMed
30Lepercq, J, Conard, J, Borel-Derlon, A, Darmon, JY, Boudignat, O, Francoual, C et al. Venous thromboembolism during pregnancy: a retrospective study of enoxaparin safety in 624 pregnancies. BJOG 2001; 108: 1134–140.Google ScholarPubMed
31Forestier, F, Daffos, F, Capella-Pavlovsky, M. Low molecular weight heparin (PK 10169) does not cross the placenta during the second trimester of pregnancy: study by direct fetal blood sampling under ultrasound. Thromb Res 1984; 34: 557–60.CrossRefGoogle Scholar
32Sanson, BJ, Lensing, AW, Prins, MH, Ginsberg, JS, Barkagan, ZS, Lavenne-Pardonge, E et al. Safety of low molecular weight heparin in pregnancy; a systematic review. Thromb Haemost 1999; 81: 669–72.CrossRefGoogle ScholarPubMed
33Hunt, BJ, Doughty, HA, Majumdar, G, Copplestone, A, Kerslake, S, Buchanan, N et al. Thromboprophylaxis with low molecular weight heparin (Fragmin) in high risk pregnancies. Thromb Haemost 1997; 77: 39–43.Google ScholarPubMed
34Nelson-Piercy, C, Letsky, EA, de Swiet, M. Low molecular weight heparin for obstetric thromboprophylaxis: experience of sixty-nine pregnancies in sixty-one women at high risk. Am J Obstet Gynecol 1997; 176: 1062–1068.CrossRefGoogle ScholarPubMed
35Warkentin, TE, Levine, MN, Hirsh, J, Horsewood, P, Roberts, RS, Gent, M et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. NEJM 1995; 332:1330–336.CrossRefGoogle ScholarPubMed
36de Valk, HW, Banga, JD, Wester, JW, Brouwer, CB, van Hessen, MW, Meuwissen, OJ et al. Comparing subcutaneous danaparoid with intravenous unfractionated heparin for the treatment of venous thromboembolism: a randomized controlled trial. Ann Intern Med 1995; 123: 1–9.CrossRefGoogle ScholarPubMed
37Magnani, HN. Heparin-induced thrombocytopenia (HIT): an overview of 230 patients treated with Orgaran (Org 10172). Thromb Haemost 1993; 70: 554–61.Google ScholarPubMed
38Douketis, JD, Ginsberg, JS, Burrows, RF, Duku, EK, Webber, CE, Brill-Edwards, P. The effects of long-term heparin therapy during pregnancy on bone density. Thromb Haemost 1996; 75: 254–57.Google ScholarPubMed
39Dahlman, TC. Osteoporotic fractures and the recurrence of thromboembolism during pregnancy and the puerperium in 184 women undergoing thromboprophylaxis with heparin. Am J Obstet Gynecol 1993; 168: 1265–270.CrossRefGoogle ScholarPubMed
40Monreal, M, Lafoz, E, Olive, A, del Rio, L, Vedia, C. Comparison of subcutaneous unfractionated heparin with a low molecular weight heparin (Fragmin) in patients with venous thromboembolism and contraindications for coumarin. Thromb Haemost 1994; 71: 7–11.Google ScholarPubMed
41Pettila, V, Leinonen, P, Markkola, A, Hiilesmaa, V, Kaaja, R. Postpartum bone mineral density in women treated for thromboprophylaxis with unfractionated heparin or LMW heparin. Thromb Haemost 2002; 87: 182–86.CrossRefGoogle ScholarPubMed
42Bara, L, Samama, MM. Pharmacokinetics of low molecular weight heparins. Acta Chir Scand 1988; 543: 65–72.Google ScholarPubMed
43Bradbrook, ID, Magnani, HN, Moelker, HC, Morrison, PJ, Robinson, J, Rogers, HJ et al. ORG 10172: a low molecular weight heparinoid anticoagulant with a long half life in man. Br J Clin Pharmacol 1987; 23: 667–75.CrossRefGoogle ScholarPubMed
44Weitz, JI. Low-molecular-weight heparins. N Engl J Med 1997; 337: 688–98.CrossRefGoogle ScholarPubMed
45Jordan, RE, Oosta, GM, Gardner, WT, Rosenberg, RD. The kinetics of hemostatic enzyme-antithrombin interactions in the presence of low molecular weight heparin. J Biol Chem 1980; 255: 10081–10090.CrossRefGoogle ScholarPubMed
46Holmer, E, Kurachi, K, Soderstrom, G. The molecular-weight dependence of the rate-enhancing effect of heparin on the inhibition of thrombin, factor Xa, factor IXa, factor XIa, factor XIIa and kallikrein by antithrombin. Biochem J 1981; 193: 395–400.CrossRefGoogle ScholarPubMed
47Holmer, E, Soderberg, K, Bergqvist, D, Lindahl, U. Heparin and its low molecular weight derivatives: anticoagulant and antithrombotic properties. Haemostasis 1986; 16: 1–7.Google ScholarPubMed
48Bara, L, Billaud, E, Gramond, G, Kher, A, Samama, M. Comparative pharmacokinetics of low molecular weight heparin and unfractionated heparin after intravenous and subcutaneous administration. Thromb Res 1985; 39: 631–36.CrossRefGoogle ScholarPubMed
49Alhenc-Gelas, M, Jestin-Le Guernic, C, Vitoux, JF, Kher, A, Aiach, M, Fiessinger, JN. Adjusted versus fixed doses of the low-molecular-weight heparin Fragmin in the treatment of deep vein thrombosis. Fragmin-Study Group. Thromb Haemost 1994; 71: 698–702.Google ScholarPubMed
50Levine, MN, Planes, A, Hirsh, J, Goodyear, M, Vochelle, N, Gent, M. The relationship between antifactor Xa level and clinical outcome in patients receiving enoxaparine low molecular weight heparin to prevent deep vein thrombosis after hip replacement. Thromb Haemost 1989; 62: 940–44.Google ScholarPubMed
51Samama, MM. Contemporary laboratory monitoring of low molecular weight heparins. Clin Lab Med 1995; 15: 119–23.CrossRefGoogle ScholarPubMed
52Laposata, M, Green, D, Van Cott, EM, Barrowcliffe, TW, Goodnight, SH, Sosolik, RC. College of American Pathologists Conference XXXI on Laboratory Monitoring of Anticoagulant Therapy: the clinical use and laboratory monitoring of low-molecular-weight heparin, danaparoid, hirudin and related compounds, and argatroban. Arch Pathol Lab Med 1998; 122: 799–807.Google ScholarPubMed
53Boneu, B. Low molecular weight heparin therapy: is monitoring needed? Thromb Haemost 1994; 72: 330–34.Google ScholarPubMed
54MedWatch, Aventis Pharmaceuticals Safetly Alert, 2002. www.fda.gov/medwatch/SAFETY/2002/lovenox.htmGoogle Scholar
55Ginsberg, JS, Chan, WS, Bates, SM, Kaatz, S. Anticoagulation of pregnant women with mechanical heart valves. Arch Intern Med 2003; 163: 694–98.CrossRefGoogle ScholarPubMed
56Imperiale, TF, Petrulis, AS. A meta-analysis of low-dose aspirin for prevention of pregnancy-induced hypertensive disease. JAMA 1991; 266: 260–64.CrossRefGoogle ScholarPubMed
57Elkayam, U, Singh, H, Irani, A, Akhter, MW. Anticoagulation in Pregnant Women With Prosthetic Heart Valves. J Cardiovasc Pharmacol Ther 2004; 9: 107–15.CrossRefGoogle ScholarPubMed
58Rowan, JA, McCowan, LM, Raudkivi, PJ, North, RA. Enoxaparin treatment in women with mechanical heart valves during pregnancy. Am J Obstet Gynecol 2001; 185: 633–37.CrossRefGoogle ScholarPubMed
59Abildgaard, U, Gjestvang, FT, Lossius, P, Hodne, E. Low molecular heparin in a pregnant women with heart valve prosthesis. Tidsskr Nor Laegeforen 1999; 119: 4319–20.Google Scholar
60Arnaout, MS, Kazma, H, Khalil, A, Shasha, N, Nasrallah, A, Karam, K, Alam, SE. Is there a safe anticoagulation protocol for pregnant women with prosthetic valves? Clin Exp Obstet Gynecol 1998; 25: 101–104.Google Scholar
61Bauersachs, R, Lindhoff-Last, E. Anticoagulation of pregnant women with mechanical heart valves using low-molecular-weight heparin. Arch Intern Med 2003; 163: 2788–789.CrossRefGoogle ScholarPubMed
62Behrendt, P, Schwartzkopff, B, Perings, S, Gerhardt, A, Zotz, RB, Stauer, AB. Successful thrombolysis of St. Jude Medical Aortic Prosthesis with tissue-type plasminogen activator in a pregnant woman: A case report. Cardiol Rev 2002; 10: 349–53.CrossRefGoogle Scholar
63Ellison, J, Thomson, AJ, Walker, ID, Greer, IA. Use of enoxaparin in a pregnant woman with a mechanical heart valve prosthesis. BJOG 2001; 108: 757–59.Google Scholar
64Lavoie, JP, Leduc, L, Mercier, LA. Embolic myocardial infarction in a pregnant woman with a mechanical heart valve on low molecular weight heparin. Can J Cardiol 2004; 20: 917–19.Google Scholar
65Lee, LH, Liauw, PCY, Ng, AS. Low molecular weight heparin for thromboprophylaxis during pregnancy in 2 patients with mechanical mitral valve replacement. Thromb Haemost 1996; 76: 628–30.Google ScholarPubMed
66Lev-Ran, O, Kramer, A, Gurevitch, J, Shapira, I, Mohr, R. Low-molecular weight heparin for prosthetic heart valves: treatment failure. Ann Thoracic Surg 2000; 69: 264–66.CrossRefGoogle ScholarPubMed
67Leyh, RG, Fischer, S, Ruhparwar, A, Haverich, A. Anticoagulation for prosthetic heart valves during pregnancy: Is low-molecular-weight heparin an alternative? Eur J Cardiothorac Surg 2002; 21; 577–79.CrossRefGoogle ScholarPubMed
68Lisowska, A, Prokop, J, Hirnle, T, Juszczyk, G, Skibińska, E, Musial, WJ, Klonowska-Dziatkiewicz, E, Wrabec, K. Recurrent thrombosis of a mitral mechanical heart valve prosthesis during puerperium - A case report. Kardiologia Polska 2004; 61, 49–52.Google ScholarPubMed
69Mahesh, B, Evans, S, Bryan, AJ. Failure of low molecular-weight heparin in the prevention of prosthetic mitral valve thrombosis during pregnancy: Case report and a review of options for anticoagulation. J Heart Valve Dis 2002; 11: 745–50.Google Scholar
70Obergfell, A, Langenfeld, H, Hopp, H, Steigerwald, U, Grossmann, R. Thrombosis of a prosthetic aortic valve during pregnancy despite therapeutic dosage of Nadroparin. Thromb Haemost 2004; 91: 839–40.Google ScholarPubMed
71Oles, D, Berryessa, R, Campbell, K, Bhatti, MA. Emergency redo mitral valve replacement in a 27-year-old pregnant female with a clotted prosthetic mitral valve, preoperative fetal demise and postoperative ventricular assist device: a case report. Perfusion 2001; 16: 159–64.CrossRefGoogle Scholar
72Roberts, N, Ross, D, Flint, S, Arya, R, Blott, M. Thromboembolism in pregnant women with mechanical prosthetic heart valves anticoagulated with low molecular-weight heparin. BJOG 2001; 108: 327–29.Google ScholarPubMed
73Geelani, MA, Singh, S, Verma, A, Nagesh, A, Betigeri, V, Nigam, M. Anticoagulation in patients with mechanical valves during pregnancy. Asian Cardiovasc Thorac Ann 2005; 13: 30–33.CrossRefGoogle ScholarPubMed
74Gohlke-Barwolf, C, Acar, J, Oakley, C, Butchart, E, Burckhart, D, Bodnar, E et al. Guidelines for prevention of thromboembolic events in valvular heart disease: study group of the working group on valvular heart disease of the European Society of Cardiology. Eur Heart J 1995; 16: 1320–30.Google Scholar
75Bonow, RO, Carabello, BA, Chatterjee, K, de Leon, AC Jr, Faxon, DP, Freed, MD et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. (Writing Committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006; 114: e84–231.CrossRefGoogle Scholar
76Evans, WA, Laifer, SA, McNanley, TJ, Ruzycky, A. Management of Thromboembolic Disease Associated With Pregnancy. J Matern Fetal Med 1997; 6: 21–27.Google ScholarPubMed
77Wilson, W, Taubert, KA, Gewitz, M, Lockhart, PB, Baddour, LM, Levison, M et al. Prevention of infective endocarditis: guidelines from the American Heart Association. A guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; April: ePublication. 1736–54.Google Scholar