warfarin and Fetal-Death

To review maternal and foetal outcomes in women with mechanical heart valves (MHVs) treated with vitamin-K antagonists (VKAs), first-trimester heparin followed by VKAs (sequential treatment), low molecular weight heparin (LMWH) and unfractionated heparin (UFH) during pregnancy, in order to inform practice.. Medline, Embase and Central were searched from inception until February 2016. Two reviewers independently screened 1786 titles, reviewed 110 full-texts and extracted data and assessed risk-of-bias from 46 articles. Pooled incidence (95% confidence intervals) was calculated for maternal and foetal outcomes. Included studies had a moderate or high risk-of-bias. With VKAs, sequential treatment and LMWH, maternal mortality occurred in 0.9% (0.4-1.4), 2.0% (0.8-3.1) and 2.9% (0.2-5.7), thromboembolic complications in 2.7% (1.4-4.0), 5.8% (3.8-7.7) and 8.7% (3.9-13.4), livebirths in 64.5% (48.8-80.2), 79.9% (74.3-85.6) and 92.0% (86.1-98.0) and anticoagulant-related foetal/neonatal adverse events (embryopathy or foetopathy) in 2.0% (0.3-3.7), 1.4% (0.3-2.5) and 0%, respectively. When UFH is used throughout pregnancy, 11.2% (2.8-19.6) suffered thromboembolic complications. Foetal loss and adverse events occurred with first-trimester warfarin doses ≤ 5 mg/day, although there were more livebirths [83.6% (75.8-91.4) vs. 43.9% (32.8-55.0)] and fewer foetal anomalies [2.3% (0.7-4.0) vs. 12.4% (3.3-21.6)] with lower doses than with warfarin > 5 mg/day.. VKAs are associated with fewest maternal complications but also with fewest livebirths. Sequential treatment does not eliminate anticoagulant-related foetal/neonatal adverse events. LMWH is associated with the highest number of livebirths. The safety of UFH throughout pregnancy and first-trimester warfarin  ≤ 5 mg/day remains unconfirmed.

Topics: Anticoagulants; Female; Fetal Death; Fetal Diseases; Heart Valve Prosthesis; Heparin; Heparin, Low-Molecular-Weight; Humans; Incidence; Maternal Mortality; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Pregnancy Trimester, First; Thromboembolism; Vitamin K; Warfarin

Anti-phospholipid syndrome (APS) is an autoimmune prothrombotic disorder characterised by the predisposition to venous and/or arterial thrombosis and obstetric morbidity. Management of APS centres on attenuating the procoagulant state whilst balancing the risks of anticoagulant therapy. Cases of recurrent thromboses and obstetric complications occur despite optimum therapy. Alternative therapies for refractory cases are subject to disparity among clinicians due to the current lack of clinical evidence present. This review aims to address the current management strategies for refractory thrombotic and obstetric cases and future therapeutic interventions. The role and current clinical evidence of using long term low molecular weight heparin (LMWH) as an alternative to warfarin therapy for refractory thromboses is evaluated. Potential alternatives for thromboses including statins, hydroxychloroquine, Rituximab are reviewed as well as the additional avenues to target in the future as the pathogenic mechanisms of APS are unveiled. The optimal management for refractory obstetric APS cases is subject to controversy. This review focuses and assesses the current evidence for the uses of low dose prednisolone, intravenous immunoglobulin and hydroxycholoroquine in obstetric cases. The treatment modalities for the management of refractory APS require further clinical evidence.

Topics: Antibodies, Monoclonal, Murine-Derived; Antiphospholipid Syndrome; Clinical Trials as Topic; Evidence-Based Medicine; Female; Fetal Death; Heparin, Low-Molecular-Weight; Humans; Hydroxychloroquine; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Immunoglobulins, Intravenous; Pregnancy; Rituximab; Secondary Prevention; Thrombosis; Warfarin

For haemostatic and circulatory reasons pregnancy is associated with an about 6-fold relative increase of thrombotic risk which is further raised by additional risk factors, such as history of thrombosis or acquired and hereditary thrombophilia, respectively. Recently, the thrombophilias have been revealed as risk factors for severe preeclampsia, abruptio placentae, fetal growth retardation, abortion and still birth as well. Thus, there are several situations in which the question for the need of antithrombotic medication is raised in a pregnant woman, either for therapy of acute thromboembolism or for prophylaxis of thrombosis and obstetrical complications, respectively. While acute thromboembolism has to be treated in every case, indication for prophylaxis has to be weighed in the light of the individual risk profile of the pregnant woman and the potential side effects and inconvenience of the medication. The first part of this article deals with the pregnancy related problems of coumarins, heparins and aspirin and demonstrates that the low molecular weight heparins are the anticoagulants of choice for most indications in pregnancy. The second part of this overview shows in which specific situations and how the antithrombotic medications mentioned above are used in pregnancy.

Topics: Abnormalities, Drug-Induced; Abortion, Spontaneous; Abruptio Placentae; Administration, Oral; Adult; Anticoagulants; Aspirin; Blood Coagulation Tests; Coumarins; Female; Fetal Death; Fetal Growth Retardation; Fibrinolytic Agents; Heart Valve Prosthesis; Heparin; Heparin, Low-Molecular-Weight; Humans; Infant, Newborn; Platelet Aggregation Inhibitors; Pre-Eclampsia; Pregnancy; Pregnancy Complications, Cardiovascular; Puerperal Disorders; Pulmonary Embolism; Risk Factors; Thrombocytopenia; Thrombophilia; Thrombosis; Warfarin

Antiphospholipid syndrome is the most frequent cause of acquired thrombophilia. Aspirin may have some indications. CURRENT KONWLEDGE AND KEY POINTS: The usefulness of low doses of aspirin is now well demonstrated in the prevention of obstetric complications associated with antiphospholipid antibodies (especially pregnancy loss). When heparin is combined with low-dose aspirin, the recurrent rate of fetal loss is lower than 30%. In patients with arterial or venous thrombosis, there is a high rate of recurrence during the two first years except if high-dose warfarin was used (i.e., INR > or = 3). The association warfarin-aspirin in secondary prevention of thrombosis may be evaluated in prospective studies. It is not so clear in the literature and in our experience that warfarin is superior to aspirin in stroke recurrence prevention in patients with antiphospholipid antibodies, except in Sneddon's syndrome. There are no guidelines in primary thrombosis prevention in patients with antiphospholipid antibodies. In lupus patients, aspirin may not be sufficient after many years of follow-up in preventing a first episode of thrombosis. Prospective studies may be undertaken. Atherosclerotic patients with antiphospholipid antibodies are particularly exposed to the risk of thrombosis after revascularisation or angioplasty and stent implantation. Aspirin may have a place in those patients but these must be evaluated. FUTUR PROSPECTS AND PROJECTS: Except in prevention of obstetric complications, the usefulness of aspirin in patients with antiphospholipid antibodies must be evaluated in prospective studies.

Topics: Adult; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Antiphospholipid Syndrome; Arteriosclerosis; Aspirin; Cyclooxygenase Inhibitors; Drug Therapy, Combination; Female; Fetal Death; Fibrinolytic Agents; Humans; Male; Platelet Aggregation Inhibitors; Pregnancy; Pregnancy Complications; Primary Prevention; Recurrence; Risk Factors; Thrombosis; Warfarin

Topics: Abortion, Habitual; Adult; Antigens; Aspirin; Biomarkers; Enzyme-Linked Immunosorbent Assay; Female; Fetal Death; Heparin; Humans; Male; Middle Aged; Phospholipids; Pregnancy; Risk Assessment; Sensitivity and Specificity; Venous Thrombosis; Warfarin

Topics: Abnormalities, Drug-Induced; Adrenal Cortex Hormones; Alcoholic Beverages; Animals; Anticonvulsants; Antineoplastic Agents; Diethylstilbestrol; Estrogens; Female; Fetal Death; Fetus; Humans; Hydantoins; Iodides; Organomercury Compounds; Pregnancy; Smoking; Teratogens; Tetracycline; Thalidomide; Thiourea; Warfarin

Topics: Abnormalities, Drug-Induced; Abnormalities, Multiple; Animals; Female; Fetal Death; Heart Valve Prosthesis; Humans; Infant, Newborn; Pregnancy; Pregnancy Complications, Cardiovascular; Warfarin

Topics: Fetal Death; Humans; Oxidoreductases; Vitamin K; Vitamin K Epoxide Reductases; Warfarin

The management of anticoagulation in pregnant women with mechanical heart valves is complex. The maternal and fetal outcomes of 32 pregnancies in 15 women on three different anticoagulation regimens were compared. Anticoagulation with low-molecular-weight heparin (n=4), warfarin (n=22) and combination therapy (n=6) resulted in adverse maternal events in four (100%), three (50%) and three (14%) women, and resulted in fetal losses in one (25%), 17(77%) and three (50%) pregnancies, respectively. Whereas the rate of fetal loss in the warfarin group was high, all women in the LMWH and half of those in the combination group had serious adverse maternal events, including valve thrombosis, maternal death and postpartum haemorrhage.

Topics: Adult; Anticoagulants; Death, Sudden; Drug Therapy, Combination; Female; Fetal Death; Heart Valve Prosthesis; Heparin, Low-Molecular-Weight; Humans; Postpartum Hemorrhage; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Retrospective Studies; Risk Factors; Thrombosis; Warfarin; Young Adult

Topics: Adrenergic beta-Antagonists; Adult; Anticoagulants; Drug Therapy, Combination; Female; Fetal Death; Heart Valve Prosthesis; Humans; Mitral Valve; Pregnancy; Pregnancy Complications, Cardiovascular; Pulmonary Edema; Rheumatic Heart Disease; Treatment Outcome; Warfarin

Topics: Abortion, Induced; Adult; Antibodies, Anticardiolipin; Anticoagulants; Antiphospholipid Syndrome; Cholecystectomy; Cholecystitis; Female; Fetal Death; Hearing Loss, Sensorineural; Hearing Loss, Sudden; Heparin, Low-Molecular-Weight; Humans; Pregnancy; Pregnancy Trimester, Second; Tinnitus; Treatment Outcome; Warfarin

Warfarin-associated fetal hemorrhage is a fatal event. We report the case of a 39-year-old woman who had been taking warfarin for 23 years since undergoing mitral valve replacement. Thereafter, when she was found to be pregnant, the medication was switched to heparin from 6 to 21 weeks of gestation. Following this, she was prescribed oral warfarin again (3.5 mg per day), with a strict control of prothrombin time/international normalized ratio (PT/INR). At 23 weeks of gestation, fetal intracranial hemorrhage occurred because of maternal exposure to warfarin. Maternal PT/INR does not correlate well with the activity of warfarin in the fetus and currently, there is no direct way to prevent fetal intracranial hemorrhage. Hence, further research on the optimal coagulation therapy in pregnant women with valve replacement should be encouraged.

Topics: Adult; Anticoagulants; Female; Fetal Death; Fetal Diseases; Heart Valve Prosthesis Implantation; Heparin; Humans; International Normalized Ratio; Intracranial Hemorrhages; Pregnancy; Pregnancy Complications, Hematologic; Thromboembolism; Warfarin

To evaluate maternal complications and perinatal outcomes in women with mechanical heart valves treated with warfarin and heparin during pregnancy.. A retrospective chart review was performed on 45 pregnancies in 28 women who were previously fitted with mechanical valve prostheses and treated between 1991 and 2005 at Seoul National University Hospital. Outcome parameters were maternal complications and perinatal outcomes.. Overall, there were 27 live births (60%), 7 stillbirths (15.6%), 2 therapeutic terminations in the second trimester (4.4%), 9 first-trimester spontaneous abortions (20%) and 2 neonatal deaths after preterm delivery. After excluding 9 first-trimester spontaneous abortions and 3 pregnancies administered warfarin throughout pregnancy, there were significantly more live births among patients administered heparin only after a diagnosis of pregnancy than among those administered warfarin from the second trimester (11 of 11 vs. 13 of 22, p = 0.015). One patient with mitral valve thrombosis during heparinization in the first trimester received valve replacement surgery and then aborted. Late postpartum hemorrhage occurred in 1 patient. All stillbirths and therapeutic terminations occurred in women being administered warfarin.. Warfarin use from the second trimester in combination anticoagulation regimens increases the risk of an adverse perinatal outcome.

Topics: Abortion, Spontaneous; Abortion, Therapeutic; Adult; Anticoagulants; Aortic Valve; Female; Fetal Death; Gestational Age; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve; Obstetric Labor, Premature; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Retrospective Studies; Thrombosis; Warfarin

We describe a pair of twins, whose mother was being treated by oral anticoagulant drugs, as a result of having received mitral heart valve implantation in the past. The male twins monochorionic, monoamniotic--but one infant showed the features of fetal warfarin syndrome. In the study we discussed the pharmacogentetics and individual variation in the human metabolism during treatment with warfarin-perinatal growth and prevalence of congenital malformations. We analysed the threats to the fetus and mother, connected with administration of anticoagulant drugs.

Topics: Abnormalities, Multiple; Adult; Anticoagulants; Diseases in Twins; Female; Fetal Death; Humans; Infant, Newborn; Male; Mitral Valve Insufficiency; Pregnancy; Pregnancy Complications, Cardiovascular; Prenatal Exposure Delayed Effects; Twins; Warfarin

This study was undertaken to evaluate the risks and pregnancy outcome in women with prosthetic heart valves on different anticoagulent regimens.. A retrospective chart review of 82 pregnancies in 33 women with mechanical valve prostheses at a tertiary referral center from 1987 to 2002. The main outcome measures were major maternal complications and perinatal outcome.. The valve replaced was mitral (60.6%), aortic (18.2%), and both (21.2%). Fifty-four pregnancies (65.9%) resulted in live births, 9 (11.0%) had stillbirths (all on warfarin), and 12 (14.6%) had spontaneous and 7 (8.5%) therapeutic abortions (all on warfarin). The rate of spontaneous abortion was highest in women on warfarin throughout pregnancy (P < .01). The live birth rate was higher in women on heparin compared with those on warfarin (P < .01), and in those on heparin/warfarin compared with warfarin alone (P < .01). There were no maternal deaths; however, 3 patients had mitral valve thrombosis (2 on heparin and 1 on warfarin) necessitating surgery in 1 patient and medical thrombolysis in 2 patients. Hemorrhagic complications occurred in 5 patients, 4 of whom required transfusion.. No single anticoagulant regimen confers complete protection from thromboembolic phenomena in pregnancy. Despite a high maternal morbidity rate, the perinatal outcome is acceptable when pregnancy progresses beyond the first trimester.

Topics: Abortion, Spontaneous; Abortion, Therapeutic; Birth Weight; Delivery, Obstetric; Female; Fetal Death; Fetal Growth Retardation; Gestational Age; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve; Obstetric Labor, Premature; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Retrospective Studies; Thrombosis; Vitamin K; Warfarin

To examine if fetal risks associated with Warfarin anticoagulation during pregnancy may have been over-estimated at the time the drug was contraindicated during pregnancy.. Seven case series with the same therapeutic objective for Warfarin anticoagulation published after 1980 were identified. The frequencies of fetal complications were calculated and compared with those of the 1980 compilation.. The frequencies of embryopathy, stillbirths, and neonatal deaths were similar to the 1980 database, but higher with respect to spontaneous abortions (24.1 vs. 8.6%) and premature deliveries (13.9 vs. 4.6%), and lower regarding live births (73.3 vs. 83.7%).. Fetal risks associated with Warfarin anticoagulation during pregnancy have not been overestimated. Warfarin should not be given in cases where other anticoagulants do not increase the risk for the expecting mother.

Topics: Abortion, Spontaneous; Anticoagulants; Contraindications; Female; Fetal Death; Fetal Diseases; Heart Valve Diseases; Humans; Infant, Newborn; Maternal Exposure; Obstetric Labor, Premature; Pregnancy; Pregnancy Complications, Cardiovascular; Retrospective Studies; Risk Assessment; Warfarin

To assess the determinants of pregnancy outcome in patients with mechanical valve prostheses anticoagulated with warfarin.. Between January 1987 and January 2000, 52 patients with mechanical valve prostheses who had 71 pregnancies were anticoagulated with warfarin for the entire duration of pregnancy. Warfarin was withdrawn 48 hours before and 24 hours after a scheduled cesarean delivery carried out by the end of the 37th gestational week. The targeted international normalized ratio ranged between 2.25 and 4.0, depending on the prosthetic model. Exact univariate and multivariable analyses were performed to assess which among the following variables predicted poor pregnancy outcome: patient age, prosthetic model, site of implantation, average international normalized ratio, and average daily dose of warfarin.. Pregnancy loss occurred in 23 of 71 of pregnancies, stillbirth in five of 71, embryopathy in four of 71 (two aborted fetuses and two full-term infants). There were no maternal deaths or thromboembolic or hemorrhagic complications. Warfarin daily dosage over 5 mg per day was a significant predictor of poor pregnancy outcome (P <.001).. The risk for pregnancy complications in patients treated with sodium warfarin is higher when the mean daily dose exceeds 5 mg.

Topics: Abortion, Spontaneous; Adult; Age Distribution; Dose-Response Relationship, Drug; Female; Fetal Death; Heart Valve Prosthesis; Humans; Middle Aged; Multivariate Analysis; Odds Ratio; Predictive Value of Tests; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Pregnancy, High-Risk; Prenatal Care; Probability; Retrospective Studies; Risk Assessment; Risk Factors; Thromboembolism; Warfarin

A 27-year-old Laotian woman with a St Jude mechanical mitral valve became pregnant, requiring a change in her anticoagulant after the first trimester when her warfarin sodium (coumadin) was replaced with enoxaparin sodium (lovenox). Her prosthetic valve clotted and became dysfunctional. She was 16 weeks pregnant and was taken to the operating room for emergency surgery for replacement of the valve. The fetus had not been viable for 1-2 weeks, but still remained in utero. The clotted valve was replaced with another St Jude valve of a slightly smaller diameter (27 mm). The patient could not be weaned from bypass so a right ventricular assist device (RVAD) was inserted. The patient was weaned from the RVAD after 2 days of support. Two days following removal of the RVAD the fetus spontaneously aborted. The patient had a long, complicated hospital course and was discharged 3 months later. She subsequently died 4 months after discharge of a cerebral hemorrhage from excessive anticoagulation.

Topics: Adult; Anticoagulants; Blood Coagulation; Cardiac Surgical Procedures; Cerebral Hemorrhage; Enoxaparin; Equipment Failure; Fatal Outcome; Female; Fetal Death; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Heart-Assist Devices; Humans; Mitral Valve; Pregnancy; Warfarin

In women who have prosthetic heart valves, pregnancy is risky for mother and fetus. Heparin has been considered safer for the fetus than warfarin, but may not provide adequate anticoagulation for the mother. We examined prospectively gathered data from 100 pregnancies in 67 women with mechanical valves (age range, 19 to 45 years). A subgroup of 20 patients was compared with a control group of relatives and neighbors who conceived at similar ages. Fetal loss occurred in 44 of the 100 pregnancies, due to the following causes: spontaneous abortion (28), intrauterine fetal death (4), stillbirth (3), neonatal death (1), premature birth (2), Rh incompatibility (2), and maternal death (4). Age, parity, atrial fibrillation, and left ventricular enlargement did not affect the outcome. Tricuspid valve disease that required diuretics was associated with a higher rate of fetal loss (17 out of 23 pregnancies, versus 27 out of 77; p = 0.001), but did not affect the mother Of 66 pregnancies in which the mother was on heparin, 38 (576%) resulted in a healthy baby, compared with 18 out of 34 (52.9%) pregnancies in which the mother was on warfarin (p = NS). All thromboembolic complications occurred with heparin therapy (9 cases; p = 0.02). In the control group, fetal loss was 24 %, due exclusively to spontaneous abortion. Women with mechanical valves have higher rates of fetal loss and maternal complications. In our study, tricuspid valve disease adversely affected fetal outcome, which is a new finding that warrants further study. Warfarin was more effective than heparin in preventing thromboembolism in the mothers, and it did not show a significant impact on the babies.

Topics: Adult; Anticoagulants; Female; Fetal Death; Heart Valve Prosthesis Implantation; Heparin; Humans; Infant, Newborn; Middle Aged; Parity; Pregnancy; Pregnancy Complications; Pregnancy Complications, Hematologic; Pregnancy Outcome; Prospective Studies; Thromboembolism; Tricuspid Valve; Warfarin

The purpose of this study was to assess the incidence of warfarin fetal complications and whether they are dose-dependent.. Gravid patients with mechanical heart valves require long-term anticoagulant therapy. Controversy exists concerning the appropriate treatment of these patients.. Forty-three women on warfarin carrying out 58 pregnancies were studied. For each patient with full-term pregnancy a caesarian section was scheduled for the 38th week during brief warfarin discontinuation. Maternal and fetal complications were evaluated. Fetal complications were divided according to the warfarin dosage < or = 5 mg and > 5 mg necessary to keep an international normalized ratio (INR) of 2.5 to 3.5, and analyzed subsequently.. A total of 58 pregnancies were observed: 31 healthy babies (30 full term, 1 premature) and 27 fetal complications (22 spontaneous abortions, 2 warfarin embryopathies, 1 stillbirth, 1 ventricular septal defect, 1 growth retardation) were recorded. Two maternal valve thromboses occurred. No fetal or maternal bleeding was observed during caesarian sections or premature vaginal delivery. Patients whose warfarin doses during pregnancy were > 5 mg had 22 fetal complications, whereas those taking a dose < or = 5 mg had only five fetal complications (p = 0.0001). For an increase of the warfarin dose there was a substantially increased probability of fetal complications (p < 0.0001; p < 0.7316).. There is a close dependency between warfarin dosage and fetal complications. Patients on warfarin anticoagulation may be delivered by planned caesarian section at the 38th week while briefly interrupting anticoagulation.

Topics: Abnormalities, Drug-Induced; Anticoagulants; Cesarean Section; Dose-Response Relationship, Drug; Female; Fetal Death; Heart Valve Prosthesis Implantation; Humans; Infant, Newborn; International Normalized Ratio; Male; Pregnancy; Pregnancy Complications, Cardiovascular; Prosthesis Failure; Thrombosis; Warfarin

Topics: Abnormalities, Drug-Induced; Adult; Anticoagulants; Chondrodysplasia Punctata; Female; Femur; Fetal Death; Fetal Growth Retardation; Gestational Age; Humans; Male; Nose; Pregnancy; Syndrome; Ultrasonography, Prenatal; Warfarin

Topics: Abnormalities, Drug-Induced; Anticoagulants; Female; Fetal Death; Heart Valve Prosthesis; Humans; Pregnancy; Pregnancy Complications, Hematologic; Warfarin

We studied the outcome of 41 pregnancies in an attempt to identify an appropriate and safe anticoagulant regimen for pregnant women with cardiac valve prosthesis. The cumulative number of events: (neonatal death, premature deliveries, intrauterine fetal death and spontaneous abortion) was 66.6%, 20%, 12.5% and 20% in the Coumadin, Fraxiparine, Heparin and porcine valve groups, respectively. We conclude that in pregnant women with mechanical heart valves, low molecular weight heparin therapy is a superior strategy compared to warfarin.

Topics: Adult; Anticoagulants; Female; Fetal Death; Heart Valve Prosthesis; Heparin; Humans; Nadroparin; Obstetric Labor, Premature; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Warfarin

To study the outcome of pregnancy in women with artificial heart valves treated in major European centres, and to compare the safety and efficacy of different anticoagulant regimens and of mechanical and bioprosthetic valves.. Retrospective study.. The information was obtained by questionnaire sent to all major cardiac centres in Europe sending one cardiologist from each centre a covering letter suggesting that the questionnaire be handed on where appropriate to the most relevant colleague.. 214 pregnancies were reported in 182 women; 151 pregnancies in 133 women with mechanical valves, and 63 pregnancies in 45 women with bioprostheses. Most women were in New York Heart Association class I or II and in sinus rhythm. 150 women with mechanical valves and 11 (17%) with bioprostheses received anticoagulants during pregnancy. One patient with an aortic valve prosthesis refused to take anticoagulants. Including the spontaneous abortions reported as well as the therapeutic abortions 83% of the pregnancies in women with bioprostheses and 73% in those with mechanical valves resulted in a healthy baby, full term or premature, who did well (NS). The incidence of stillbirths (3% and 6%) and of reported spontaneous abortions are excluded (because they are unlikely to have been fully reported), the success rate was 91% for women with bioprosthetic valves and 84% for women with mechanical valves (NS). 114 (53%) of the women had taken warfarin for some part of the pregnancy (46 (40%) of these during the first trimester) but there were no embryopathies. There were 13 valve thromboses (four fatal), eight embolic events (two fatal), and seven bleeds in women with mechanical valves. Most of these complications occurred with heparin but fatal aortic valve thrombosis occurred in the one woman who refused anticoagulant treatment out of the 151 women with mechanical valves. There were no maternal deaths in the bioprosthesis group but in 17/49 (35%) of these valves functional deterioration led to urgent replacement during pregnancy (two) or soon after.. The outcome of pregnancy was similar for women with mechanical valves or bioprostheses. Warfarin treatment was safe and effective and was not associated with embryopathy. Heparin treatment was associated with more thromboembolic complications and more bleeding complications. Bioprostheses deteriorate rapidly during pregnancy.

Topics: Abortion, Spontaneous; Adolescent; Adult; Aortic Valve; Bioprosthesis; Cardiology Service, Hospital; Europe; Female; Fetal Death; Heart Valve Prosthesis; Heparin; Humans; Medical Audit; Middle Aged; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Retrospective Studies; Warfarin

During the 13 year period 1971 to 1984 there were 38 pregnancies in 21 renal transplant patients at the Johannesburg Hospital. Twenty-two ended with live births and included two sets of twins; there were nine spontaneous abortions, six therapeutic abortions, and one stillbirth. Maternal complications were mild in the majority but five patients suffered deterioration in renal function, two undergoing transplant nephrectomy as a result of this. There were seven neonatal deaths, including both sets of twins; death was due to prematurity in six and congenital malformation (diaphragmatic hernia) in one. A further infant had congenital pyloric stenosis which was corrected surgically. Pregnancies were analysed according to whether or not their outcome was successful. Those with a successful outcome had less exposure to warfarin during pregnancy (p = 0.0025) and showed a tendency towards lower immunosuppressive doses of prednisone and azathioprine although these did not reach significance. Although these results indicate an unhappy prognosis for both the mother and fetus, two redeeming features are to be noted. Pregnancy outcome improved markedly in the latter years, possibly owing to non-exposure to warfarin, less immunosuppression, and improvement in neonatal care, and four of the five mothers who suffered deterioration in renal function were notoriously unco-operative in their medical care. Pregnancy can only be recommended in the transplanted patient who has stable renal function, is compliant in taking of medications, and whose graft is of such age that the immunosuppressive drug dose is minimal. Warfarin should be avoided.

Topics: Abnormalities, Drug-Induced; Abortion, Spontaneous; Abortion, Therapeutic; Acute Kidney Injury; Adolescent; Adult; Dose-Response Relationship, Drug; Female; Fetal Death; Humans; Immunosuppressive Agents; Infant, Newborn; Kidney Transplantation; Patient Compliance; Pregnancy; Pregnancy Complications; Warfarin

Topics: Abnormalities, Drug-Induced; Female; Fetal Death; Heart Valve Prosthesis; Heparin; Humans; Infant, Newborn; Pregnancy; Pregnancy Complications, Hematologic; Thromboembolism; Warfarin

Massive subchorionic hematoma (Breus' mole) of the placenta occurred in a stillbirth. The mother was receiving oral warfarin sodium. The extravasated blood was mostly fetal in origin.

Topics: Adult; Chorion; Female; Fetal Blood; Fetal Death; Hematoma; Humans; Placenta Diseases; Pregnancy; Rheumatic Heart Disease; Warfarin

During the past 15 years, 12 patients with prosthetic valves were treated during 18 pregnancies in the four Dublin maternity hospitals. These patients were on long-term anticoagulants and their pregnancies were reviewed to assess the problems associated with anticoagulation. One baby had warfarin embryopathy, six pregnancies ended in spontaneous abortions and there were two intrauterine deaths. On the basis of the findings a policy on the most appropriate anticoagulant regimen in such cases was formulated.

Topics: Abortion, Spontaneous; Adult; Female; Fetal Death; Heart Valve Prosthesis; Heparin; Humans; Maternal-Fetal Exchange; Pregnancy; Pregnancy Complications, Cardiovascular; Warfarin

A retrospective analysis of 40 patients with cardiac disease who received sodium warfarin (Coumadin) therapy during pregnancy has been performed. The fetal mortality was 12,5%, but no case of congenital epiphyseal stippling was detected. The incidence of maternal postpartum haemorrhage was high. Warfarin should whenever possible be withheld during the 1st trimester of pregnancy and replaced by heparin.

Topics: Abnormalities, Drug-Induced; Adult; Female; Fetal Death; Fetus; Heart Valve Diseases; Humans; Pregnancy; Pregnancy Complications; Pregnancy Complications, Cardiovascular; Retrospective Studies; Rheumatic Heart Disease; Warfarin

Topics: Abnormalities, Drug-Induced; Abortion, Spontaneous; Embryo, Mammalian; Female; Fetal Death; Humans; Infant, Newborn; Pregnancy; Warfarin

The case is described of a patient whose third pregnancy ended successfully, after 2 perinatal deaths caused by severe pre-eclampsia in the second trimester of her previous pregnancies. Anticoagulant therapy with warfarin was given in the third pregnancy.

Topics: Adult; Female; Fetal Death; Humans; Pre-Eclampsia; Pregnancy; Recurrence; Warfarin

Topics: Animals; Dog Diseases; Dogs; Drug Combinations; Female; Fetal Death; Indans; Indenes; Maternal-Fetal Exchange; Pregnancy; Pregnancy Complications; Pregnancy, Animal; Rodenticides; Warfarin

This report is based on information obtained from a questionnaire sent to major cardiac centres in the United Kingdom. This produced details of 39 pregnancies in 34 patients after valve replacement. The 39 pregnancies gave rise to 30 healthy babies. The small size of the series probably reflects both the increasing rarity of young women with rheumatic heart disease in this country and the cautious attitude of their cardiologists. This makes it likely that these women represented the best end of the spectrum of cardiac function after valve replacement. Twenty-four pregnancies in 20 women who were not given anticoagulants producted 23 healthy babies and 1 spontaneous abortion. This group comprised 6 patients with free aortic homografts, 1 patient with a fascia lata mitral valve, 1 with a Beall tricuspid prosthesis, 1 with a combined mitral homograft and Starr Edwards aortic prosthesis, and 1 with mitral and aortic frame-mounted fascia lata valves. There were no maternal deaths or thromboembolic complications in this group which included 5 patients who were in atrial fibrillation. Fifteen pregnancies in 14 women who received anticoagulants gave rise to 7 healthy babies. The fetal losses were one stillbirth, one intrauterine death at 34 weeks, and 3 spontaneous abortions; one surviving child has hydrocephalus as a result of blood clot and there were 2 maternal deaths. This group included 13 patients with Starr Edwards valves, 11 mitral and 2 aortic. A patient with a Hammersmith mitral valve was the only one to have been treated with heparin and her valve thrombosed. One patient with a mounted mitral homograft had a cerebral embolus. Nine of these patients were in atrial fibrillation. In 3 additional patients the valve replacement was carried out during pregnancy. Two of the patients survived operation. In one of these who was treated with warfarin the pregnancy well, but there is an increased fetal wastage in patients pregnancy gave rise to a congenitally malformed baby who died in the neonatal period. The baby born to the mother who did not receive anticoagulants has a hare-lip and talipes. Women with artificial valves can tolerate the haemodynamic load of pregnancy well, but there is an increased fetal wastage in patients taking oral anticoagulants. This is probably largely attributable to fetal haemorrhage but there is also a risk of malformation caused by a teratogenic effect of warfarin. Experience gained in non-pregnant patients suggests that withholdin

Topics: Abnormalities, Drug-Induced; Abortion, Spontaneous; Adolescent; Adult; Anticoagulants; Female; Fetal Death; Heart Valve Prosthesis; Heparin; Humans; Intracranial Embolism and Thrombosis; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Warfarin

A successful cesarean section performed in a 24-year-old woman with rheumatic heart disease and a Starr-Edwards mitral valve prosthesis is reported. In the 33rd week of pregnancy, previous warfarin sodium therapy was discontinued and dipyridamole therapy instituted. Successful pregnancy and cesarean section in patients with mitral valve prostheses are possible with this regimen.

Topics: Adult; Cesarean Section; Dipyridamole; Female; Fetal Death; Heart Valve Prosthesis; Hemorrhage; Humans; Mitral Valve; Pregnancy; Pregnancy Complications, Cardiovascular; Rheumatic Heart Disease; Thromboembolism; Warfarin

Topics: Acute Disease; Adolescent; Adult; Aged; Aneurysm; Child; Chronic Disease; Disseminated Intravascular Coagulation; Embolism, Amniotic Fluid; Female; Fetal Death; Fibrinolysis; Hemangioma; Heparin; Humans; Iliac Artery; Infusions, Parenteral; Lung Neoplasms; Lymphatic Metastasis; Male; Melanoma; Middle Aged; Pregnancy; Sepsis; Streptococcal Infections; Syndrome; Thrombophlebitis; Thumb; Warfarin

Topics: Abnormalities, Drug-Induced; Animals; Bone and Bones; Cleft Lip; Cleft Palate; Dose-Response Relationship, Drug; Embryo Implantation; Embryo, Mammalian; Female; Fetal Death; Hemorrhage; Mice; Mice, Inbred Strains; Placenta Diseases; Pregnancy; Prothrombin Time; Sodium Chloride; Time Factors; Vitamin K; Vitamin K 1; Warfarin

Topics: Adolescent; Adult; Female; Fetal Death; Heparin; Humans; Parity; Pregnancy; Pregnancy Complications, Cardiovascular; Prothrombin Time; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Abortion, Missed; Abortion, Spontaneous; Adult; Anticoagulants; Female; Fetal Death; Fetus; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Phenindione; Pregnancy; Pregnancy Complications, Cardiovascular; Thromboembolism; Warfarin

Topics: Adult; Anticoagulants; Female; Femoral Vein; Fetal Death; Heparin; Humans; Leg; Pregnancy; Pregnancy Complications, Cardiovascular; Thrombophlebitis; Vitamin K; Warfarin

Topics: Abnormalities, Drug-Induced; Adult; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Female; Fetal Death; Heart Valve Prosthesis; Heparin; Humans; Labor, Obstetric; Mitral Valve; Mitral Valve Insufficiency; Phenindione; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Thromboembolism; Warfarin

Topics: Animals; Animals, Newborn; Blood Coagulation Tests; Cesarean Section; Female; Fetal Death; Fetal Diseases; Fetus; Hemorrhage; Pregnancy; Pregnancy, Animal; Prothrombin Time; Rabbits; Warfarin

Topics: Female; Fetal Death; Fetus; Heart Valve Prosthesis; Humans; Infant Mortality; Infant, Newborn; Placenta; Pregnancy; Pregnancy Complications, Cardiovascular; Warfarin

Topics: Adult; Chlorpropamide; Digoxin; Female; Fetal Death; Furosemide; Gestational Age; Heart Valve Prosthesis; Humans; Mitral Valve Stenosis; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy in Diabetics; Warfarin