warfarin and Postpartum-Hemorrhage

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

This study was undertaken to analyze the maternal and perinatal outcome in women with prosthetic heart valves on different anticoagulant regimens.. A retrospective chart review of pregnancies in 40 women with mechanical valve prostheses at a tertiary referral centre from 1997 to 2010. The main outcome measures were major maternal complications and perinatal outcome.. The valves replaced were mitral (67.5%), aortic (15.0%), or both (17.5%). Forty-nine pregnancies (72.1%) resulted in live births, 3(4.4%) had stillbirths, and 13(19.1%) had spontaneous abortions and 1(1.4%) underwent therapeutic abortions. The live birth rate was higher in women on heparin (78.3%) compared with those on warfarin (66.9%). There were 2 maternal deaths due to acute mitral valvular thrombosis while on acenocoumarol in the second trimester. Hemorrhagic complications occurred in 3 patients on heparin in the postpartum period, 2 of whom required transfusion. In addition one patient who was on acenocoumarol developed secondary hemorrhage.. No anticoagulant regimen can be said to be entirely safe for use during pregnancy as there is a degree of risk with each regimen. Further larger studies are needed to come up with sufficient evidence-based recommendations for the best possible management of such patients to reduce the maternal risks after mechanical heart valve replacement without compromising fetal outcome.

Topics: Abortion, Spontaneous; Academic Medical Centers; Acenocoumarol; Adult; Anticoagulants; Female; Heart Valve Diseases; Heart Valve Prosthesis; Heparin; Humans; Incidence; India; Medical Records; Mitral Valve; Postpartum Hemorrhage; Pregnancy; Pregnancy Complications; Pregnancy Complications, Cardiovascular; Pregnancy Complications, Hematologic; Pregnancy Outcome; Retrospective Studies; Thrombosis; Warfarin; Young Adult

Eighteen patients were given carefully controlled intravenous heparin for thromboembolic disease of pregnancy. Thirteen were treated in later gestation and postparium, mainly following warfin therapy. One was treated in early pregnancy and 4 in the postpartum period. Heparin was delivered by constant infusion and dosage regulated by maintaining the thrombin time at 2 to/ times normal. Therapy was stopped for a few hours before and after delivery so that the thrombin time was normal or nearly normal at birth. Two minor episodes of thrombosis recurred in 1 patient while on warfarin, and significant postpartum bleeding occurred in one other. Substituting heparin for warfarin in late gestation was of value in preventing neonatal bleeding complications.

Topics: Adolescent; Adult; Anticoagulants; Blood Coagulation Tests; Female; Heparin; Humans; Postpartum Hemorrhage; Pregnancy; Pregnancy Complications, Hematologic; Pregnancy Trimester, Second; Pregnancy Trimester, Third; Pulmonary Embolism; Thromboembolism; Warfarin