An audit of pregnant women with prosthetic heart valves at a tertiary hospital in South Africa

Abstract

BackgroundCardiac 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.AimTo evaluate obstetric outcomes in women with prosthetic heart valves in an under-resourced country.MethodsA retrospective chart review was performed of 61 pregnant patients with prosthetic valve prostheses referred to our tertiary hospital over a five-year period.ResultsSixty-one (6%) of 1 021 pregnant women with a diagnosis of cardiac disease had prosthetic heart valves. Fifty-nine had mechanical valves and were on prophylactic anticoagulation therapy, three had stopped their medication prior to pregnancy and two had bioprosthetic valves. There were forty-one (67%) live births, two (3%) early neonatal deaths, 12 (20%) miscarriages and six (10%) stillbirths. Maternal complications included mitral valve thrombosis (n = 4), atrial fibrillation (n = 8), infective endocarditis (n = 6), caesarean section wound haematomas (n = 7), broad ligament haematoma (n = 1) and warfarin embryopathy (n = 4). Haemorrhagic complications occurred in five patients and all five required blood transfusions.ConclusionProphylactic anticoagulation with warfarin in patients with mechanical heart valve prostheses was associated with high rates of maternal and neonatal complications, including significant foetal wastage in the first and early second trimesters of pregnancy. Health professionals providing care for pregnant women with prosthetic heart valves must consistently advise on family planning matters, adherence to anticoagulation regimes and consider the use of prophylactic anticoagulant regimens other than warfarin, particularly during the first trimester of pregnancy.

Prosthetic heart valves in pregnancy, outcomes for women and their babies: a systematic review and meta‐analysis

“…27 There were seven retrospective studies, two population-based cohort studies, 20,21 two multicentre unselected case series 28,32,33 and three single-centre unselected case series 28,30,31 (Table 1). Ten studies captured a total of 305 women undertaking 392 pregnancies.…”

“…All included studies reported information on maternal mortality and any pregnancy loss. Eight of the 11 studies allowed identification of perinatal mortality 20,21,[27][28][29]31,32,34 and three studies had insufficient details to differentiate early pregnancy loss from fetal death at >22 weeks. 30,33,35 No studies reported the incidence of infective endocarditis or neonatal admissions to the intensive care unit.…”

“…21 Of the remaining studies without control groups, one study 32 was awarded the maximum six stars, seven were awarded five stars [27][28][29]31,[33][34][35] and one was awarded three stars. 30 All included studies were assessed as including an adequate representation of cases, with appropriate follow up (Table 1).…”

2015 ESC Guidelines for the management of infective endocarditis

“…Częstość występowania IZW u kobiet w ciąży ocenia się na 0,006% [196]. Częstość IZW u kobiet z chorobą serca wynosi 0-1,2% i jest wyższa u kobiet z mechaniczną protezą zastawkową [461][462][463][464]. Dlatego też IZW u kobiet w ciąży spotyka się wyjątkowo rzadko, a choroba może wynikać z wcześniej istniejącego uszkodzenia serca lub uzależnienia od dożylnych narkotyków.…”

Recommendations for the anticoagulation of pregnant patients with mechanical heart valves

“…[15] Warfarin is therefore not recommended in the first trimester (grade 1A). [16][17] In addition, there is an increased risk of fetal ocular and neurological abnormalities, a 30% risk of fetal loss, and an increased risk of fetal intracranial haemorrhage at any time during pregnancy, but particularly at the time of delivery. [3,[18][19][20][21] In pregnant women at higher risk of thromboembolism, such as those with older-generation valve types in the mitral position, e.g.…”