Anticoagulation for the Pregnant Patient with a Mechanical Heart Valve, No Perfect Therapy: Review of Guidelines for Anticoagulation in the Pregnant Patient

Abstract

Heart valve replacement with a mechanical valve requires lifelong anticoagulation. Guidelines currently recommend using a vitamin K antagonist (VKA) such as warfarin. Given the teratogenic effects of VKAs, it is often favorable to switch to heparin-derived therapies in pregnant patients since they do not cross the placenta. However, these therapies are known to be less effective anticoagulants subjecting the pregnant patient to a higher chance of a thrombotic event. Guidelines currently recommend pregnant women requiring more than 5 mg a day of warfarin be switched to alternative therapy during the first trimester. This case report highlights a patient who was switched to alternative therapy during her first pregnancy and suffered a devastating cerebrovascular accident (CVA). Further complicating her situation was during a subsequent pregnancy; this patient continued warfarin use during the first trimester and experienced multiple transient ischemic attacks (TIAs). This case highlights the increased risk of thrombotic events in pregnant patients with mechanical valves. It also highlights the difficulty of providing appropriate anticoagulation for the pregnant patient who has experienced thrombotic events on multiple anticoagulants.

Coagulation conundrum in obstetric anesthesia with COVID-19

“…Though mechanical valves are durable, patients will need anticoagulation for life to prevent thrombosis. 4 Management of mechanical prosthetic valves in pregnancy poses a unique challenge since inadequate anticoagulation may lead to fatal valve thrombosis while excessive anticoagulation may cause bleeding during delivery. Vitamin K Antagonists (VKA) like warfarin can cause warfarin embryopathy characterized by nasal hypoplasia and stippled epiphysis if administered in the first trimester of pregnancy.…”

Pregnancy outcomes in patients with cardiac valve replacement

“…Factors include operation type, valve prosthesis, anticoagulation status, and anticoagulant medication all play a role in the risk of complications during pregnancy in people who have had heart surgery. Symptoms, cardiac function, and functional capacity are other factors that impact the result [7] .…”

Anticoagulant Treatment of COVID-19 as Early as Possible—Sulodexide and Perspectives

“…The local antiinflammatory and anticoagulant effect of inhaled heparin may act through its negative charges on the positively charged local toxic proteins in COVID-19 for potential use in mild to moderate COVID-19. 27,28 32 and DOAC Dipstick or other point-of-care methods for DOACs 33 to avoid excessive anticoagulation by presence of two types of anticoagulants (►Fig. 1).…”