Combined use of warfarin and adjusted subcutaneous heparin during pregnancy in patients with an artificial heart valve

Lee, Pui-Kee; Wang, Rebecca Y.C.; Chow, Joseph S. F.; Cheung, King‐Loong; Wong, Vivian Taam; Chan, T. Y. K.

doi:10.1016/s0735-1097(86)80116-4

Cited by 49 publications

(14 citation statements)

References 14 publications

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“…Twenty studies ‡ reported switching to hep-*References 7 11,[19][20][21][22][23][24][25][26][27][28][29][30][31][33][34][35]37,38,40,41. †References 9,22,24,28,30,32,[34][35][36]38,39,42. ‡References 8,9,[19][20][21][22]24,[26][27][28][29][30][31][33][34][35]37,38,40,41.…”

Section: Resultsmentioning

confidence: 99%

Anticoagulation of Pregnant Women With Mechanical Heart Valves

Chan¹,

Anand²,

Ginsberg³

2000

Arch Intern Med

686

484

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Background:The management of women with prosthetic heart valves during pregnancy poses a particular challenge as there are no available controlled clinical trials to provide guidelines for effective antithrombotic therapy. Oral anticoagulants such as warfarin sodium cause fetal embryopathy; subcutaneous administration of heparin sodium has been reported to be ineffective in preventing thromboembolic complications.Objective: To identify the risks of maternal and fetal complications in women with mechanical heart valves treated with different anticoagulation regimens during pregnancy.Methods: We performed a systematic review of the literature to determine pooled estimates of maternal and fetal risks associated with the 3 commonly used approaches:(1) oral anticoagulants (OA) throughout pregnancy, (2) replacing OA with heparin in the first trimester (from 6-12 weeks' gestation), and (3) heparin use throughout pregnancy. Fetal outcomes included spontaneous abortions and fetopathic effects, and maternal outcomes were major bleeding, thromboembolic complications, and death.Results: The use of OA throughout pregnancy is associated with warfarin embryopathy in 6.4% (95% confidence interval [CI], 4.6%-8.9%) of livebirths. The sub-stitution of heparin at or prior to 6 weeks, and continued until 12 weeks, eliminated this risk. Overall risks for fetal wastage (spontaneous abortion, stillbirths, and neonatal deaths) were similar in women treated with OA throughout, compared with women treated with heparin in the first trimester. Maternal mortality was 2.9% (95% CI, 1.9%-4.2%). Major bleeding events occurred in 2.5% (95% CI, 1.7%-3.5%) of all pregnancies, most at the time of delivery. The regimen associated with the lowest risk of valve thrombosis (3.9%; 95% CI, 2.9-5.9%) was the use of OA throughout; using heparin only between 6 and 12 weeks' gestation was associated with an increased risk of valve thrombosis (9.2%; 95% CI, 5.9%-13.9%).Conclusions: Thromboembolic prophylaxis of women with mechanical heart valves during pregnancy is best achieved with OA; however, this increases the risk of fetal embryopathy. Substituting OA with heparin between 6 and 12 weeks reduces the risk of fetopathic effects, but with an increased risk of thromboembolic complications. The use of low-dose heparin is definitely inadequate; the use of adjusted-dose heparin warrants aggressive monitoring and appropriate dose adjustment. Large prospective trials to determine the best regimen for these women are needed.

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Section: Resultsmentioning

confidence: 99%

Anticoagulation of Pregnant Women With Mechanical Heart Valves

Chan¹,

Anand²,

Ginsberg³

2000

Arch Intern Med

686

484

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“…Dans la littérature, le pourcentage de thrombose prothétique varie entre 0 et 9,2 % [13, [16][17][18][19]. Nos résul-tats, comme ceux de Sareli et al [18], s'expliqueraient par l'utilisation de prothèses mécaniques récentes, type Saint-Jude, réputées peu thrombogènes, dont 62,5 % de nos patientes étaient porteuses.…”

Section: Discussionunclassified

“…Le risque thromboembo- Iturbe-Alessio et al [12] avaient trouvé un taux de 13,2 % d'hémorragie sous héparine. Lee et al [17] rapportaient deux cas d'hémorragie de la délivrance massive sous anticoagulants. Ce type d'accident était évalué à un taux d'environ 8 % dans le péripartum pour l'héparine et les AVK.…”

Section: Discussionunclassified

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Prothèse valvulaire cardiaque et grossesse au CHU de Dakar : aspects épidémiologiques, cliniques, pronostiques et modalités thérapeutiques

Mbaye

Moreira

Guèye

et al. 2009

Journal de Gynécologie Obstétrique et Biologie de la Reproducti

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“…Antiplatelet agents have also been evaluated as substitutes for warfarin during gestation and were found to be associated with a high risk (20%) of cerebral embolism [32]. Conflicting results have been reported in evaluating the use of adjusted dose heparin to maintain an aPTT level of 1.5 to 2.5 times normal during the 6th to 12th weeks of gestation with respect to the risk of thrombotic and thromboembolic complications [33][34][35]. These studies are limited due to use of older-generation valve prosthesis as well as use of low doses of heparin [2••].…”

Section: Special Considerationsmentioning

confidence: 99%

Antithrombotic therapy for prosthetic valves: Routine treatment and special considerations

2001

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The use of prosthetic heart valves has increased over the past 3 decades. Antithrombotic agents remain the mainstay of therapy to prevent thromboembolic events caused by the presence of a prosthetic heart valve. We examine the risks of thromboembolic events as well as the risks and benefits of antithrombotic therapy in patients with mechanical and bioprosthetic heart valves. We also review the data regarding the use of antithrombotic therapy in special groups of patients, such as those with intracranial bleeding, pregnant women with prosthetic heart valves, and patients with prosthetic heart valves undergoing surgery.

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Combined use of warfarin and adjusted subcutaneous heparin during pregnancy in patients with an artificial heart valve

Cited by 49 publications

References 14 publications

Anticoagulation of Pregnant Women With Mechanical Heart Valves

Anticoagulation of Pregnant Women With Mechanical Heart Valves

Prothèse valvulaire cardiaque et grossesse au CHU de Dakar : aspects épidémiologiques, cliniques, pronostiques et modalités thérapeutiques

Antithrombotic therapy for prosthetic valves: Routine treatment and special considerations

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