Limited dose warfarin throughout pregnancy in high-risk patients with mechanical valves: A randomized clinical trial

Hassouna, Ahmed; Ammar, Ayman; Elnahas, Yasser; Toema, Ahmed; Allam, Hemat

doi:10.1016/j.ehj.2014.04.004

Cited by 9 publications

(5 citation statements)

References 22 publications

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“…In addition, these studies only describe the first-trimester dose of warfarin, which may or may not reflect the dose used later in pregnancy, when warfarin fetopathy can continue to occur. Finally, women with stable INRs in the three months prior to pregnancy may require higher doses of VKAs during pregnancy 16 . Thus, while it appears that foetal adverse events increase when the dose of warfarin is >5 mg/day, foetal loss and adverse events can occur in women with doses of warfarin ≤5 mg/day.…”

Section: Discussionmentioning

confidence: 99%

“…Finally, women with stable INRs in the three months prior to pregnancy may require higher doses of VKAs during pregnancy. 16 Thus, while it appears that foetal adverse events increase when the dose of warfarin is >5 mg/day, foetal loss and adverse events can occur in women with doses of warfarin ≤5 mg/day. The safety of first-trimester VKA doses ≤5 mg/day still needs to be confirmed, and requires discussion with the patient.…”

Section: Discussionmentioning

confidence: 99%

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Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis

D’Souza

Ostro

Shah

et al. 2017

European Heart Journal

158

164

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AimsTo 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.Methods and resultsMedline, 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.ConclusionsVKAs 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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis

D’Souza

Ostro

Shah

et al. 2017

European Heart Journal

158

164

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“…[20][21][22][23][24] Compared with western counterparts, Indian women are at increased risk due to higher prevalence of rheumatic valvular heart disease. 25 Management is similar to that in nonpregnant women.…”

Section: Arterial Thromboembolism and Strokementioning

confidence: 73%

Thromboembolic Disorders during Pregnancy: Cardiologist Perspective

Hegde

2018

Ind J Car Dis Wom

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The hematologic changes which occur during pregnancy make it a hypercoagulable state. Various factors such as hereditary thrombophilia, obesity, etc. increase the risk of venous thromboembolism in these patients. Though the prevalence is low, it can contribute to significant mortality and morbidity. Deep vein thrombosis is the most common type of venous thromboembolism and pulmonary embolism can sometimes be fatal. Various diagnostic modalities like compression duplex ultrasound of leg veins, echo, ventilation-perfusion scan, and computed tomographic pulmonary angiogram can help in diagnosis. Proper treatment can improve both maternal and fetal outcome.

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“…Finally, women with stable INRs in the three months prior to pregnancy may require higher doses of VKAs during pregnancy. 16 Thus, while it appears that foetal adverse events increase when the dose of warfarin is >5 mg/day, foetal loss and adverse events can occur in women with doses of warfarin < _5 mg/day. The safety of first-trimester VKA doses < _5 mg/day still needs to be confirmed, and requires discussion with the patient.…”

Section: Discussionmentioning

confidence: 99%

662: Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis

D’Souza

Ostro

Malinowski

et al. 2016

American Journal of Obstetrics and Gynecology

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Limited dose warfarin throughout pregnancy in high-risk patients with mechanical valves: A randomized clinical trial

Cited by 9 publications

References 22 publications

Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis

Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis

Thromboembolic Disorders during Pregnancy: Cardiologist Perspective

662: Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis

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