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Balancing Thromboembolic Risk of a Mechanical Valve in Postpartum Hemorrhage
Abstract Number: S-09
Abstract Type: Case Report/Case Series
A 38-year-old G8P5 obese (BMI 36) woman presented with postpartum vaginal bleeding after undergoing IOL for IUFD at 16 weeks gestation. She had a history of severe coronary artery disease that required percutaneous angioplasty and stenting, followed by a 2-vessel CABG and mechanical mitral valve replacement. Postpartum, she was placed on an enoxaparin bridge to warfarin, with a target INR of 2.5-3.5. Six days later, she presented with heavy vaginal bleeding and lightheadedness. Presenting hemoglobin/hematocrit were 8.6/28, respectively, and INR was 2.4. Warfarin and enoxaparin were discontinued, and an infusion of standard heparin was initiated. The patient continued to have heavy vaginal bleeding and hemoglobin/hematocrit decreased to 6.8/22. She required transfusion of 2 units of pRBCs, and a decision was made to perform hysterectomy for continued bleeding in the setting of a need for continued anticoagulation.
Weighing the risks and benefits for this patient, the heparin infusion was discontinued 6 hours before hysterectomy, which was performed with general anesthesia. Peripheral access was favored over central access given the potential for thrombosis and/or hematoma development. A radial arterial catheter was placed and connected to LidCo to monitor CO, stroke volume variation, and other hemodynamic parameters. Cerebral oximetry was utilized as an additional monitor given her risk for embolic stroke from the mechanical valve. The surgical procedure was uncomplicated with an EBL of 150ml. She required no colloid or blood products and remained hemodynamically stable both during and after surgery.
This case presented the unique challenge of balancing the risk of severe intraoperative hemorrhage and maintaining appropriate anticoagulation for thromboprophylaxis in a patient with a mechanical valve. Withholding anticoagulation in patients with a mechanical heart valve increases the thromboembolic risk by 3.7 fold(1). Surgery itself adds additional thrombotic risk perioperatively(1). Continuing anticoagulation with heparin in the perioperative period is often utilized for the ability to rapidly change the plasma concentration in the event of increased hemorrhage. There is currently no consensus for an optimal approach to perioperative anticoagulation in these patients.
1. Cannegieter SC, Rosendaal FR, Briet E. (1994). Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation, 89(2):635-41.