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Peripartum Management of Stenotic Mechanical Mitral Valve Requiring Warfarin Therapy
Abstract Number: SU-13
Abstract Type: Case Report/Case Series
A 21 year-old primiparous female at 35 weeks gestation presented with gestational hypertension in the setting of a mechanical mitral valve, requiring anticoagulation with warfarin during pregnancy. The patient underwent AV septal defect repair as an infant, followed by 2 mitral valve replacements (MVR), the last being in 1999. She now had significant MV stenosis, necessitating a 3rd MVR, however, she became pregnant before the surgery was performed. Her most recent echo showed peak MV velocity of 2.4 m/s with a 12 mmHg gradient across the valve. She was admitted for anticoagulation with IV heparin infusion, with goal heparin correlation value 0.5-0.7; warfarin was discontinued. Delivery plan was induction of labor at 36 weeks, with discontinuation of heparin during active labor. Upon normalization of aPTT, epidural analgesia would be offered. Cardiology cited a 20% risk of MV thrombosis and death during the period off anticoagulation.
Invasive BP monitoring was initiated. At 3cm cervical dilation, heparin was stopped. A fentanyl PCA was used for labor analgesia, prior to normalization of aPTT. However SVD occurred 2.5 hours later, before neuraxial anesthesia could be offered. NICU was present, but no resuscitation was needed. No fetal defects were noted. Blood loss was 400ml. Oxytocin and cytotec were given. Heparin was resumed 5.5 hours postpartum, and warfarin reinitiated PPD 1.
Congenital heart disease in pregnancy is becoming more common, accounting for 25% of maternal cardiac deaths in the last 30 years(1). Mechanical heart valves present many challenges. Acute valvular thrombosis necessitating ECMO or emergent cardiac surgery is a feared complication. Anticoagulation with warfarin, a known teratogen, may be preferred to heparin in pregnancy due to reduced risk of catastrophic valve thrombosis and death. Anticoagulation with heparin throughout pregnancy has been associated with a 15% mortality and 10-fold higher risk of valve thrombosis compared to warfarin(2). While discontinuation of anticoagulation for delivery is necessary, this time period should be minimized, as it presents the highest risk of valve thrombosis.
In patients with mechanical heart valves, multidisciplinary antepartum consultation is imperative. Discussion should focus on type of anticoagulation and risk to fetus, mode of delivery, balancing risk of peripartum hemorrhage with that of valve thrombosis, likelihood of clinical decompensation, active vs. passive second stage of labor, how to minimize time off anticoagulation, need for invasive monitoring and labor analgesia options. Cardiac surgery and the ECMO team should be made aware of the patient. Postpartum anticoagulation should be resumed 4-6 hours after vaginal delivery, 6-12 hours after cesarean delivery(3).
1) Chan WS, et al. Arch Intern Med 2000:191-96.
2) Dob DP and Yentis SM. IJOA 2006:137-44.
3) Mclintock C, et al. Obstet & Gynecol Survey 2010:82-84.