Prosthetic Heart Valves and Pregnancy: Challenges and Solutions

Abstract

With improved outcomes of valvular heart diseases and prosthetic valves, many women now survive into child-bearing age and pregnancy. However, the presence of prosthetic valves in pregnancy has an adverse impact on both maternal and fetal outcomes. The bioprosthetic or tissue valves are less thrombogenic. They do not need any anticoagulation and lead to normal pregnancy with normal baseline valve function. However, they have high rate of structural degeneration, especially in the young with an attendant need of reoperation leading to morbidity. Mechanical valves have excellent hemodynamics during pregnancy but are inherently thrombogenic leading to thromboembolic complications, necessitating uninterrupted anticoagulation. Anticoagulation itself leads to a host of maternal and fetal bleeding complication as well as adverse fetal anomalies. The use of low-dose warfarin throughout pregnancy has the best maternal safety profile. Added to this regimen, targeted replacement with parenteral heparin during the first (6–12 weeks) and late third trimesters (beyond 36 weeks) leads to virtual elimination of embryopathy as well as appreciable reductions of maternal mortality. Proper preconception counseling and antenatal care coupled with planned labor or delivery is essential to ensure best outcomes. These patients are best managed in a tertiary care center with proper expertise in managing adverse cardiovascular, obstetric, and neonatal outcomes.