Selecting anticoagulation regimen to fit the pregnancy in women with mechanical cardiac valvular prostheses

Abstract

Advances in cardiovascular surgery and postoperative care make pregnancy possible for women with cardiac valvular prostheses due to impacts on maternal survival rates. However, mechanical cardiac valvular prostheses represent a high risk for increased maternal mortality and morbidity due to haemorrhage, heart failure, valvular thrombosis, and maternal thromboembolism events throughout pregnancy. It remains challenging to select an anticoagulation regimen that is safe and effective during the pregnancy and postpartum periods. Foetal risks include the teratogenic effects of medications; intracranial haemorrhage; intrauterine growth restriction, which results in a child small for its gestational age at birth; prematurity; and intrauterine foetal death. Vaginal delivery is recommended, after adapting an anticoagulant therapy. Caesarean sections might be considered for obstetric reasons or for patients at high risk for hemodynamic instability or valve thrombosis, or in patients taking warfarin. In this review, we provide a pregnancy-centred framework to assist clinicians in recommending the right anticoagulation regimen therapy for the management of pre-existing valvular pathology-associated pregnancies. A therapeutic anticoagulation schedule may improve both maternal and foetal outcomes. Moreover, a contraindication for pregnancy exists in the presence of severe mitral or aortic diseases or a mechanical valvular prosthesis when effective anticoagulation is not possible.