Case Report

VALVULAR HEART DISEASE IN PREGNANCY

ANDALAS UNIVERSITY

By:

dr. Aswin Boy Pratama, SpOG

Trainee of Fetomaternal Subspeciality Education
Program

Mentor:
Prof. Dr. dr. Hj. Yusrawati, SpOG, Subs-KFM
(K)
Dr. Dr. dr. Joserizal Serudji SpOG, Subs-KFM
(K)

FETOMATERNAL SUBSPECIALITY EDUCATION PROGRAM

OBSTETRICS AND GYNECOLOGY
MEDICAL FACULTY OF ANDALAS UNIVERSITY
2024
 PROGRAM STUDI SUBSPESISALIS OBSTETRI DAN
GINEKOLOGI PEMINATAN KEDOKTERAN FETOMATERNAL
FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUP Dr. M. DJAMIL PADANG

LEMBAR PENGESAHAN

Nama : dr. Aswin Boy Pratama, SpOG

Semester : I (Satu)

Telah menyelesaikan kasus Kehamilan

dengan Penyulit Valvular Heart Disease

Padang, April 2024

Pembimbing Peserta Pendidikan Subspesialis Obgyn

Peminatan Kedokteran Fetomaternal

Dr.Dr.dr.Joserizal Serudji SpOG(K) dr. Aswin Boy Pratama,SpOG

MENGETAHUI

KPS SUBSPESIALIS OBGYN

PEMINATAN KEDOKTERAN
FETOMATERNAL FK UNAND

Prof.Dr.dr.Hj.Yusrawati,SpOG(K)
 CHAPTER 1
INRODUCTION

Case: Mrs. Windy Syafira 26 years old 01188258 with G 3P2A0H2 36-37 weeks
gestational ages with valvular heart disease presents to fetomaternal. The patient
regularly control by a cardiologist. The patient was diagnosed valvular heart
disease by a cardiologist in The Tertiary Hospital. The patient was advised not to
get pregnant but the patient failed to prevent the pregnancy. Previous
contraceptive history was unclear

As a result of improved diagnostic and reparative techniques, congenital heart

diseases are becoming a significant problem for women of childbearing
age. Nowadays, more pregnant women are being diagnosed with an acquired heart
disease because of the tendency to delay childbearing and increasing age-related
risk of developing complications of hypertension, diabetes, obesity and other
diseases. Pregnancy in conjunction with heart disease is a complicated condition
that requires multidisciplinary prenatal care (consisting of an obstetrician
gynaecologist, cardiologist, anaesthesiologist). Low molecular weight heparins
should be the first choice medication for antithrombotic prophylaxis. Since
pregnancy can aggravate a heart disease, preconception counselling and
evaluation of the heart function are recommended.
 CHAPTER II
LITERATURE REVIEW

2.1 INTRODUCTION
Cardiovascular (CV) disease complicates an estimated 1% to 4% of all
pregnancies and is the leading cause of death in pregnant and postpartum women
in the United States.1,2 Valvular heart disease is a common cause of CV disease
that affects women of childbearing age.3,4 Congenital heart disease is the leading
cause of valvular heart disease in the United States; however, rheumatic heart
disease is a prevalent condition especially among immigrant populations. 5,6 Most
women with valvular heart disease will do well during pregnancy, but high-risk
conditions such as severe mitral stenosis (MS) or aortic stenosis (AS), can be
associated with significant maternal morbidity and mortality. Management of
anticoagulation of pregnant women with mechanical heart valves presents unique
challenges to reduce the risk of maternal and fetal complications. Women with
valvular heart disease who are pregnant or considering pregnancy should be
managed by a multidisciplinary Pregnancy Heart Team consisting of cardiologists
and high-risk obstetricians.
Hemodynamic changes start early in pregnancy. Cardiac output increases 30% to
50% and peaks between the second and third trimesters. 7,8 Changes in cardiac
output are driven by an increase in stroke volume in the first half of pregnancy
followed by a gradual rise in heart rate. As a result of placental maturation,
systemic vascular resistance and blood pressure decrease in the first and second
trimesters and returns to pre-pregnancy levels in the third trimester. Women with
valvular heart disease, especially left-sided obstructive lesions, may have limited
cardiac reserve to accommodate these hemodynamic changes. As a result, close
serial monitoring during pregnancy is necessary to assess for clinical
decompensation. The changes in flow can lead to increases in mitral and aortic
transvalvular gradients and an overestimation of lesion severity. Direct valve
planimetry for patients with AS or MS may more accurately reflect the degree of
valve stenosis, especially for patients newly diagnosed during pregnancy. The
hypercoagulable state of pregnancy increases the risk of thromboembolic events
during pregnancy and the first 6 to 12 weeks postpartum, further complicating the
anticoagulation management of women with mechanical valves.9
Labor and delivery is associated with sudden hemodynamic changes and increases
in oxygen consumption. After delivery, dramatic changes in hemodynamics occur
as a result of autotransfusion of uterine blood volume, relief of caval pressure, and
mobilization of dependent edema. The sudden increase in preload can lead to
clinical decompensation and women with high-risk lesions will need to be
followed closely immediately after delivery and in the subsequent days post-
delivery.

2.2 PRECONCEPTION COUNSELING

Reproductive age women with valvular heart disease should undergo counseling
before conception by a collaborative Pregnancy Heart Team consisting of a
maternal fetal medicine (MFM) specialist and cardiologist with experience in
caring for pregnant women with heart disease.10 The goal of preconception
counseling is to review and individualize the maternal and fetal risk of pregnancy.
Baseline cardiac function should be assessed with an electrocardiogram and
echocardiogram to start. Exercise stress testing can be an important tool to assess
exercise capacity, development of arrhythmias and symptomatic response, which
may guide risk stratification and treatment before conception. Additional imaging
modalities such as cardiac MRI or computed tomography may be used to further
assess valvular function, anatomy of structures not well seen by echocardiogram,
and associated aortopathies.
For women planning pregnancy, medications should be reviewed for safety during
pregnancy. Angiotensin-converting enzyme inhibitors and angiotensin receptor
blockers are teratogenic and can be changed to medications with a better safety
profile during pregnancy. Bosentan and statins are also considered teratogenic and
should be stopped before pregnancy. For women with mechanical valves taking
warfarin, shared decision making will help guide the appropriate choice of
anticoagulation in the first trimester. Beta blockers are generally considered safe
in pregnancy. Women may frequently present during pregnancy with newly
diagnosed or newly symptomatic valvular heart disease and collaborative care
between MFM, cardiology, anesthesia, and other specialists is needed to reduce
ongoing maternal, obstetric, and fetal risk.

2.3 RISK ASSESSMENT

The most common maternal complications of valvular heart disease during
pregnancy are heart failure, arrhythmias, and thromboembolic complications.
Postpartum hemorrhage can be a common complication for women on
anticoagulation. Cardiac symptoms can be managed in many women with
diuresis, medical therapy, and reducing level of physical activity. If symptoms are
refractory to conservative management, valve intervention during pregnancy may
be necessary. Percutaneous balloon valvuloplasty performed by experienced
operators is preferred for stenotic lesions. Ideally these interventions should be
performed after the fourth month in the second trimester to minimize radiation
exposure during organogenesis.6 Valve surgery with cardiopulmonary bypass
performed during pregnancy is associated with rates of fetal death up to 30%,
especially when surgery is emergent and/or performed at early gestational
age.11,12 If surgery is needed, however, the second trimester is the preferred time
frame with use of high flow on cardiopulmonary bypass to provide adequate
placental perfusion.13
Maternal cardiac risk can be estimated using the lesion specific modified World
Health Organization (WHO) classification. 6 Women with severe MS and severe
symptomatic AS are considered to be at extremely high risk of maternal morbidity
or mortality (WHO IV) and pregnancy is contraindicated. Most other types of
valvular heart disease in pregnancy are considered to be moderate to high risk
(WHO II-III). Those with regurgitant lesions such as aortic regurgitation and
mitral regurgitation usually tolerate pregnancy well due to the decreased systemic
afterload during pregnancy. Individualized risk can be further estimated using
pregnancy-specific risk indices developed in large cohorts, including the
CARPREG II and the ZAHARA models. 4,14,15 Contraception should be discussed
with all women with valvular heart disease but highly effective contraception
should be particularly recommended for women at high risk of pregnancy
complications. Estrogen-containing contraception increases the risk of venous and
arterial thrombosis and hypertension and should be avoided in women with
cardiac disease, especially those at increased thrombotic risk. In such patients,
long-acting progesterone-only methods are recommended, such as an intrauterine
device or subdermal implants.16

2.4 DELIVERY CONSIDERATIONS

Unless indicated for obstetric indications, a vaginal delivery is preferred for most
women with valvular heart disease.1 Vaginal delivery is associated with less blood
loss, more rapid recovery, and less thrombogenic and infectious risk. Patients at
elevated risk of complications should discuss a delivery plan in consultation with
a multidisciplinary team consisting of a MFM specialist, cardiologist, and
obstetric anesthesiologist. Women with stable cardiac disease can undergo full-
term delivery at 39 weeks of gestation. 1 Good pain control with regional
anesthesia during vaginal delivery can minimize the catecholamine release
associated with sudden increases in heart rate and stroke volume. Epidural is
preferred over spinal anesthesia due to lower rates of hypotension. Women with
moderate to severe left-sided obstructive lesions may benefit from an assisted
second stage of labor using forceps or vacuum, which shortens the time to
delivery and minimizes the frequency and intensity of maternal effort with
Valsalva maneuver, which transiently drops cardiac output. Cesarean delivery
should be considered in women with severe heart failure (New York Heart
Association [NYHA] class III-IV), high-risk aortic disease, and severe forms of
pulmonary hypertension.6 For women requiring delivery while fully
anticoagulated on warfarin, Cesarean delivery should be considered to minimize
the risk of fetal intracranial hemorrhage. Telemetry is recommended during labor
and delivery and up to 24 hours after delivery in women at risk for developing
arrhythmias. Women with severely stenotic or symptomatic valvular disease may
require monitoring in a cardiac care or telemetry unit for at least 24 hours after
delivery, with close monitoring of hemodynamics and volume status.
2.5 SPECIFIC VALVE LESIONS
Mitral Stenosis
MS is the most common valvular lesion managed during pregnancy and its
prevalence is more common in areas of the world with a higher burden of
rheumatic heart disease.17 In some cases, MS may be congenital and due to a
dysplastic valve or as a result of valve stenosis following an earlier intervention
during childhood, as may be the case in patients with surgical repair of atrio-
ventricular (AV) septal defects. During pregnancy, the physiologic increase in
stroke volume and heart rate lead to higher gradients across the stenosed mitral
valve and an increase in left atrial pressure. These changes can lead to worsening
heart failure symptoms or the development of new symptoms in women who were
previously asymptomatic. The hemodynamic changes of pregnancy can also lead
to atrial arrhythmias, including atrial fibrillation, which can in turn precipitate
pulmonary congestion.18 In up to a quarter of women, pregnancy may be the first
time a diagnosis of MS is made.17,19

Maternal outcomes
MS is associated with an increased risk of heart failure and atrial arrhythmias
during pregnancy. Women with moderate or severe stenosis (mitral valve area
(MVA) <1.5 cm2), baseline maternal NYHA class III or IV, or a history of cardiac
complications before pregnancy represent the groups at highest risk of maternal
complications.17,18,20 Most complications can be managed medically and rates of
mitral valve intervention and maternal mortality are low, especially in North
American and European cohorts.
Many women with MS will develop or experience progression of symptoms
during pregnancy. Among 44 women with MS representing 46 pregnancies
treated in California, 74% advanced ≥ 1 NYHA class during pregnancy. 19 Women
with moderate or severe MS had high rates of developing heart failure or atrial
arrhythmias, whereas women with mild MS had maternal outcomes similar to
women without valvular disease. In a Canadian cohort of 74 women representing
80 pregnancies, 31% developed pulmonary edema and 11% developed
arrhythmias, with risk proportional to severity of stenosis. 18 Heart failure was
managed medically in both cohorts and no maternal deaths were reported.

Similar rates of maternal complications were reported among the 273 women with
MS participating in the International Registry of Pregnancy and Cardiac Disease
(ROPAC).17 In this cohort, 15 patients (5.9%) underwent mitral valve intervention
including percutaneous balloon mitral commissurotomy (n = 14) and surgical
valve replacement (n = 1). Most interventions occurred in women who were
symptomatic before pregnancy. One woman with severe MS died during
pregnancy and 2 died postpartum. Women with moderate and severe MS have
high rates of preterm delivery and intrauterine growth restriction (IUGR).19

Management
The medical management of women who become symptomatic during pregnancy
consists of beta blockers, diuretics, and activity restriction. Beta blockers slow the
heart rate, lengthen diastolic filling time, and lower left atrial pressure. 21 Beta-1
selective agents, such as metoprolol, are preferred so as to avoid interfering with
beta-2 mediated uterine relaxation. Furosemide should be used in patients with
pulmonary edema or ongoing symptoms despite beta blockers. Women who
develop atrial fibrillation should be anticoagulated, usually with low molecular
weight heparin, unfractionated heparin, or warfarin depending on the trimester
and clinical context. Anticoagulation should also be considered in women with
severe MS and other risk factors for stroke, such as spontaneous
echocardiographic contrast in the left atrium, large left atrium (≥60 mL/m 2), or
congestive heart failure.1 Rate control with beta blockers or digoxin should be
used as an initial strategy, though many women will ultimately undergo electrical
cardioversion (which is considered safe in pregnancy) due to ongoing symptoms,
poor rate control, or hemodynamic instability.
Women who remain severely symptomatic despite adequate medical therapy and
activity restriction may need to undergo mitral valve intervention during
pregnancy. Percutaneous mitral balloon valvotomy (PMBV) can be safely
performed during pregnancy and result in improved valve area and
gradients.11,22 Due to risk of ionizing radiation to the fetus, PMBV should be
avoided during the first trimester, if possible, and performed by experienced
operators. Surgical mitral valve replacement may be considered in women with
refractory symptoms who are not candidates for PMBV but is associated with
high rates of fetal mortality, estimated at 20% to 30%.11,12
Most women with MS can undergo a vaginal delivery with regional anesthesia,
with preference for epidural placement. 23 An assisted second stage should be
considered for women with moderate to severe stenosis. Cesarean delivery is
reserved for obstetric indications and decompensated heart failure. Due to the
hemodynamic shifts that occur postpartum, monitoring in a special care unit for at
least 24 hours after delivery is recommended.
Careful preconception counseling of women with MS is critical in order to
identify severity of stenosis, symptoms, and need for intervention before
pregnancy. Similar to non-pregnant patients, the 2014 American Heart
Association (AHA)/American College of Cardiology (ACC) Valvular Heart
Disease Guidelines recommends PMBV, when feasible, in patients with severe
symptomatic MS (Class I recommendation) before pregnancy. In order to avoid
clinical decompensation and need for intervention during pregnancy. The
AHA/ACC Guidelines also recommend PMBV in patients with severe MS who
are asymptomatic (Class I recommendation). The decision to intervene in
asymptomatic women before pregnancy should depend on valve area, exercise
tolerance, and the presence of pulmonary hypertension, especially among women
who are not candidates for PMBV.6,23,24

Aortic Stenosis
AS in pregnancy is most often caused by congenital bicuspid aortic valve and less
commonly other congenital abnormalities or rheumatic heart
disease.24,25 Pregnancy is well tolerated in women with mild and moderate AS.
Women with severe AS are at higher risk of developing cardiac complications,
such as heart failure or atrial arrhythmias, however the risk of maternal mortality
and need for aortic valve intervention during pregnancy is low. Women with
congenital bicuspid valve or Marfan syndrome may have an associated aortopathy
which further increases maternal risk and warrants additional monitoring before
and during pregnancy. Pregnancy is contraindicated in women with bicuspid
aortic valve when aortic dilation is >50 mm and in women with Marfan syndrome
when aortic dilation is >45 mm.6
In a Canadian cohort of 39 women representing 49 pregnancies, cardiac
complications, including heart failure or arrhythmias, were observed in 10% of
women with severe AS. Only 1 woman required aortic valve intervention during
pregnancy and no maternal deaths were reported. 25 Other series have reported that
heart failure occurs in 3.8% to 44% of patients, with the highest rate observed in
the smallest (n = 12) cohort.19,26,27 Maternal complications are associated with
severity of AS, especially when symptomatic, and maternal age >30
years.26,27 Maternal mortality in contemporary cohorts and need for valvular
intervention during pregnancy is low. Valve deterioration and need for aortic
valve intervention may be higher in women with severe AS after pregnancy,
although the causes for this are not well-understood. 25,26 Women with severe AS
experience higher rates of preterm delivery, low birth weight, and fetal death.19,26

Management
Women who become symptomatic should be managed with activity restriction.
Diuretics should be carefully used in women who develop pulmonary edema so as
to avoid a sudden drop in preload. Women who remain symptomatic despite
conservative management may need valvular intervention during pregnancy with
a preference for percutaneous aortic balloon valvuloplasty if the valve anatomy is
favorable and an experienced team is available. Percutaneous transcatheter aortic
valve replacement for bicuspid severe AS has been successfully performed during
pregnancy, and may be preferred over valvuloplasty if significant aortic
regurgitation is present.28 Women who develop severe symptoms early in
pregnancy may consider pregnancy termination. Similar to patients with MS,
vaginal delivery is the preferred mode of delivery with an assisted second stage
for women with moderate to severe stenosis, though Cesarean delivery may be
considered for patients with severe symptoms.6,24 Regional anesthesia with an
epidural is preferred for pain control but hemodynamics should be monitored
closely to avoid a sudden drop in preload and systemic vascular resistance, which
may poorly tolerated.

MITRAL REGURGITATION AND AORTIC REGURGITATION

The most common causes of mitral regurgitation (MR) during pregnancy are
rheumatic heart disease and mitral valve prolapse. Patients with previously
repaired (or unrepaired) AV septal defects may also have significant left-sided AV
valve regurgitation. In contrast, aortic regurgitation (AR) is more commonly
associated with congenital bicuspid aortic valve or aortopathy, and less commonly
rheumatic heart disease. Both MR and AR are well tolerated during pregnancy,
even if severe, due to the fall in systemic vascular resistance and blood pressure.
Surgical intervention before pregnancy is reserved for women meeting routine
indications for surgery, including severe symptomatic valve disease. Exercise
testing before pregnancy can be considered to assess for exercise tolerance and
symptoms.29 Women who develop heart failure symptoms or left ventricular
dysfunction can be treated with diuretics and vasodilators, such as hydralazine or
nitrates, with care to avoid hypotension which can lead to placental
hypoperfusion. Angiotensin-converting enzyme inhibitors and angiotensin
receptor blockers are contraindicated during pregnancy.
PULMONIC STENOSIS
Pulmonic stenosis (PS) is most commonly a result of congenital valve disease but
may also occur as a result of homograft calcification after a Ross procedure or
prosthetic valve stenosis in patients with repaired tetralogy of Fallot. Mild and
moderate PS are well tolerated during pregnancy. Severe PS is associated with
high rates of hypertensive disorders, such as preeclampsia, preterm delivery, and
thromboembolic complications.30 Although severe PS may be well tolerated
during pregnancy, some women may experience right ventricular heart failure or
arrhythmias. As a result, women with severe PS, even if asymptomatic, should be
considered for balloon valvuloplasty, surgical val-votomy, or percutaneous valve
replacement before pregnancy.31
PULMONIC REGURGITATION
Pulmonic regurgitation (PR) may be secondary to prior tetralogy of Fallot repair,
balloon valvuloplasty for isolated PS, or develop in patients with a prior right
ventricle to pulmonary artery conduit. PR is generally well tolerated during
pregnancy. Similar to the systemic vascular resistance, pulmonary vascular
resistance also decreases during pregnancy. However, the increased plasma
volume and CO associated with pregnancy can lead to right-sided heart failure
symptoms in women with severe PR, especially in the presence of underlying
right ventricular (RV) dysfunction, RV hypertrophy, or additional obstructive
lesions such as branch pulmonary artery stenosis. 32,33 Right-sided heart failure can
often be treated with diuretics and activity restriction. Valve intervention is rarely
needed during pregnancy.6 In women with severe PR before pregnancy who are
symptomatic or have progressive RV dilatation or dysfunction, pulmonary valve
replacement is recommended.31

TRICUSPID REGURGITATION
Isolated tricuspid regurgitation (TR) in young women is uncommon and, when
present, occurs in the setting of Ebstein anomaly, rheumatic heart disease, or
endocarditis. Patients with AV septal defects commonly have right-sided AV
valve regurgitation. The hemodynamic changes of pregnancy are usually well
tolerated in women with TR, even if severe. Ebstein anomaly is associated with
atrial septal defect and Wolff-Parkinson-White syndrome. As a result, pregnancy
may be associated with progressive cyanosis and/or arrhythmias in women at
risk.34 Ebstein anomaly is also associated with increased risk of preterm
delivery.35 Secondary TR can occur as a result of RV pressure or volume overload
as a result of left-sided heart disease and pulmonary hypertension, cardiac
conditions associated with significantly elevated maternal risk during pregnancy.

PROSTHETIC VALVES
Pregnancy is a prothrombotic state and is associated with an increased risk of
valve thrombosis in women with prosthetic heart valves. Pregnant women with
mechanical heart valves require careful anticoagulation management to prevent
severe maternal morbidity while minimizing anticoagulation-related risk to the
fetus. Although hypercoagulability risk increases throughout pregnancy and peaks
in the immediate postpartum period, valve thrombosis frequently occurs in the
first trimester and may be related to sub-therapeutic anticoagulation, underscoring
the importance of preconception counseling.36,37
Anticoagulation
Warfarin is the standard of care for mechanical valves in non-pregnant patients to
prevent thromboembolic complications. However, warfarin crosses the placenta
and is associated with an embryopathy, consisting of nasal hypoplasia, stippled
epiphyses, and choanal atresia, when exposure occurs between 6 and 12 weeks of
gestation.37 Later exposure is associated with central nervous system abnormalities
and intracranial hemorrhage. The most common fetal adverse even is miscarriage
and fetal demise can occur at any gestational age.
Warfarin has a dose-dependent effect on fetal outcomes with the highest risk
associated with daily warfarin doses >5 mg, 38 though lower risk with lower doses
has not been demonstrated in all studies. 36 In a 2017 meta-analysis, the rate of
livebirths among women taking ≤5 mg compared with >5 mg of warfarin daily
was 83.6% versus 43.9%, respectively.39 The rate of embryopathy/fetopathy was
2.3% with lower dose (≤5 mg) and 12.4% with higher dose (>5 mg) of warfarin.
Women treated with low molecular weight heparin (LMWH) alone during
pregnancy had the highest rate of livebirth at 92%.
LMWH does not cross the placenta and is therefore not associated with congenital
malformations. Weight-based dosing is administered twice daily and cleared by
the kidneys. Dose adjustment in response to peak anti-Xa levels is needed due to
changes in renal clearance and volume of distribution over the course of
pregnancy.40 In contemporary studies, dose-adjusted LMWH is still associated
with thromboembolic complication in 4% to 17% of pregnancies.39,41,42
Thromboembolic complications occur throughout pregnancy and may be related
to sub-therapeutic anticoagulation during transition of anticoagulants, especially
in the first trimester, or sub-therapeutic LMWH levels. Fixed dose LMWH is
associated with significantly higher thromboembolic complications compared
with dose-adjusted regimens.43 The measurement of peak anti-Xa levels may not
sufficiently assure adequate anticoagulation. Among pregnant women with peak
anti-Xa levels within the recommended range of 0.8 to 1.2 U/mL, 57% had sub-
therapeutic trough levels (<0.6 U/ml).44 Low trough levels were still observed
among women with peak anti-Xa levels at the upper range of 1.0 to 1.2 U/ml.
Several small series have demonstrated favorable thromboembolic outcomes
among women treated with close monitoring of both peak and trough anti-Xa
levels, with peak levels targeted to 1 to 1.2 U/mL.37
Comparing Anticoagulation Strategies
Four anticoagulation strategies were compared in a meta-analysis of contemporary
studies representing 800 pregnancies between 1974 and 2014.42 Studies were
excluded if fixed dose LMWH or unfractionated heparin (UFH) were used or if
ball-in-cage valves were present in greater than 10% of reported pregnancies.
Maternal risk was lowest in women using vitamin K antagonist (VKA) throughout
pregnancy and 3-times-higher in women using alternative strategies, see Table 2.
Maternal deaths were rare and adverse events were driven by systemic
thromboembolism or valve thrombosis. Fetal risk was lowest in women using
LMWH throughout pregnancy or LMWH plus VKA. Differences in fetal
outcomes were driven by spontaneous abortions; congenital defects were
uncommon. Women taking low-dose VKA throughout pregnancy had similar fetal
outcomes compared with women taking LMWH or LMWH plus VKA. A similar
metaanalysis demonstrated that women treated with VKA throughout pregnancy
had the lowest proportion of livebirths compared with women treated with
LMWH (64.5% vs 92%) but had a lower risk of thromboembolic complications
(2.7% vs 8.7).39

Management
Women with bioprosthetic and mechanical valves should be treated with a baby
aspirin during the second and third trimesters. For women with mechanical
valves, warfarin continued throughout pregnancy offers the lowest risk of
maternal thromboembolic complications but carries a higher risk of miscarriage
and embryopathy, as described previously. The 2014 ACC/AHA Valvular Heart
Disease Guidelines and the 2018 ESC Pregnancy and Heart Disease Guidelines
recommend continuing warfarin at doses ≤5 mg/d during the first trimester and
transitioning to dose-adjusted LMWH or intravenous (IV) UFH when the daily
dose is >5 mg/d.6,45 Regardless of anticoagulant choice in the first trimester,
treatment with warfarin is usually recommended in the 2nd and 3rd trimesters.
Discontinuation of warfarin and starting IV UFH before planned vaginal delivery
is recommended. Women who are therapeutically anticoagulated on warfarin and
need to be delivered should undergo Cesarean delivery to minimize traumatic fetal
hemorrhagic.

The AHA/ACC guidelines recommend targeting a peak anti-Xa level of 0.8 to 1.2
U/mL 4 to 6 hours after dosing for women treated with LMWH during pregnancy.
Given the higher risk of thromboembolic complications in women with sub-
therapeutic anticoagulation, aiming for peak levels in the 1.0 to 1.2 U/mL range
with trough levels greater than 0.6 U/mL may be reasonable, and is recommended
in the 2018 ESC pregnancy and heart disease guidelines. 6 Because the safety
profile of low-dose warfarin is based on a small number of studies and the risk of
fetal loss is present throughout pregnancy, even at lower warfarin doses, some
investigators advocate for using LMWH throughout pregnancy with closely
monitored anti-Xa levels.46 Favorable clinical outcomes have been demonstrated
in women treated with this strategy, but high levels of medication adherence and
patient engagement are needed. This strategy may be desirable for women who
are at otherwise low risk of thromboembolic complications (eg, mechanical valve
in aortic position) or women who place higher value on avoiding potential fetal
risk than maternal complications.
Valve thrombosis during pregnancy should be confirmed with transesophageal
echocardiogram and treated first with heparin and, if needed, thrombolytic therapy
for women with small thrombus and mild symptoms. Tissue-type plasminogen
activator is associated with hemorrhagic complications but has been successfully
Choosing Prosthetic Valve Type Before Pregnancy
Mechanical heart valves offer superior hemodynamic profile and durability
compared with bioprosthetic valves. Younger age at bioprosthetic valve
implantation is associated with accelerated valve degeneration, which further
shortens durability in women of reproductive age.

CHAPTER III
DISCUSSION

Pregnancy in the setting of mild to moderate valvular heart disease is often well
tolerated. Patients with severe mitral or severe symptomatic AS are at increased
risk of severe maternal morbidity and mortality and pregnancy may be
prohibitively high risk unless valve intervention is performed. Care by a
multidisciplinary Pregnancy Heart Team consisting of MFM specialists and
cardiologists can improve preconception counseling and coordinated pregnancy
and postpartum care to minimize maternal and fetal complications.
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