Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study

Objective: To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country. Methods: We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitami...

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Autores principales:	Anish Keepanasseril, Ajith Ananthakrishna Pillai, Jyoti Baghel, Swaraj Nandini Pande, Nivedita Mondal, Hemachandren Munuswamy, Pankaj Kundra, Rohan D’Souza
Formato:	article
Lenguaje:	EN
Publicado:	Ubiquity Press 2021
Materias:	mechanical heart valves pregnancy anticoagulation warfarin heparin sequential treatment Diseases of the circulatory (Cardiovascular) system RC666-701 Public aspects of medicine RA1-1270
Acceso en línea:	https://doaj.org/article/4518535e32774a2fa9eb7560ea697576
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spelling	oai:doaj.org-article:4518535e32774a2fa9eb7560ea6975762021-11-08T08:07:54ZAlternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study2211-817910.5334/gh.1011https://doaj.org/article/4518535e32774a2fa9eb7560ea6975762021-10-01T00:00:00Zhttps://globalheartjournal.com/articles/1011https://doaj.org/toc/2211-8179Objective: To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country. Methods: We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitamin K antagonists (VKAs) throughout pregnancy versus sequential anticoagulation (heparins in the first trimester and peripartum period and VKAs for the remainder of pregnancy), at a tertiary centre in South India, from January 2011 to August 2020. Results: We identified 138 pregnancies in 121 women, of whom 32 received VKAs while 106 were on sequential anticoagulation. There were no differences between groups with regard to maternal deaths [0 vs. 6 (5.7%), p = 0.34], thromboembolic events [2 (6.3%) vs. 15 (14.2%), p = 0.36], haemorrhagic complications [4 (12.5%) vs. 12 (11.3%), p = 0.85], cardiac events [1 (3.1% vs. 17 (16%), p = 0.07], spontaneous miscarriages [5 (15.6%) vs. 13 (12.3%), p = 0.62], stillbirths [0 vs. 5 (5.4%), p = 0.581] or neonatal deaths [2 (8.7%) vs. 1 (1.1%), p = 0.11]. Both cases of warfarin embryopathy received >5 mg warfarin in the first trimester. Thromboembolic events were associated with subtherapeutic doses of heparin in the first and third trimesters and the early postpartum period. Fetal growth restriction and preterm birth complicated 34 (29.3%) and 26 (22.4%) pregnancies respectively. Conclusion: Pregnancy complications associated with MHVs in middle-income countries may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if daily doses >5 mg and ensuring therapeutic levels of heparin during bridging in the first and third trimesters and peripartum period. Administration of low-dose aspirin should be considered as this may prevent placentally-mediated complications of pregnancy. Highlights: Pregnancy complications associated with MHVs in LMICs may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if the daily dose is >5 mg, ensuring therapeutic levels of heparin in the first trimester and peripartum period. Placentally-mediated complications of pregnancy can be prevented by administering low-dose aspirin. Vitamin K antagonists or sequential regimen can be used as suitable alternatives to LMWH for anticoagulation in pregnant women with MHVs.Anish KeepanasserilAjith Ananthakrishna PillaiJyoti BaghelSwaraj Nandini PandeNivedita MondalHemachandren MunuswamyPankaj KundraRohan D’SouzaUbiquity Pressarticlemechanical heart valvespregnancyanticoagulationwarfarinheparinsequential treatmentDiseases of the circulatory (Cardiovascular) systemRC666-701Public aspects of medicineRA1-1270ENGlobal Heart, Vol 16, Iss 1 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	mechanical heart valves pregnancy anticoagulation warfarin heparin sequential treatment Diseases of the circulatory (Cardiovascular) system RC666-701 Public aspects of medicine RA1-1270
spellingShingle	mechanical heart valves pregnancy anticoagulation warfarin heparin sequential treatment Diseases of the circulatory (Cardiovascular) system RC666-701 Public aspects of medicine RA1-1270 Anish Keepanasseril Ajith Ananthakrishna Pillai Jyoti Baghel Swaraj Nandini Pande Nivedita Mondal Hemachandren Munuswamy Pankaj Kundra Rohan D’Souza Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study
description	Objective: To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country. Methods: We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitamin K antagonists (VKAs) throughout pregnancy versus sequential anticoagulation (heparins in the first trimester and peripartum period and VKAs for the remainder of pregnancy), at a tertiary centre in South India, from January 2011 to August 2020. Results: We identified 138 pregnancies in 121 women, of whom 32 received VKAs while 106 were on sequential anticoagulation. There were no differences between groups with regard to maternal deaths [0 vs. 6 (5.7%), p = 0.34], thromboembolic events [2 (6.3%) vs. 15 (14.2%), p = 0.36], haemorrhagic complications [4 (12.5%) vs. 12 (11.3%), p = 0.85], cardiac events [1 (3.1% vs. 17 (16%), p = 0.07], spontaneous miscarriages [5 (15.6%) vs. 13 (12.3%), p = 0.62], stillbirths [0 vs. 5 (5.4%), p = 0.581] or neonatal deaths [2 (8.7%) vs. 1 (1.1%), p = 0.11]. Both cases of warfarin embryopathy received >5 mg warfarin in the first trimester. Thromboembolic events were associated with subtherapeutic doses of heparin in the first and third trimesters and the early postpartum period. Fetal growth restriction and preterm birth complicated 34 (29.3%) and 26 (22.4%) pregnancies respectively. Conclusion: Pregnancy complications associated with MHVs in middle-income countries may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if daily doses >5 mg and ensuring therapeutic levels of heparin during bridging in the first and third trimesters and peripartum period. Administration of low-dose aspirin should be considered as this may prevent placentally-mediated complications of pregnancy. Highlights: Pregnancy complications associated with MHVs in LMICs may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if the daily dose is >5 mg, ensuring therapeutic levels of heparin in the first trimester and peripartum period. Placentally-mediated complications of pregnancy can be prevented by administering low-dose aspirin. Vitamin K antagonists or sequential regimen can be used as suitable alternatives to LMWH for anticoagulation in pregnant women with MHVs.
format	article
author	Anish Keepanasseril Ajith Ananthakrishna Pillai Jyoti Baghel Swaraj Nandini Pande Nivedita Mondal Hemachandren Munuswamy Pankaj Kundra Rohan D’Souza
author_facet	Anish Keepanasseril Ajith Ananthakrishna Pillai Jyoti Baghel Swaraj Nandini Pande Nivedita Mondal Hemachandren Munuswamy Pankaj Kundra Rohan D’Souza
author_sort	Anish Keepanasseril
title	Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study
title_short	Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study
title_full	Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study
title_fullStr	Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study
title_full_unstemmed	Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study
title_sort	alternatives to low molecular weight heparin for anticoagulation in pregnant women with mechanical heart valves in middle-income countries: a cohort study
publisher	Ubiquity Press
publishDate	2021
url	https://doaj.org/article/4518535e32774a2fa9eb7560ea697576
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Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study

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