2. Objectives:Objectives:
Normal Physiology during pregnancyNormal Physiology during pregnancy
Cardiac TestingCardiac Testing
Common cardiac problemsCommon cardiac problems
3. about 1% of pregnancies complicated
by heart diseases
leading cause of maternal mortality
Mortality rate 50% in case pulmonary
hypertension
CARDIOVASCULARCARDIOVASCULAR
DISORDERSDISORDERS
4. Physiologic adaptation to pregnancyPhysiologic adaptation to pregnancy
Increase blood volume on 40 -50 %Increase blood volume on 40 -50 %
Increase cardiac output 30-50%Increase cardiac output 30-50%
Decreased systemic vascular resistanceDecreased systemic vascular resistance
The heart elevated upward and rotated forward to the leftThe heart elevated upward and rotated forward to the left
Pulse increase about 10-15 beat/min after 14-20 weeks,Pulse increase about 10-15 beat/min after 14-20 weeks,
palpitationpalpitation
Disturbed rhythm: arrhythmia, premature atrial contractions,Disturbed rhythm: arrhythmia, premature atrial contractions,
premature ventricalar systolepremature ventricalar systole
Increase clot factors (VII, VIII, IX, X, fibrinogen)Increase clot factors (VII, VIII, IX, X, fibrinogen)
Cardiac output changes during labor and birthCardiac output changes during labor and birth
Intravascular volume changes just after childbirthIntravascular volume changes just after childbirth
Cardiac hypertrophyCardiac hypertrophy
5. Physiologic adaptation to pregnancyPhysiologic adaptation to pregnancy
If cardiac changes are not well toleratedIf cardiac changes are not well tolerated
cardiac failure can develop during pregnancy,cardiac failure can develop during pregnancy,
labour, postpartumlabour, postpartum
If myocardial disease develops, valvularIf myocardial disease develops, valvular
disease exists or congenital heart defect isdisease exists or congenital heart defect is
present, cardial decompensation ispresent, cardial decompensation is
anticipatedanticipated
6. Percent change in heart rate, stroke volume, andPercent change in heart rate, stroke volume, and
cardiac output measured in the lateral positioncardiac output measured in the lateral position
throughout pregnancy compared with pregnancythroughout pregnancy compared with pregnancy
valuesvalues
7. Hemodynamic changes duringHemodynamic changes during
labor and deliverylabor and delivery
Anxiety, pain, uterine contraction.Anxiety, pain, uterine contraction.
Oxygen consumptionOxygen consumption ↑ threefold.↑ threefold.
↑↑ CO during labor (↑ SV and ↑ HR).CO during labor (↑ SV and ↑ HR).
↑↑ SBP & DBP (especially 2SBP & DBP (especially 2ndnd
stage)stage)
Those changes are influenced by the form ofThose changes are influenced by the form of
anesthesia and analgesia.anesthesia and analgesia.
8. Hemodynamic changesHemodynamic changes post partumpost partum
Blood shifting “auto-transfusion”
(from the contracting uterus to the
systemic circulation)
Increase in effective blood volume
Substantial increase in LV filling pressure, SV and CO
Clinical deterioration
Blood loss
during delivery-
• HR and CO return to pre-labor values within 1 hour. MAP and SV within 24 hours.
• Hemodynamic adaptation persists post partum and return to pre-pregnancy values
within 12-24 weeks after delivery.
Increase in venous return
(relief of caval compression)
9. History
Exercise capacity
Current or past evidence of HF
Associated arrhythmias
Physical exam
Cardiac Hemodynamics
Severity of heart disease, PA pressures
Echo, MRI.
Exercise testing
Useful if the history is inadequate to allow assessment of functional capacity
During pregnancy
Evaluate once each trimester and whenever there is change in symptoms
Multidisciplinary approach, Fetal Echo
Beforeconception
During Labor & Delivery
Multidisciplinary approach (Obstetrician, Cardiologist, Anesthesiologist)
Tailor management to specific needs
10. High-risk pregnancyHigh-risk pregnancy
Pulmonary HTN and Eisenmenger’sPulmonary HTN and Eisenmenger’s
syndrome.syndrome.
Symptomatic obstructive cardiac lesions:Symptomatic obstructive cardiac lesions:
■ AS, PS, uncorrected coarctation of the aorta.AS, PS, uncorrected coarctation of the aorta.
Marfan’s Syndrome with dilated aortic root.Marfan’s Syndrome with dilated aortic root.
Systemic ventricular dysfunctionSystemic ventricular dysfunction
Severe cyanotic heart disease.Severe cyanotic heart disease.
Patients with prosthetic valves.Patients with prosthetic valves.
Significant uncorrected CHD.Significant uncorrected CHD.
11. Contraindications to PregnancyContraindications to Pregnancy
Lesion Maternal
death rate
(%)
• Severe Pulmonary Hypertension 50
• Severe obstructive lesions:
AS,PS, HOCM, Coarctation.
17
• Systemic Ventricular Dysfunction,
NYHA class III or IV
7
13. Routine chest radiography delivers 20 m.radsRoutine chest radiography delivers 20 m.rads
Standard fluoroscopy delivers 1-2 rads/minStandard fluoroscopy delivers 1-2 rads/min
Current recommendationCurrent recommendation
■ >5 rads: very low risk>5 rads: very low risk
■ 5-10 rads: counseling for low risk5-10 rads: counseling for low risk
■ 10-15 rads during 110-15 rads during 1stst
6 weeks: individual6 weeks: individual
■ >15 rads: termination pf pregnancy>15 rads: termination pf pregnancy
Cardiac Tests PerformedCardiac Tests Performed
14. Magnetic Resonance ImagingMagnetic Resonance Imaging
Pulmonary Artery Catheterization: Great helpPulmonary Artery Catheterization: Great help
in managing high risk patient duringin managing high risk patient during
pregnancy, labor and deliverypregnancy, labor and delivery
Cardiac CatheterizationCardiac Catheterization
■ Can be doneCan be done
Cardiac Tests PerformedCardiac Tests Performed
15. Pregnancy result in case ofPregnancy result in case of
Cardiovascular DisordersCardiovascular Disorders
miscarriagesmiscarriages
Preterm labor and birthPreterm labor and birth
IUGRIUGR
Congenital heart lesions (4-16%)Congenital heart lesions (4-16%)
Maternal mortalityMaternal mortality
16. Maternal cardiac disease risk groupMaternal cardiac disease risk group
Group I (mortality rate 1%)Group I (mortality rate 1%)
■ Corrected tetralogy FallotCorrected tetralogy Fallot
■ Pulmonic/tricuspid diseasePulmonic/tricuspid disease
■ Mitral stenosisMitral stenosis
■ Patern ductus arteriosusPatern ductus arteriosus
■ Ventricular septal defectVentricular septal defect
■ Atrial septal defectAtrial septal defect
Group II (mortality rate 5-15%)Group II (mortality rate 5-15%)
■ Mitral stenosis with atrial fibrillationMitral stenosis with atrial fibrillation
■ Uncorrected tetralogy FallotUncorrected tetralogy Fallot
■ Aortic coarctation (uncomplicated)Aortic coarctation (uncomplicated)
■ Marfan syndrome with normal aortaMarfan syndrome with normal aorta
Group III (mortality rate 20-50%)Group III (mortality rate 20-50%)
■ Aortic coarctation (complicated)Aortic coarctation (complicated)
■ Myocardial infarctionMyocardial infarction
■ Marfan syndrome with aortic involvementMarfan syndrome with aortic involvement
■ Pulmonary hypertensionPulmonary hypertension
17. NEW YORK HEART ASSOCIATION FUNCTIONALNEW YORK HEART ASSOCIATION FUNCTIONAL
CLASSIFICATION (NYHA) OF HEART DISEASECLASSIFICATION (NYHA) OF HEART DISEASE
CLASS ICLASS I No signs or symptoms of cardiacNo signs or symptoms of cardiac
decompensation.decompensation.
CLASS IICLASS II No symptoms at rest but minorNo symptoms at rest but minor
limitation of physical activity.limitation of physical activity.
CLASS IIICLASS III No symptoms at rest but markedNo symptoms at rest but marked
limitation of physical activity.limitation of physical activity.
CLASS IVCLASS IV Symptoms present at rest incresesSymptoms present at rest increses
discomfort with any kind of physicaldiscomfort with any kind of physical
activity.activity.
18. What is the prognosis for a womanWhat is the prognosis for a woman
with a cardiac disease depending onwith a cardiac disease depending on
the NYHA risk group classification?the NYHA risk group classification?
19. Prognosis depending on the functional
status
In general, women in NYHA classes I and II
lesions usually do well during pregnancy and have
a favorable prognosis with a mortality rate of <1%.
Patients in NYHA classes III and IV may have a
mortality rate of 5% to 15%. These patientsshould
be advised against becoming pregnant.
20. What are the clinical features in a normalWhat are the clinical features in a normal
pregnancy which can mimic a cardiac disease ?pregnancy which can mimic a cardiac disease ?
21. The clinical features in a normal pregnancy
which can mimic a cardiac disease are
1. Dyspnea - due to hyperventilation, elevated
diaphragm..
2. Pedal Edema
3. Cardiac impulse- Diffused and shifted laterally
from elevated diaphragm.
4. Jugular veins may be distended and JVP raised.
22. What are the indications for Termination ofWhat are the indications for Termination of
pregnancy?pregnancy?
23. The indications for Termination of pregnancy:
Because of high maternal risks, MTP is indicated
in:
1.Eisenmenger’s syndrome.
2.Marfan’s syndrome with aortic involvement
3.Pulmonary hypertension.
4.Coarctation of aorta with valvular involvement.
•Termination should be done before 12 weeks of
pregnancy.
24. Contraindications to pregnancyContraindications to pregnancy
Pulmonary hypertensionPulmonary hypertension
Shunt lesions associated with EisenmengerShunt lesions associated with Eisenmenger
syndromesyndrome
Complex cyanotic congenital heart diseaseComplex cyanotic congenital heart disease
Aortic coarctation complicated by articAortic coarctation complicated by artic
dissectiondissection
Poor ventricular functionPoor ventricular function
Marfan syndrome with marked aorticMarfan syndrome with marked aortic
dilatationdilatation
27. Arial septal defectArial septal defect
Left-to-right shuntLeft-to-right shunt
Undetected becauseUndetected because
woman is asymptomaticwoman is asymptomatic
Uncomplicated pregnancyUncomplicated pregnancy
Right-side heart failure orRight-side heart failure or
arrhythmia as a result ofarrhythmia as a result of
increased blood volumeincreased blood volume
28.
29. Ventricular septal defectVentricular septal defect
Left-to-right shuntLeft-to-right shunt
Diagnosed and corrected duringDiagnosed and corrected during
infancy and childhood, notinfancy and childhood, not
common in pregnancycommon in pregnancy
Not complicated pregnancyNot complicated pregnancy
Risk for: arrhythmias, heart failure,Risk for: arrhythmias, heart failure,
pulmonary hypertensionpulmonary hypertension
ManagementManagement
■ RestRest
■ decrease ofdecrease of
physicalphysical
activityactivity
■ anticoagulantsanticoagulants
30. Patent ductus arteriosusPatent ductus arteriosus
Left-to-right shuntLeft-to-right shunt
Diagnosed and corrected duringDiagnosed and corrected during
infancyinfancy
Possible complicationsPossible complications
■ arrhythmias,arrhythmias,
■ heart failure,heart failure,
■ pulmonary hypertensionpulmonary hypertension
■ EndocarditisEndocarditis
■ Pulmonary emboliPulmonary emboli
ManagementManagement
■ RestRest
■ decrease of physical activitydecrease of physical activity
■ anticoagulantsanticoagulants
32. Coarctation of the aortaCoarctation of the aorta
Pregnancy safe for mother withPregnancy safe for mother with
uncomplicated coarctationuncomplicated coarctation
ComplicationsComplications
■ HypertensionHypertension
■ Congestive heart failureCongestive heart failure
■ Aortic ruptureAortic rupture
ManagementManagement
■ RestRest
■ Antihypertensive medications (beta-blockers)Antihypertensive medications (beta-blockers)
■ Vaginal birth with epidural anesthesia andVaginal birth with epidural anesthesia and
shortening of the II stage (vacuum- orshortening of the II stage (vacuum- or
forceps assisted)forceps assisted)
■ Antibiotic prophylaxisAntibiotic prophylaxis
36. Mitral StenosisMitral Stenosis
The pressure gradient across the narrow valveThe pressure gradient across the narrow valve
increases secondary to theincreases secondary to the increased heart rateincreased heart rate andand
blood volumeblood volume
Left atrial pressure increases, back pressure into theLeft atrial pressure increases, back pressure into the
lungs causeslungs causes breathlessnessbreathlessness,, swelling in theswelling in the legslegs
and may lead toand may lead to atrial arrhythmiasatrial arrhythmias..
Stretching of the atrium can also occur causingStretching of the atrium can also occur causing
palpitations and arrhythmiapalpitations and arrhythmia..
37. Mitral StenosisMitral Stenosis
Maternal mortality rate in classes III and IVMaternal mortality rate in classes III and IV
■ 5 %without arterial fibrillation5 %without arterial fibrillation
■ 15% with arterial fibrillation15% with arterial fibrillation
There is marked increase in the followingThere is marked increase in the following
issues regarding the fetusissues regarding the fetus
■ Rate of prematurityRate of prematurity
■ Fetal growth retardationFetal growth retardation
■ Low neonatal birth weightLow neonatal birth weight
38. Mitral StenosisMitral Stenosis
Therapeutic approach is:Therapeutic approach is:
■ to reduce the heart rateto reduce the heart rate
■ and decrease left atrial pressureand decrease left atrial pressure
Restrict physical activityRestrict physical activity
Restrict salt intakeRestrict salt intake
diureticsdiuretics
Beta blockersBeta blockers
Digoxin (if patient is in a. fib)Digoxin (if patient is in a. fib)
Calcium channel blockersCalcium channel blockers
if medical therapy is ineffective surgeryif medical therapy is ineffective surgery
may be necessary after 20 weeksmay be necessary after 20 weeks
■ Balloon valvuloplastyBalloon valvuloplasty
■ Surgery (repair/replacement)Surgery (repair/replacement)
39. Mitral StenosisMitral Stenosis
Vaginal delivery can be permitted in mostVaginal delivery can be permitted in most
patientspatients
Hemodynamic monitoring is recommendedHemodynamic monitoring is recommended
(Swan) and should be continued several(Swan) and should be continued several
hours following deliveryhours following delivery
40. Aortic StenosisAortic Stenosis
AS lead to obstruction toAS lead to obstruction to
left ventricular ejectionleft ventricular ejection
Mild AS is usually toleratedMild AS is usually tolerated
Moderate to severe AS isModerate to severe AS is
likely to be associated withlikely to be associated with
symptomatic deteriorationsymptomatic deterioration
during pregnancyduring pregnancy
Women with valve areaWomen with valve area
<1.0 should consider valve<1.0 should consider valve
replacement prior toreplacement prior to
pregnancypregnancy
41. Aortic StenosisAortic Stenosis
Symptoms often develop in the 2nd and 3rd trimesterSymptoms often develop in the 2nd and 3rd trimester
■ Exertional dyspneaExertional dyspnea
■ Chest painChest pain
■ SyncopeSyncope
Fetal effects includedFetal effects included
■ Intrauterine growth retardationIntrauterine growth retardation
■ Premature deliveryPremature delivery
■ Reduced birth weightReduced birth weight
■ Increase in cardiac defectsIncrease in cardiac defects
42. Ischemic Heart DiseaseIschemic Heart Disease
MI is rare in childbearing womanMI is rare in childbearing woman
Risk factors increaseRisk factors increase
■ AgeAge
■ SmokingSmoking
■ StressStress
■ Cocaine useCocaine use
■ HyperbilirubinemiaHyperbilirubinemia
■ DMDM
■ Family history of IHDFamily history of IHD
■ HypertensionHypertension
■ Oral contraceptivesOral contraceptives
43. Ischemic Heart DiseaseIschemic Heart Disease
MangementMangement
■ OxygenOxygen
■ AspirinAspirin
■ Beta-blockersBeta-blockers
■ NitratesNitrates
■ HeparinHeparin
■ Side-lying positionSide-lying position
■ Vaginal birth is preferable with avoiding of maternalVaginal birth is preferable with avoiding of maternal
pushing (vacuum- or forceps-assisted)pushing (vacuum- or forceps-assisted)
■ Diuretic postpartumDiuretic postpartum
45. Primary Pulmonary HypertensionPrimary Pulmonary Hypertension
Constriction of the arteriolar vessels in theConstriction of the arteriolar vessels in the
lung, leads to increase in the pulmonarylung, leads to increase in the pulmonary
artery pressure right ventricularartery pressure right ventricular
hypertension, hypertrophy, dilatation, righthypertension, hypertrophy, dilatation, right
ventricular failure with tricuspidventricular failure with tricuspid
regurgitationregurgitation
Associated with high maternal mortalityAssociated with high maternal mortality
estimated to be 50%, half of them occursestimated to be 50%, half of them occurs
a few hours to several days post partuma few hours to several days post partum
usually related to sudden death orusually related to sudden death or
progressive RV failure, although the exactprogressive RV failure, although the exact
cause of death is not clearcause of death is not clear
Deterioration usually occurs in theDeterioration usually occurs in the
second/third trimestersecond/third trimester
46. Primary Pulmonary HypertensionPrimary Pulmonary Hypertension
Symptoms may includeSymptoms may include
■ FatigueFatigue
■ DyspneaDyspnea
■ Chest painChest pain
■ Edema and ascitesEdema and ascites
■ SyncopeSyncope
Diagnostic testDiagnostic test
■ Chest radiogramChest radiogram
■ ECGECG
■ EchoCGEchoCG
■ Dopler studiesDopler studies
47. Primary Pulmonary HypertensionPrimary Pulmonary Hypertension
Fetal effects includeFetal effects include
■ High incidence of prematurityHigh incidence of prematurity
■ Fetal growth retardationFetal growth retardation
■ Fetal lossFetal loss
Pregnancy should be discouraged in allPregnancy should be discouraged in all
patients with primary pulmonary HTNpatients with primary pulmonary HTN
48. Primary Pulmonary HypertensionPrimary Pulmonary Hypertension
For patients who chose to continue pregnancyFor patients who chose to continue pregnancy
■ Nifedipin or prostacycline (for pulmonaryNifedipin or prostacycline (for pulmonary
vasodilatation)vasodilatation)
■ AnticoagulantAnticoagulant
■ Continuous hemodynamic monitoring during laborContinuous hemodynamic monitoring during labor
and deliveryand delivery
Antiembolic strockingAntiembolic strocking
Side-lying positionSide-lying position
Oxygen therapyOxygen therapy
Epidural analgesiaEpidural analgesia
49. Marfan SyndromeMarfan Syndrome
Autosomal dominant genetic disorderAutosomal dominant genetic disorder
characterizedcharacterized
■ weakness of the connective tissue,weakness of the connective tissue,
■ resulting in joint deformities,resulting in joint deformities,
■ ocular lens dislocation,ocular lens dislocation,
■ weakness of aortic wall and rootweakness of aortic wall and root
Mitral valve prolapse (90%)Mitral valve prolapse (90%)
Aortic insufficiency (25%) risk ofAortic insufficiency (25%) risk of
aortic dissection and rupturingaortic dissection and rupturing
Pregnancy in patients with Marfan poses 2Pregnancy in patients with Marfan poses 2
problemsproblems
■ Cardiovascular complications of the motherCardiovascular complications of the mother
■ Risk of having a child who inherits Marfan’sRisk of having a child who inherits Marfan’s
syndromesyndrome
Cardiovascular problemsCardiovascular problems
■ Dilation of the ascending aorta, may lead toDilation of the ascending aorta, may lead to
development of aortic regurgitation and heartdevelopment of aortic regurgitation and heart
failurefailure
■ Proximal and distal dissections of the aorta withProximal and distal dissections of the aorta with
possible involvement of the coronariespossible involvement of the coronaries
50. Marfan’s SyndromeMarfan’s Syndrome
Obstetrical complicationsObstetrical complications
■ Cervical incompetenceCervical incompetence
■ Abnormal placental location (previa)Abnormal placental location (previa)
■ Postpartum hemorrhagePostpartum hemorrhage
Preconception counselingPreconception counseling
■ Patients with more than mild dilation of the aorta, or history ofPatients with more than mild dilation of the aorta, or history of
aortic dissection should be advised against pregnancyaortic dissection should be advised against pregnancy
■ Progressive dilation of the aorta during gestation may occurProgressive dilation of the aorta during gestation may occur
even with a normal-sized aortaeven with a normal-sized aorta
Preconception echo evaluation allows for evaluation of thePreconception echo evaluation allows for evaluation of the
aortic root, CT, MRI.aortic root, CT, MRI.
Periodic echocardiographic follow-up is recommendedPeriodic echocardiographic follow-up is recommended
51. Marfan’s SyndromeMarfan’s Syndrome
ManagementManagement
■ Vigorous physical activity should be avoidedVigorous physical activity should be avoided
■ Beta blockers (reduces the rate of aortic dilation)Beta blockers (reduces the rate of aortic dilation)
■ If substantial dilation/dissection should occur,If substantial dilation/dissection should occur,
depending on the stage of pregnancydepending on the stage of pregnancy
therapeutic abortion,therapeutic abortion,
early delivery orearly delivery or
surgical intervention should be consideredsurgical intervention should be considered
52. Infective endocarditisInfective endocarditis
Inflammation of endocardiumInflammation of endocardium
Cause: microorganismsCause: microorganisms
Clinical manifestation:Clinical manifestation:
■ incompetence of heart valvesincompetence of heart valves
■ Congestive heart failureCongestive heart failure
■ Cerebral emboliCerebral emboli
TreatmentTreatment
■ AntibioticsAntibiotics
53. Eisenmenger SyndromeEisenmenger Syndrome
Right-to-left or bidirectional shunting atRight-to-left or bidirectional shunting at
atrial or ventricular level and combinedatrial or ventricular level and combined
with elevated pulmonary vascularwith elevated pulmonary vascular
resistanceresistance
High risk of maternal (30-50%) and fetalHigh risk of maternal (30-50%) and fetal
(50%) morbidity and mortality(50%) morbidity and mortality
Pregnancy is contraindicatedPregnancy is contraindicated
(contraception or termination of(contraception or termination of
pregnancy)pregnancy)
Death usually (75%) occurs between theDeath usually (75%) occurs between the
first few days and weeks after delivery,first few days and weeks after delivery,
but the cause is unclearbut the cause is unclear
54. Eisenmenger SyndromeEisenmenger Syndrome
Patients should be monitored closely for any signs ofPatients should be monitored closely for any signs of
deteriorationdeterioration
Early elective hospitalization is recommendedEarly elective hospitalization is recommended
Activity is strictly limitedActivity is strictly limited
Hemodynamic monitoring is requiredHemodynamic monitoring is required
Anticoagulant???Anticoagulant???
Prophylaxis of hypovolemiaProphylaxis of hypovolemia
OxygenOxygen
Epidural analgesiaEpidural analgesia
55. CardiomyopathyCardiomyopathy
CardiomyopathiesCardiomyopathies are diseases of the heartare diseases of the heart
muscle itself. People with cardiomyopathies --muscle itself. People with cardiomyopathies --
sometimes called an enlarged heart -- havesometimes called an enlarged heart -- have
hearts that are abnormally enlarged,hearts that are abnormally enlarged,
thickened, and/or stiffened. As a result, thethickened, and/or stiffened. As a result, the
heart's ability to pump blood is weakened.heart's ability to pump blood is weakened.
Without treatment, cardiomyopathies worsenWithout treatment, cardiomyopathies worsen
over time and often lead to heart failure andover time and often lead to heart failure and
abnormal heart rhythms.abnormal heart rhythms.
56. Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy
Most cases have favorable outcomesMost cases have favorable outcomes
Symptoms may worsen, especially in patients whoSymptoms may worsen, especially in patients who
were already symptomaticwere already symptomatic
■ Increased SOBIncreased SOB
■ FatigueFatigue
■ Chest painChest pain
■ SyncopeSyncope
The risk of the fetus of inheriting the disease is asThe risk of the fetus of inheriting the disease is as
high as 50%high as 50%
60. 10.What is warfarin fetal embryopathy ?10.What is warfarin fetal embryopathy ?
61. Warfarin use in first trimester can be teratogenic
and can cause fetal embryopathy( 15 to 25 % )
which includes
· Nasal cartilage hypoplasia,
· Stippling of bones,
· IUGR and
·
62. Warfarin vs. HeparinWarfarin vs. Heparin
WarfarinWarfarin
Crosses the placenta.Crosses the placenta.
↑↑early abortion, prematurity,early abortion, prematurity,
andand embryopathyembryopathy when used inwhen used in
11stst
trimester (6trimester (6thth
–12–12thth
weeks).weeks).
CNS & Eye abnormalities (2CNS & Eye abnormalities (2ndnd
& 3& 3rdrd
trimester).trimester).
Bleeding in the fetusBleeding in the fetus
(especially at delivery)(especially at delivery)
■ Should be stopped beforeShould be stopped before
delivery.delivery.
HeparinHeparin
Does not cross the placentaDoes not cross the placenta
No teratogenicityNo teratogenicity
No fetal bleedingNo fetal bleeding
Twice daily SC injectionTwice daily SC injection
Risk of osteoporosisRisk of osteoporosis
■ <2% symptomatic fractures.<2% symptomatic fractures.
■ but 30% decrease in bone density.but 30% decrease in bone density.
Risk for thrombocytopeniaRisk for thrombocytopenia
↑↑↑↑ Risk of thrombosisRisk of thrombosis
“warfarin embryopathy”: Nasal hypoplasia, Bone epiphysis, optic atrophy,
blindness, seizures.
Overall risk around 5%. Decreases with the use of UFH in the first 3 months
63. Dose-dependent Fetal Complications of warfarin inDose-dependent Fetal Complications of warfarin in
pregnant women with Mechanical Heart Valvespregnant women with Mechanical Heart Valves
Outcome of pregnanciesOutcome of pregnancies
WARFARIN
DOSE (MG)
Healthy fetuses Fetal
complications
Total
≤ 5 28
• 27 FT
•1 PR
5/33 (15%)
• 4 SA
• 1 GR
•0 WE (0%)
33
> 5 3 FT 22/25 (88%)
• 2 WE (9%)
• 18 SA
• 1 SB
• 1 VSD
25
Total 31 27 58
FT = full term, GR = growth retardation; PR = preterm; SA = spontaneous abortion; SB =
still birth; WE = warfarin embryopathy
.
64. Unfractionated HeparinUnfractionated Heparin
4X higher incidence of Thrombo-embolism4X higher incidence of Thrombo-embolism
during pregnancy than oral anticoagulantsduring pregnancy than oral anticoagulants..
1.1. Hanania G, et al. pregnancy in patients with valvular prosthesis-Hanania G, et al. pregnancy in patients with valvular prosthesis-
retrospective cooperative study in France (155 Cases). J Arch Mal Coeurretrospective cooperative study in France (155 Cases). J Arch Mal Coeur
Vaiss 1994;87:429-437Vaiss 1994;87:429-437..
Failure of adjusted dose SC heparin to preventFailure of adjusted dose SC heparin to prevent
thrombo-embolic phenomena in pregnantthrombo-embolic phenomena in pregnant
womenwomen (n= 40)(n= 40) with mechanical valve prosthesis.with mechanical valve prosthesis.
■ Adjusted doses of SC heparin does not improveAdjusted doses of SC heparin does not improve
fetal outcome and increases maternal mortalityfetal outcome and increases maternal mortality..
2. Salazare E, et al. Filure of adjusted dose heparin to prevent
thromboembolisc phenomena in pregnant patients with mechanical
cardiac valve prosthesis. J Am Coll Cardiol 1996;1698-1703.
65. Frequency of fetal and maternal complications according to theFrequency of fetal and maternal complications according to the
anticoagulation regimen used during pregnancy in women withanticoagulation regimen used during pregnancy in women with
mechanical heart valve prosthesis.mechanical heart valve prosthesis.
Adapted from Chen et al. (976 women, 1234 pregnancies)Adapted from Chen et al. (976 women, 1234 pregnancies)
Anticoagulation regimen
Embryopath
y (%)
Spontaneou
s abortion
(%)
Thrombo-
embolic
complications
(%)
Maternal death
(%)
Vitamin K antagonist
throughout pregnancy
6.4 25 31/788 (3.9%) 10/561 (1.8%)
Heparin throughout
pregnancy
0 24 7/21 (33%) 3/20 (15%)
• Low dose 0 20 60 40
• Adjusted dose 0 25 25 6.7
Heparin during first
trimester, then vitamin K
antagonists
(with or without heparin before
delivery)
3.4 25 21/229 (9.2%) 7/167 (4.2%)
66. Low-dose ASALow-dose ASA
The additional use of low-dose aspirin shouldThe additional use of low-dose aspirin should
be considered, particularly inbe considered, particularly in
Women with high-risk valves.Women with high-risk valves.
Patients with cyanosis.Patients with cyanosis.
Patients with intra-cardiac shunts.Patients with intra-cardiac shunts.
Women with previous TIAs and/or strokes.Women with previous TIAs and/or strokes.
And women with atrial fibrillation.And women with atrial fibrillation.
67. LMWHLMWH
Do not cross the placenta.Do not cross the placenta.
Do not require frequent PTT monitoringDo not require frequent PTT monitoring
and have a longer half-life than UFH.and have a longer half-life than UFH.
The data to support the use of LMWH, however, is not yetThe data to support the use of LMWH, however, is not yet
available.available.
A successful use of LMWH was reported in small number ofA successful use of LMWH was reported in small number of
patients and more information is required before LMWHpatients and more information is required before LMWH
can be recommended for anticoagulation in a patient with acan be recommended for anticoagulation in a patient with a
prosthetic valve during pregnancyprosthetic valve during pregnancy11
..
Recently, two cases of LMWH treatment failure resulting inRecently, two cases of LMWH treatment failure resulting in
thrombosed prosthetic heart valves were reported in 2000thrombosed prosthetic heart valves were reported in 200022
..
LMWH should not be recommended at the present time inLMWH should not be recommended at the present time in
patients with heart valve prostheses during pregnancy.patients with heart valve prostheses during pregnancy.
68. Mechanical Valves andMechanical Valves and
Anticoagulation during PregnancyAnticoagulation during Pregnancy
Heparin may not prevent valve thrombosis: ?Heparin may not prevent valve thrombosis: ?
how much ?route.how much ?route.
Adequate anticoagulation difficult.Adequate anticoagulation difficult.
Heparin can produce osteoporosis.Heparin can produce osteoporosis.
Little data regarding LMWH.Little data regarding LMWH.
Warfarin can cause embryopathy.Warfarin can cause embryopathy.
Baby ASA safe + probably beneficial.Baby ASA safe + probably beneficial.
1-4% mortality in pregnant women with1-4% mortality in pregnant women with
mechanical valve prosthesis, Whatever themechanical valve prosthesis, Whatever the
anticoagulation regimen.anticoagulation regimen.
No Ideal Solution
69. Suggested algorithm for the management ofSuggested algorithm for the management of
anticoagulation in patients with mechanicalanticoagulation in patients with mechanical
prosthetic heart valves during pregnancyprosthetic heart valves during pregnancy
Pregnancy in patients with
prosthetic heart valves
Higher risk
First-generation prosthesis
In the mitral position
Lower risk
Second-generation prosthesis
And any mechanical prosthesis in the
aortic position
Coumadin to INR
3.0-4.5 for 36
weeks followed by
IV heparin to
aPTT of > 2.5-3.5
SC or IV (better)
heparin-(aPTT 2.5-3.5)
for 12 weeks
Coumadin
(INR 3.0-4.5)
to 36th
week
IV heparin
(aPTT > 2.5)
SC Heparin
(aPTT 2.0-3.0)
for 12 weeks
Coumadin
(INR 2.5-3.0)
to 36th week
SC Heparin
(aPTT 2.0-3.0)
SC heparin
(aPTT 2.0-3.0)
Throughout
pregnancy
1-4% mortality in
pregnant women with
mechanical valve
prosthesis, Whatever
the anticoagulation
regimen.
70. Mode of deliveryMode of delivery
Vaginal deliveryVaginal delivery
With facilitated second stageWith facilitated second stage
is preferred & safeis preferred & safe
Invasive hemodynamicInvasive hemodynamic
monitoring only in:monitoring only in:
■ Severe valve stenosisSevere valve stenosis
■ Recent heart failure.Recent heart failure.
■ Severe cyanotic heart diseaseSevere cyanotic heart disease
■ Pulmonary HTN.Pulmonary HTN.
Cesarean sectionCesarean section
Avoids physical stress of laborAvoids physical stress of labor
butbut notnot free from hemodynamicfree from hemodynamic
consequences.consequences.
Indications in CHD only for:Indications in CHD only for:
■ Obstetric reasons.Obstetric reasons.
■ Therapeutic anticoagulation withTherapeutic anticoagulation with
coumadin at onset pf labor.coumadin at onset pf labor.
■ Pulmonary hypertension.Pulmonary hypertension.
■ Unstable aortic lesion with risk ofUnstable aortic lesion with risk of
dissection.dissection.
■ Severe obstructive lesionsSevere obstructive lesionsBreast-feeding
• Can be encouraged in women
taking anticoagulants.
• Heparin is not secreted in
breast milk
• and the amount of warfarin is
low.
71. Endocarditis prophylaxisEndocarditis prophylaxis
Antibiotic prophylaxis at the time of delivery is not recommended forAntibiotic prophylaxis at the time of delivery is not recommended for
patients expected to have uncomplicated vaginal delivery orpatients expected to have uncomplicated vaginal delivery or
cesarian section, unless clinically overt infection is presentcesarian section, unless clinically overt infection is present 1,21,2
Patients atPatients at high risk for endocarditishigh risk for endocarditis may receive antibiotics at themay receive antibiotics at the
discretion of their physiciandiscretion of their physician22
::
■ Those with prosthetic heart valves.Those with prosthetic heart valves.
■ Previous IE.Previous IE.
Antibiotics for prophylaxis against endocarditis
Ampicillin No major adverse
effects
Given along with gentamicin
to high-risk patients to
prevent IE
B 2 gr IV or IM within 30 min before
delivery.
And 1 gr PO, IV or IM 6 hrs later.
Vancomycine No major adverse
effects
Given along with gentamicin
to high-risk patients to
prevent IE
Cm I gr IV over 1-2 hours, given 30 min
before delivery.
Gentamicin No major adverse
effects
Given along with Ampicilline
or Gentamicin to high-risk
patients to prevent IE
C 1.5 mg/kg within 30 min before
delivery (max 120 mg)
72. Peripartum CardiomyopathyPeripartum Cardiomyopathy
A form of dilated CMP with LV systolic dysfunction thatA form of dilated CMP with LV systolic dysfunction that
results in the signs and symptoms of heart failureresults in the signs and symptoms of heart failure
CriteriaCriteria
■ Development in last month of pregnancy or the first 5 monthsDevelopment in last month of pregnancy or the first 5 months
after deliveryafter delivery
■ Absence of heart disease prior to last month of pregnancyAbsence of heart disease prior to last month of pregnancy
■ Absence of identifiable cause of heart failureAbsence of identifiable cause of heart failure
■ LV systolic dysfunctionLV systolic dysfunction
Etiology is unknownEtiology is unknown
TheoriesTheories
■ Genetic predispositionGenetic predisposition
■ AutoimmunityAutoimmunity
■ Viral infectionViral infection
73. Peripartum CardiomyopathyPeripartum Cardiomyopathy
Associated risk factors:Associated risk factors:
■ Age - over 35Age - over 35
■ twin pregnancytwin pregnancy
■ gestational hypertensiongestational hypertension
■ MultiparityMultiparity
■ African-american raceAfrican-american race
■ use of tocolytic therapyuse of tocolytic therapy
Motality rate 25-50%Motality rate 25-50%
75. Peripartum CardiomyopathyPeripartum Cardiomyopathy
clinical course variesclinical course varies
■ 50-60% of patients demonstrate complete recovery50-60% of patients demonstrate complete recovery
within the first 6 monthswithin the first 6 months
■ The rest of the patients demonstrate either further clinicalThe rest of the patients demonstrate either further clinical
deterioration, leading to cardiac transplant or prematuredeterioration, leading to cardiac transplant or premature
death, or persistent LV dysfunction and chronic heartdeath, or persistent LV dysfunction and chronic heart
failurefailure
■ No agreement on recommendation for futureNo agreement on recommendation for future
pregnanciespregnancies
■ Pregnancy contraindicatedPregnancy contraindicated
Persistent cardiomegalyPersistent cardiomegaly
Cardiac dysfunctionCardiac dysfunction
76. Peripartum CardiomyopathyPeripartum Cardiomyopathy
ManagementManagement
■ Acute heart failure treatment with O2,Acute heart failure treatment with O2,
diuretics, digoxin and vasodilatorsdiuretics, digoxin and vasodilators
(hydralazine is safe)(hydralazine is safe)
■ Because of the increased incidence ofBecause of the increased incidence of
thromboembolic events, anticoagulationthromboembolic events, anticoagulation
therapy is recommendedtherapy is recommended
77. 11. What are the risk factors for cardiac failure11. What are the risk factors for cardiac failure
during pregnancy ?during pregnancy ?
79. Pulmonary hypertension as a risk ofPulmonary hypertension as a risk of
adverse outcomeadverse outcome
Pulmonary hypertensionPulmonary hypertension
(Eisenmenger Syndrome)(Eisenmenger Syndrome)
Increased rate of adverse maternal eventsIncreased rate of adverse maternal events
Up to 30-40% (Up to 30-40% (↑ PVR)↑ PVR)
When systolic PAP > 75% systemic pressure
↑↑ intravascular volumeintravascular volume HFHF
(CO limited by Pulmonary vascular disease and Ventricular dysfunction)(CO limited by Pulmonary vascular disease and Ventricular dysfunction)
↓↓ SVR (after 1SVR (after 1stst
trimester)trimester) ↑↑R-L ShuntR-L Shunt CyanosisCyanosis
Exacerbated during labor and deliveryExacerbated during labor and delivery
Bed rest (2Bed rest (2ndnd
trimester), O2 (if helpful), ? Anticoagulation,trimester), O2 (if helpful), ? Anticoagulation,
Cesarian section, invasive monitoring, early ambulationCesarian section, invasive monitoring, early ambulation
80. Care managementCare management
Preconceptual councellingPreconceptual councelling
■ Peripartum riskPeripartum risk
PregnancyPregnancy
■ Decisions after evaluation riskDecisions after evaluation risk
If possible – multidisciplinary approchIf possible – multidisciplinary approch
(cardiologist, perinsatologist,(cardiologist, perinsatologist,
anesthesiologist, ginecologist)anesthesiologist, ginecologist)
81. AssessmentAssessment
InterviewInterview
■ Personal medical historyPersonal medical history
■ Heart disease (congenital, streptococcal infections, rheumaticHeart disease (congenital, streptococcal infections, rheumatic
fever, valvular disease, endocarditis, angina, MI)fever, valvular disease, endocarditis, angina, MI)
■ Factors increase stress of the heart (anemia, infection, edema)Factors increase stress of the heart (anemia, infection, edema)
■ Review cardiovascular and pulmonary systemReview cardiovascular and pulmonary system
Chest pain, edema on face, hand, feet, hypertension, heartChest pain, edema on face, hand, feet, hypertension, heart
murmur, palpitation,dyspnea, diaphoesis, pallor, syncopemurmur, palpitation,dyspnea, diaphoesis, pallor, syncope
Cough, hemoptysis, shortness of breath,Cough, hemoptysis, shortness of breath,
■ MedicationMedication
■ Emotional status (depression, anxiety, fear of morbidity andEmotional status (depression, anxiety, fear of morbidity and
mortality for herself and featus)mortality for herself and featus)
82. AssessmentAssessment
ExaminationExamination
■ Vital signVital sign
■ Oxygen saturation levelOxygen saturation level
■ Pattern of edemaPattern of edema
■ Discomphort of pregnancyDiscomphort of pregnancy
■ Weight gainWeight gain
■ Sign of potential cardiac decompensationSign of potential cardiac decompensation
83. Sign of potential cardiacSign of potential cardiac
decompensationdecompensation
Subjective symptomsSubjective symptoms
■ Increasing fatigue or difficulty ofIncreasing fatigue or difficulty of
breathing or both with usual activitiesbreathing or both with usual activities
■ Feeling of smotheringFeeling of smothering
■ Frequent coughFrequent cough
■ Palpitations; feeling that her heart isPalpitations; feeling that her heart is
racingracing
■ Swelling of face, feet, legs, fingersSwelling of face, feet, legs, fingers
84. Conti…….Conti…….
Objective signsObjective signs
■ Irregular weak, rapid pulse (more 100b/m)Irregular weak, rapid pulse (more 100b/m)
■ Progressive generalised edemaProgressive generalised edema
■ Cracles at the base of lungsafter 2Cracles at the base of lungsafter 2
inspirations and exhalationsinspirations and exhalations
■ Orthopnea; increasing dyspneaOrthopnea; increasing dyspnea
■ Rapid respirations (more 25 b/m)Rapid respirations (more 25 b/m)
■ Moist, frequent coughMoist, frequent cough
■ Increasing fatiqueIncreasing fatique
■ Cyanosis of lips and nail bedsCyanosis of lips and nail beds
86. Antepartum careAntepartum care
Critical period 28-32 weeks – hemodinamicCritical period 28-32 weeks – hemodinamic
changes reach their maximumchanges reach their maximum
Reduce emotional stress, hypertension, anemia,Reduce emotional stress, hypertension, anemia,
hyperthyroidism, obesityhyperthyroidism, obesity
Class I and IIClass I and II
■ 8-10 h of sleeping + 30 min naps after eating8-10 h of sleeping + 30 min naps after eating
■ Activities: housework, shopping, exercise limitedActivities: housework, shopping, exercise limited
Class IIClass II
■ Avoid any activities that causes even minor signs ofAvoid any activities that causes even minor signs of
cardiac decompensationcardiac decompensation
■ Admit to the hospital near termAdmit to the hospital near term
Class III, IVClass III, IV
■ Bed rest at the hospitalBed rest at the hospital
87. Antepartum careAntepartum care
Treatment of infections of GI, UT, RespiratoryTreatment of infections of GI, UT, Respiratory
Adequate nutrition (folic acid, protein, fluid, fiber)Adequate nutrition (folic acid, protein, fluid, fiber)
Medication:Medication:
■ anticoagulant –anticoagulant –
heparin (large molecule does not cross the placenta)heparin (large molecule does not cross the placenta)
● Recurrent vein thrombosisRecurrent vein thrombosis
● Pulmonary embolusPulmonary embolus
● rheumatic heart diseaserheumatic heart disease
● Prostetic valvesProstetic valves
● Cyanotic congenital heart defectsCyanotic congenital heart defects
Monitiring clotting factors (blood test)Monitiring clotting factors (blood test)
Avoid food high in vit K (raw, dark green and leafyAvoid food high in vit K (raw, dark green and leafy
vegetablesvegetables
Folic acidFolic acid
88. Antepartum careAntepartum care
Digoxin: crosses placentaDigoxin: crosses placenta
Procainamide: crosses placenta, no known teratogenicProcainamide: crosses placenta, no known teratogenic
effectseffects
Verapamil: crosses placenta, can produce maternalVerapamil: crosses placenta, can produce maternal
hypotensionhypotension
Propranolol: crosses placenta, no known teratogenicPropranolol: crosses placenta, no known teratogenic
effects, associated with fetak bradicardia, IUGR, pretermeffects, associated with fetak bradicardia, IUGR, preterm
labour, neonatal respiratory depressionlabour, neonatal respiratory depression
Warfarin: crosses placenta, fetal anomalies, andWarfarin: crosses placenta, fetal anomalies, and
hemorrhage, congenital malformation, preterm birth,hemorrhage, congenital malformation, preterm birth,
stillbirthstillbirth
Furosemide: crosses placenta, no known teratogenicFurosemide: crosses placenta, no known teratogenic
effects, thiazides: crosses placenta, neonatal jaudice,effects, thiazides: crosses placenta, neonatal jaudice,
thrombocitopenia, anemiathrombocitopenia, anemia
89. Conti…..Conti…..
Lidocaine: crosses placenta, safe as long asLidocaine: crosses placenta, safe as long as
toxic leves avoidedtoxic leves avoided
Quinidine: crosses placenta, no knownQuinidine: crosses placenta, no known
teratogenic effects, neonatalteratogenic effects, neonatal
thrombocytopeniathrombocytopenia
Nifedipine: crosses placenta, maternalNifedipine: crosses placenta, maternal
hypotensionhypotension
Diazoxide: crosses placenta, hyperglycemia,Diazoxide: crosses placenta, hyperglycemia,
potential relaxant of uterine smooth musclepotential relaxant of uterine smooth muscle
Sodium nitroprusside: crosses placenta, onlySodium nitroprusside: crosses placenta, only
in critical care unitin critical care unit
90. Antepartum careAntepartum care
Heart surgeryHeart surgery
■ Ideal scenario – before pregnancyIdeal scenario – before pregnancy
■ If need present – early at the second trimIf need present – early at the second trim
Closed cardiac surgery – low riskClosed cardiac surgery – low risk
Open heart surgery – high risk r/t withOpen heart surgery – high risk r/t with
artificial circulation an temporaryartificial circulation an temporary
hypoxiahypoxia
91. Intrapartum CareIntrapartum Care
Routine assessment of laboring womanRoutine assessment of laboring woman
Assessment of cardiac decompensationAssessment of cardiac decompensation
Arterial blood gasesArterial blood gases
ECGECG
BP, Ps, OxymetryBP, Ps, Oxymetry
Position: elevated upper part of body or side-lyingPosition: elevated upper part of body or side-lying
Management of discomfort: supportive care, epidural analgesiaManagement of discomfort: supportive care, epidural analgesia
Preterm laboue: betaadrenergic agonist (ritodrine, terbutaline)Preterm laboue: betaadrenergic agonist (ritodrine, terbutaline)
Labour induction (syntocinon)Labour induction (syntocinon)
Cervical rippening (prostaglandins)Cervical rippening (prostaglandins)
Vaginal birthVaginal birth
■ in side-lying positionin side-lying position
■ Oxygen maskOxygen mask
■ EpisiotomyEpisiotomy
■ vacuum extractionvacuum extraction
■ ForcepsForceps
CS: risk r/t with dramatic fluid shifts, sustained hemodinamic changesCS: risk r/t with dramatic fluid shifts, sustained hemodinamic changes
and increased blood lossand increased blood loss
Dilute oxytocin is indicated, ergot products are contraindicatedDilute oxytocin is indicated, ergot products are contraindicated
92. Postpartum CarePostpartum Care
First 24-48 h are the most hemodinamically difficultFirst 24-48 h are the most hemodinamically difficult
AssessmentAssessment
■ Vital signVital sign
■ Oxygen saturation levelsOxygen saturation levels
■ Lung and heart auscultationLung and heart auscultation
■ EdemaEdema
■ Character of bleeding, uterine toneCharacter of bleeding, uterine tone
■ Fundal heightFundal height
■ Urinary outputUrinary output
■ PainPain
Activity rest patternActivity rest pattern
Elevated the head of the bedElevated the head of the bed
Family member helpFamily member help
Brestfeeding is not contraindicatedBrestfeeding is not contraindicated
93. 13. Which is the ideal contraceptive for women13. Which is the ideal contraceptive for women
with heart disease ?with heart disease ?
94. Contraception
1. OC pills are not ideal as they can cause thrombo
embolism.
2. IUCD can cause infection- endocarditis.
3. Barrier contraceptives – Have high failure rates.
4. Progestin only pills or Long acting injectable
progesterone are better
PILL - Desogestrel
INJECTABLES
a. Medroxy progesterone 150mg IM every 3 months.
b. Norethisterone.200 mg every 2 months
5. Sterilization is best.
95. Pregnancy and CHDPregnancy and CHD
ConclusionsConclusions
Most women with heart disease can have aMost women with heart disease can have a
pregnancy proper care.pregnancy proper care.
Pre-pregnancy evaluation mandatory.Pre-pregnancy evaluation mandatory.
High-risk cases benefit from combined high-riskHigh-risk cases benefit from combined high-risk
OB and cardiac care in the same center.OB and cardiac care in the same center.
Mechanical valve thrombosis with Enoxaparin (Lovenox)®:
10 case reports
2 in South Africa1.
8 in Israel.
7 of 10 were pregnant women.
Dose of Enoxaparin ranged from 20 mg per day to 80 mg/BID, and duration up to 37 days.
This resulted in 3 patients and fetuses death secondary to valve thrombosis.
Lev Rano, Kamer A, Gurevitch J, Shapira, Mohr R. Low-molecular weight heparin for prosthetic heart valves: treatment failure. Ann Thoracic Surg 2000; 69: 264-5.
South African Study
Aim: to evaluate thrombo-prophylaxis in 110 pregnant women with prosthetic heart valves.
Study discontinued after 11 patients had been enrolled, because of 2 deaths in 7 patients randomized to Enoxaparin group.
A US study in 61 non-pregnant patients with prosthetic heart valves reported no cases of prosthetic valve thrombosis.
Lev Rano, Kamer A, Gurevitch J, Shapira, Mohr R. Low-molecular weight heparin for prosthetic heart valves: treatment failure. Ann Thoracic Surg 2000; 69: 264-5.
FDA-Medwatch 2002 Safety Alert - Lovenox®
The use of Lovenox Injection is not recommended for thromboprophylaxis in patients with prosthetic heart valves.
Cases of prosthetic heart valve thrombosis have been reported in patients with prosthetic valves who have received enoxaparin for thromboprophylaxis.
Some of these cases were pregnant women in whom thrombosis led to maternal deaths and fetal deaths.
Pregnant women with prosthetic heart valves may be at higher risk for thromboembolism
