Outcome of pregnancy in prosthetic valve patients

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Outcome of pregnancy in prosthetic valve patients

  1. 1. Cairo University Studies By Zeinab Ashour
  2. 2. Difference in Egyptian society: Age of the mothers Parity Issues of anticoagulation Residual or acquired other valvular disease
  3. 3.  1st study, restrospective, from 1989-1999 2nd study, restrospective, from 2002-2007 3rd study , prospective 2008-2009
  4. 4. Data from 1989 -1999Females attending the Kasr el Aini prosthetic valve outpatient clinic67 females , 100 pregnanciesAge range 19-45 y20 health controls ( relatives)
  5. 5. Fetal loss rates in comparison to relatives comaprison to relatives 44% 24% patients controls
  6. 6. Fetal Outcome 44% fetal loss spontanous abortion IUFD still birth neonatal death prematurity Rh incompatibility materal death 5% 9% 4% 2% 7% 64% 9%
  7. 7. healthy baby fetal loss 38 28 18 16 Heparin n=66 Warfarin n=34Heparin in the 1st trimester resulted in 57.6% healthybabies versus 52.9% when taking Warfarin
  8. 8.  15%, 5% fatal thrombosis in 8 pregnancies Infective endocarditis in 1 pregnancy, postpartum hemorrhage (5 pregnancies), bleeding during pregnancy due to placenta previa (1 pregnancy), and toxemia of pregnancy (1 pregnancy). Caesarean section was required in 2 pregnancies. Except for the 1 patient who developed infective endocarditis, all of the 9 patients who experienced acute valvular obstruction had received heparin in the 1st trimester. Five died and 4 underwent successful reoperation.
  9. 9. placenta brevia 7%PP hge 33% thrombosis 53% IE 7%
  10. 10.  Kasr el Aini NHI (M.A.Raouf, R. Riad, A.A.Ashraf, Z. Ashour & E.B Eweis ) 2002-2007 102 pregnancies, 103 babies Maternal age 18-39 y
  11. 11. HIGH RISK LOW RISK History of thrombo-  Normal dimensions embolization and function of the Atrial Fibrillation cardiac chambers Chamber dilatation  New generation valves Reduced EF especially in aortic Old generation prosthesis position Double valve replacement Less than 1 y post op
  12. 12. Valve replaced DVR 26% MVRAVR 57%17%
  13. 13. Mode of DeliveryNVD30% CS 70%
  14. 14. Fetal outcometake home babies died 13% 87%
  15. 15.  3 patients died  AR, Poor ejection fraction , dilated LV died  Pulmonary embolism after CS, died  7 developed valvular obstruction, 1 died  6 developed post partum hge, one needed blood transfusion
  16. 16.  Thesis in 2010, M.A.M. El Nasharty, M. A. Abd El Raouf, Z.A. Ashour, E.A. Hussein 66 females with prosthetic valves, age range 20-45 y admitted from 2008-2009 132 healthy controls Excluded patients  on oral anticoagulants in the 1st trimester  pulmonary hypertension  Congenital heart disease
  17. 17.  Heparin till 13th week of pregnancy, guided by PTT Warfarin guided by INR till 36th week Shift back to heparin
  18. 18. 16%16% MVR AVR 68% DVR
  19. 19. Patients Controls 13.80%9.10% 6.06% 1.52% 1.52% 0%Hemorrhage Thromboembolic Total complication rate
  20. 20. Patients Controls 15% 9.10% 5% 3.30% 3% 3% 1.60% 0.00% Abortion IUFD Neonatal death Total fetal lossThe mean INR for mothers with healthy babies was 2.15, for those with fetal losswas 2.23
  21. 21. There was an increased tendency to fetal loss with higher doses of Warfarin, but this did not reach statistical significance,No statistical difference was noted as concerns maternal complications. Hemorrhage occurred in 2 patients on low dose and 4 patients on high dose Warfarin, while thromboembolism occurred in 3 patients on low dose Warfarin
  22. 22. CS45% NVD 55%
  23. 23. 7 665 443 22 1 11 00 Hemorrhage Thromboembolism Total Complications CS n=30 NVD n=36
  24. 24. Cases Controls 2.84 2.92 1 0Low 5 min Apgar score Fetal weight
  25. 25. > 5mg <5mg4 2 2 1 1 0Abortion IUFD Neonatal death
  26. 26. Chart Title 50% 45% 40% 35%Axis Title 30% 25% Fetal Loss 20% Maternal loss 15% 10% 5% 0% 1989-1999 2002-2007 2008-2009
  27. 27.  Pregnancy in a prosthetic valve patient remains problematic. Ongoing study about pregnancy and heart disease should resolve whether it is more problematic than in an unoperated patient with valvular disease or not With proper medical care, the outcome has improved

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