ESCTS 2012

1. Cairo University Studies
By
Zeinab Ashour

2. Difference in Egyptian society:
 Age of the mothers
 Parity
 Issues of anticoagulation
 Residual or acquired other valvular disease

3.  1st study, restrospective, from 1989-1999
 2nd study, restrospective, from 2002-2007
 3rd study , prospective 2008-2009

5. Data from 1989 -1999
Females attending the Kasr el Aini prosthetic
valve outpatient clinic
67 females , 100 pregnancies
Age range 19-45 y
20 health controls ( relatives)

6. Fetal loss rates in comparison to relatives
comaprison to relatives
44%
24%
patients controls

7. Fetal Outcome 44% fetal loss
spontanous abortion IUFD
still birth neonatal death
prematurity Rh incompatibility
materal death
5% 9%
4%
2%
7%
64%
9%

8. healthy baby fetal loss
38
28
18
16
Heparin n=66 Warfarin n=34
Heparin in the 1st trimester resulted in 57.6% healthy
babies versus 52.9% when taking Warfarin

9.  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.

10. placenta brevia
7%
PP hge
33% thrombosis
53%
IE
7%

12.  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

13. 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

14. Valve replaced
DVR
26%
MVR
AVR 57%
17%

15. Mode of Delivery
NVD
30%
CS
70%

16. Fetal outcome
take home babies died
13%
87%

17.  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

18.  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

19.  Heparin till 13th week of pregnancy, guided
by PTT
 Warfarin guided by INR till 36th week
 Shift back to heparin

20. 16%
16%
MVR
AVR
68%
DVR

21. Patients Controls
13.80%
9.10%
6.06%
1.52% 1.52%
0%
Hemorrhage Thromboembolic Total complication rate

22. Patients Controls
15%
9.10%
5%
3.30% 3% 3%
1.60%
0.00%
Abortion IUFD Neonatal death Total fetal loss
The mean INR for mothers with healthy babies was 2.15, for those with fetal loss
was 2.23

23. 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

24. CS
45%
NVD
55%

25. 7
6
6
5
4
4
3
2
2
1 1
1
0
0
Hemorrhage Thromboembolism Total Complications
CS n=30 NVD n=36

26. Cases Controls
2.84 2.92
1
0
Low 5 min Apgar score Fetal weight

27. > 5mg <5mg
4
2 2
1 1
0
Abortion IUFD Neonatal death

28. 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

29.  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