Prosthetic Valves in Pregnancy

Valvular Heart Disease in Pregnancy Microchapters
Cardiac disease in pregnancy
2014 AHA/ACC guideline for the management of patients with valvular heart disease
Native Valve Stenosis in Pregnancy
Native Valve Regurgitation in Pregnancy
Prosthetic Valves in Pregnancy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Prosthetic Valves in Pregnancy

Diagnosis and Follow-up

Class I

"1. All patients with a prosthetic valve should undergo a clinical evaluation and baseline TTE before pregnancy.(Level of Evidence: C)"

"2. All patients with a prosthetic valve should undergo pre-pregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy.(Level of Evidence: C)"

"3. TTE should be performed in all pregnant patients with a prosthetic valve if not done before pregnancy. (Level of Evidence: C)"

"4. Repeat TTE should be performed in all pregnant patients with a prosthetic valve who develop symptoms.(Level of Evidence: C)"

"5. TEE should be performed in all pregnant patients with a mechanical prosthetic valve who have prosthetic valve obstruction or experience an embolic event. (Level of Evidence: C)"

"6. Pregnant patients with a mechanical prosthesis should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in the management of high-risk cardiac patients.(Level of Evidence: C)"

Medical Therapy

Class I

"1. Therapeutic anticoagulation with frequent monitoring is recommended for all pregnant patients with a mechanical prosthesis(Level of Evidence: B)"

"2. Warfarin is recommended in pregnant patients with a mechan- ical prosthesis to achieve a therapeutic INR in the second and third trimesters(Level of Evidence: B)"

"3. Discontinuation of warfarin with initiation of intravenous UFH (with an activated partial thromboplastin time [aPTT] >2 times control) is recommended before planned vaginal delivery in pregnant patients with a mechanical prosthesis.(Level of Evidence: C)"

"4. Low-dose aspirin (75 mg to 100 mg) once per day is recommended for pregnant patients in the second and third trimesters with either a mechanical prosthesis or bioprosthesis.(Level of Evidence: C)"

Class IIa

"1. Continuation of warfarin during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin to achieve a therapeutic INR is 5 mg per day or less after full discussion with the patient about risks and benefits (Level of Evidence: B)"

"2. Dose-adjusted LMWH at least 2 times per day (with a target anti-Xa level of 0.8 U/mL to 1.2 U/mL, 4 to 6 hours postdose) during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is greater than 5 mg per day to achieve a therapeutic INR (Level of Evidence: B)"

"3. Dose-adjusted continuous intravenous UFH (with an aPTT at least 2 times control) during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is greater than 5 mg per day to achieve a therapeutic INR (Level of Evidence: B)"

Class IIb

"1. Dose-adjusted LMWH at least 2 times per day (with a target anti-Xa level of 0.8 U/mL to 1.2 U/mL, 4 to 6 hours post- dose) during the first trimester may be reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is 5 mg per day or less to achieve a therapeutic INR (Level of Evidence: B)"

"2. Dose-adjusted continuous infusion of UFH (with aPTT at least 2 times control) during the first trimester may be reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is 5 mg per day or less to achieve a therapeutic INR (Level of Evidence: B)"

Class III (Harm)

"1. LMWH should not be administered to pregnant patients with mechanical prostheses unless anti-Xa levels are monitored 4 to 6 hours after administration (Level of Evidence: B)"