A Review of Valvular Heart Disease in Pregnant Women | Points to Remember
- Sliwa K, Johnson MR , Zilla P, Roos-Hesselink JW.
- Management of Valvular Disease in Pregnancy: A Global Perspective. Eur Heart J 2015;Mar 3:[Epub ahead of print].
The following are the top 11 points to remember about the management of valvular heart disease (VHD) in pregnancy:
- VHD remains an important cause of morbidity and mortality in postpartum women.
- All women with known VHD should be seen and counseled on pregnancy prior to conception. The CARdiac disease in PREGnancy (CARPREG) risk score and World Health Organization (WHO) classification should be used to assess these patients.
- Historically, stenotic valves carry greater pregnancy risk. Left-sided regurgitant valves are well tolerated in pregnancy compared to acute regurgitation and left and/or right ventricular dysfunction, which are poorly tolerated.
- When assessing a woman for valve replacement in the context of possible pregnancy, one must consider the risks and benefits involved with artificial, bioprosthesis/tissue, and mechanical valves focusing on the need for anticoagulation, valve hemodynamics, thrombotic risk, durability, and ultimate impact on fetal outcome.
- Tissue valves (xenografts, homografts, and autografts) require no anticoagulation, but are associated with a high risk of valve deterioration and need for future reoperation. Focusing on long-term calcification, degradation, and pannus overgrowth can dictate the longevity of tissue valves.
- Mechanical valves (caged ball, tilting disk, and bileaflet valves) have the best durability, but carry a thromboembolism risk with the continuous need for anticoagulation.
- Valve repair, balloon valvotomy, and percutaneous valve repairs in pregnancy remain limited in terms of data and long-term consequences; however, preliminary results are favorable.
- Delivery in anticoagulated women with prosthetic valves should follow safe transition to low molecular weight heparin or unfractionated heparin at 36 weeks and unfractionated heparin to be started 36 hours prior to induction/cesarean section or 6 hours prior to planned delivery.
- Cesarean section should be considered in patients with valvular disease in pre-term labor on oral anticoagulation, severe stenotic lesions, an ascending aorta >45 mm, severe pulmonary hypertension, or acute heart failure.
- Fibrinolysis is the treatment of choice in critically ill pregnant women who have right-sided valve thrombosis or when surgery is not immediately available.
- Ultimately, the decision for future intervention and management should be codirected by the cardiologist and obstetrician.
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