Dose-Escalated Low Molecular Weight Heparin Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre.

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Presentation transcript:

Dose-Escalated Low Molecular Weight Heparin Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre Experience Quinn J, Brooks R, Walker F, Peebles D, Cohen H (Intr. by David C Linch) Blood. 2007;110(11):Abstract #1873.

Background: Effective anticoagulation for women with mechanical heart valves during pregnancy remains a major challenge The use of standard dosage low molecular weight heparin (LMWH) is associated with an unacceptable incidence of morbidity and mortality for this patient group Dose-Escalated LMWH Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre Experience Quinn J, et al. Blood. 2007;110(11):Abstract #1873.

Objective: To determine pregnancy outcome for a cohort of women with mechanical heart valves who receive anticoagulation with a higher dosage LMWH regimen Dose-Escalated LMWH Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre Experience Quinn J, et al. Blood. 2007;110(11):Abstract #1873.

Methods: A prospective audit of anticoagulation management for a cohort of women with mechanical heart valves Twelve consecutive pregnancies in 10 women (mean age 27.8 (18-41) years) with mechanical heart valves were audited –4 with mechanical mitral valves –2 with mechanical aortic valves –2 with mechanical aortic and mitra –2 with mechanical systemic tricuspid AV valve Dose-Escalated LMWH Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre Experience Quinn J, et al. Blood. 2007;110(11):Abstract #1873.

Methods: Past obstetric history (on warfarin) included –6 fetal losses –2 miscarriages <12 weeks –4 terminations including one therapeutic at 22 weeks gestation because of an intracerebral fetal hemorrhage Dose-Escalated LMWH Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre Experience Quinn J, et al. Blood. 2007;110(11):Abstract #1873.

Results: In 11/12 pregnancies treated with LMWH, warfarin was discontinued at <6 weeks and in 1/12 at 8 weeks LMWH (dalteparin 7, enoxaparin 5) ± low-dose aspirin (4) was then started at full therapeutic dosage (subcutaneous 12 hourly) –With regular monitoring to maintain anti-Xa levels at U/mL –( in the first 4/12 pregnancies) Dose-Escalated LMWH Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre Experience Quinn J, et al. Blood. 2007;110(11):Abstract #1873.

Results: This necessitated stepwise increases in LMWH with median doses (12 hourly) pre-delivery –11,750 IU for dalteparin and –95 mg for enoxaparin Representing a median 47.7% increase over initial dosage Dose-Escalated LMWH Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre Experience Quinn J, et al. Blood. 2007;110(11):Abstract #1873.

Results: 11/12 pregnancies on LMWH resulted in live births –median BW 2.5 kg (range ) at median gestation 36 (range weeks) –with 1 IUFD at 37 weeks One patient had non-fatal valve-related thrombosis at 26 weeks associated with a sub- therapeutic anti-Xa level (0.64 U/ml) Dose-Escalated LMWH Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre Experience Quinn J, et al. Blood. 2007;110(11):Abstract #1873.

Results: Of note, she had a past history of pulmonary embolism and was heterozygous for the G20210A prothrombin gene mutation There were no other valve-related thrombotic events Minor bleeding occurred during 3 pregnancies There were 5 major bleeding episodes in 4 patients –3 antepartum (1 with placenta praevia) –1 post-partum haemorrhage plus 1 abdominal wound hematoma Dose-Escalated LMWH Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre Experience Quinn J, et al. Blood. 2007;110(11):Abstract #1873.

Conclusions: Our data suggest that in this patient group escalated dose LMWH provides effective anticoagulation These patients require meticulous anticoagulant monitoring and close surveillance for bleeding and thrombotic complications within a multidisciplinary setting, with urgent intervention when indicated Dose-Escalated LMWH Provides Effective Anticoagulation for Women with Mechanical Heart Valves During Pregnancy: A Single-Centre Experience Quinn J, et al. Blood. 2007;110(11):Abstract #1873.