الفهرس 
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Abstract
Summary and conclusions
The management of a pregnant woman with a prosthetic heart valve requires important considerations, especially when it comes to maintaining anticoagulation. Because there is a paucity of prospective data, one cannot make definitive recommendations for each patient.
The treatment of women in childbearing age with a mechanical heart valve is a real challenge for the medical staff. Warfarin is considered to be a safe and effective anticoagulant for patients with prosthetic heart valves. However, treatment during pregnancy poses many difficulties, not least during the first trimester, due to its ability to cross the placenta and its associated fetotoxicity. Treatment with Heparin during the first trimester decreases the rate of embryopathy but increases maternal morbidity and mortality.
Thus, pregnancy in women with prosthetic mechanical heart valve replacement is problematic and troublesome even now. Because the best means of handling pregnancy in patients who have mechanical valves remains a controversial issue, we conducted this Observational study to observe maternal and fetal outcomes in pregnant women with heart valve replacement in Sohag University Hospital.
All cases were subjected to complete history taking, complete physical examination (general and obstetrical), obstetric US & investigations as echocardiography, PT, PC and INR.
• Our results showed that;
The mean age of the study group was around 28 years, with a wide range from 18 to 38 years.
Around two thirds of the cases were from rural areas.
Regarding parity, one third of the cases (7 cases, 35%) were nulliparous, with a mean number of previous deliveries of 2.3. The gestational age showed a wide variation, with a mean of 29 weeks and standard deviation of more than 10 weeks.
4 cases had twins (20%) and 8 had previous CS (40%).
Regarding the preexisting chronic diseases, 20% were passive smokers, 15% hypertensive, 10 diabetic and non of them was active smoker. Previous cardiac interbention was recorded in around half of the cases (9 cases, 45%). The majority of the cases were NYHA class I (75%), followed by class II (20%) and only one case had NYHA class III (5%). Non of the cases had NYHA class IV. Clinical signs of heart failure were seen in 20% of the cases, and liver ventricular hypertension in 15% of the cases. AF before pregnancy was recorded in 10% of the cases. Regarding previous medications, beta blockers and diabetics were seen in 15% of the cases and each of antiarrhythmics and ACE inhibitors were seen in 10% of the cases.
The vast majority of the cases had mitral valve replaced; either alone in 75% of the cases or combined with aortic valve in 10% of them, while aortic valve was replaced alone in only 15% of the cases.
Regarding the obstetric intervention, CS was done for 40% of the cases, followed by vaginal delivery in 35% of them (combined with IUC in 25% of the cases), evacuation in 20% (combined with IUC in 10% of the cases) and hysterotomy in one case (5%).
We have no maternal mortality. Regarding maternal morbidity, the majority of the cases were admitted (85%), and around one third needed ICU admission (7 cases, 35%) from whom 6 cases needed ICU due to cardiac causes.
Regarding the cardiac complications, hemorrhagic complications were seen in 25% of the cases, followed by thrombosis and rapid AF (10% each), then heart failure and supraventricular arrhythmias (5% each); non of our cases experienced endocarditis, ventricular arrhythmias, mechanical valve thrombosis or pregnancy induced hypertension.
Regarding the offspring outcome, miscarriage before the 24th week occurred in 30% of the cases and IUFD in one case (5%). Preterm labor before 37th week occurred in 3 cases (15%) but non of the cases needed therapeutic abortion. The APGAR score ranged from 7 to 8 among the living kids, with a mean birthweight of 2530 grams.
Before 14 weeks of gestation, most of the cases used heparin either UFH or LMWH, with only 35% used vitamin K antagonists. This was opposite in later stages of pregnancy, where most of the cases (80%) used VKA. Lastly, in the peripartum period, 70% of the cases used UFD, 10% used LMWH, while only one case used VKA and 3 cases did not receive anything (15%).
Incidence of missed abortion was greater in patients received heparin than who received VKA (53.8%, 28.6% respectively). IUFD occurred in 14.3% of patients received VKA.
The incidence of postpartum hemorrhage was greater in patients who received VKA daily than in patients who received heparin with no significant difference. Hemorrhage was more common with MVR. Postpartum hemorrhage was more common also in patients with aortic valve prostheses than in patients with mitral valve and aortic valve prostheses.
We concluded that;
We conclude that patients with mechanical valves have more incidence of fetal loss and maternal complications.
Warfarin was as effective as heparin in preventing thromboembolic complications and valvular malfunction in the mother and seems to have less harm on the fetal outcome.
Mitral valve replaacement is associated with more maternal hemorrhagic
complications than aortc valve alone or double valve replacement.
Limitations
• Our study has some limitations:
1) Some data were incomplete as the care of many women was shared between different disciplines and, frequently between different hospitals.
2) Small sample size.
3) As the study was prospective, the implication of the data collection process on the practice of the centers involved is unknown.
4) To preserve anonymity of women some details could not be reported as the woman would become identifiable.
Recommendations
1) Women who have prosthetic heart valves and are of a child-bearing age should be counseled (ideally before conception) about the potential issues that might arise during pregnancy.
2) Having a prosthetic heart valve puts both the mother and fetus at risk; therefore, the management of these women is required throughout pregnancy in a specialized program for high-risk patients by a multi-disciplinary team.