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Education in Heart
Pregnancy and heart disease
Valvular heart disease and pregnancy part II: management of prosthetic valves
  1. Catriona J Bhagra1,
  2. Rohan D'Souza2,
  3. Candice K Silversides1
  1. 1Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
  2. 2Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Candice K Silversides, Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, Mount Sinai Hospital, Room 3-913, OPG Building, 700 University Avenue, Toronto, Ontario, Canada M5G 1Z5; candice.silversides{at}uhn.ca

https://doi.org/10.1136/heartjnl-2015-308199

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    Learning objectives

    • To recognise the maternal, fetal and neonatal risks of pregnancy in women with prosthetic heart valves.

    • To review anticoagulation strategies for women with mechanical heart valves during pregnancy.

    • To understand the principles of management in pregnant women with prosthetic heart valves.

    Introduction

    Prosthetic heart valves (PHV) have been used to treat patients with both congenital and acquired valve lesions since the first surgical replacement in 1960.1 The two principal types of PHV are the mechanical prostheses and the tissue or bioprostheses. Advances in surgical technique, valve design and anticoagulation have improved overall outcomes since their introduction.2 Worldwide, there is an increasing prevalence of rheumatic heart disease, with more young women being considered for surgical treatment.3 ,4 There are also increasing numbers of women with congenital heart disease reaching childbearing age, some of whom have PHV.

    During pregnancy, there is an increase in heart rate, stroke volume and cardiac output. These haemodynamic changes can lead to decompensation in women with PHV. Pregnancy is associated with additional risks in women with mechanical heart valves (MHV) as pregnancy is a prothrombotic state with an increased risk of thromboembolic complications (TECs), coupled with the adverse effects of oral anticoagulants on the fetus. In this article, we will review the pregnancy risks in women with PHV, strategies for anticoagulation in women with MHV and the management of complications.

    Preconception counselling and risk assessment

    Pregnancy in a woman with a PHV should be carefully planned. Preconception counselling is imperative, allowing for a comprehensive discussion of the risks of pregnancy for the mother and baby. The degree of maternal cardiac risk depends on many factors including the women's clinical status, her underlying cardiac condition, the type and position of the valve, the presence of other cardiac lesions and left ventricular systolic function. Maternal obstetric, fetal and neonatal risks should …

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