Postpartum anticoagulation in women with mechanical heart valves

Figures & data

Figure 1 Flowchart of study population.

Note: Three of the completed gestations did not have the time to anticoagulation resumption recorded after delivery.
Abbreviations: D&C, dilation and curettage; SAB, spontaneous abortion (miscarriage).

Table 1 Patient demographics (n=9 patients)

Patient characteristic
Age (years)
Median	25
Range	19–39
Race (n)
Caucasian	4
African American	2
Hispanic	2
Other	1
Tobacco use (n)
During pregnancy	3
BMI (kg/m^2)
Median	27.0
Range	19.3–46.3
Valve location (n)
Mitral	4
Aortic	5
Gravidity/parity
Median	2/0
Range	4–1/1–0
Antepartum AC (n)
Warfarin PO	1
Heparin SC	2
Enoxaparin SC	6

Abbreviations: AC, anticoagulation; BMI, body mass index; PO, by mouth; SC, subcutaneous injection.

Table 2 Maternal delivery outcomes (n=14 cases)

Maternal delivery outcomes	n (%) or median (range)
GA (w/d) at delivery
Mean	35w2d
Median	37w2d (28w2d–39w1d)
Mode of delivery
Vaginal	3 (21.4)
Vacuum-assisted	2 (14.3)
Cesarean	9 (64.3)
Anesthesia
None	1 (7.1)
Spinal	3 (21.4)
Epidural	5 (35.7)
GETA	5 (35.7)
Intrapartum AC
Warfarin PO	1 (7.1)
Heparin infusion	12 (85.7)
Enoxaparin SC	1 (7.1)
Postpartum AC
Warfarin PO	1 (7.1)
Heparin infusion	11 (79.6)
Enoxaparin SC	2 (14.3)

Abbreviations: AC, anticoagulation; GA (w/d), gestational age in weeks and days; GETA, general endotracheal anesthesia; PO, by mouth; SC, subcutaneous injection.

Table 3 Maternal outcomes. Selected maternal outcomes in the postpartum period were recorded (n=14 cases). There were no maternal deaths, CVA, or thrombosed valves noted during any of the delivery admissions. One patient suffered a CVA at 16 weeks of gestation but recovered by the time of delivery

Maternal outcomes	Time to anticoagulation postpartum
	All deliveries (n=14) n (%), or median (range)	≤6 hours (n=6) n (%), or median (range)	>6 hours (n=5) n (%), or median (range)
Time to AC resumption PP (n=11 recorded)
Median (hours)	6 (2–27)	6 (2–6)	16 (7–27)
PP hemorrhage	6 (42.8)	3 (50.0)	3 (60.0)
Transfusion	4 (28.6)	2 (33.3)	2 (40.0)
Wound hematoma	2 (14.3)	0	1 (20.0)
Intra-abdominal bleed	2 (14.3)	2 (33.3)	0
Vaginal hematoma	0	0	0
Surgical reintervention	1 (7.1)	1 (16.6)	0
Vessel embolization	1 (7.1)	1 (16.6)	0
Length of stay, total hospitalization
Median (days)	7 (3–14)	11 (6–14)	4 (3–9)
Length of stay, postpartum hospitalization
Median (days)	4 (2–10)	5 (3–9)	4 (2–7)
Valve thrombosis	0	0	0
Stroke	0	0	0
Death	0	0	0

Abbreviations: AC, anticoagulation; CVA, cerebrovascular accident; PP, postpartum.

Table 4 Maternal rhythm complications (n=14 cases). Other forms of rhythms recorded were ventricular tachycardia and high-grade ventricular arrhythmias. Peripartum rhythm complications included atrial flutter requiring cardioversion and ventricular tachycardia

Maternal cardiac status	n (%)
Known rhythm
NSR	8 (57.1)
Atrial fibrillation	0
Other	6 (42.9)
Antepartum management of cardiac rhythm
Medication	5 (35.7)
ICD/PM	2 (14.3)
Observation/expectant	8 (57.1)
Peripartum rhythm complications
Yes	3 (21.4)
No	11 (78.6)

Abbreviations: ICD, implantable cardioverter defibrillator; NSR, normal sinus rhythm; PM, pacemaker.

Table 5 Fetal and neonatal outcomes (n=14 cases). Selected fetal and neonatal outcomes were recorded for the 14 continuing pregnancies

Fetal or neonatal outcome	n (%)
Live births	13 (92.8)
Intrauterine fetal demise	1 (7.2)
Median birth weight	3,020 g
Intrauterine growth restriction	1 (7.2)
NICU admission	5 (38.5)
Apgar ≤7 at 1 minute	5 (38.5)
Apgar ≤7 at 5 minutes	4 (30.1)

Abbreviation: NICU, neonatal intensive care unit.