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1、Management of Pregnant Woman with Mechanical Heart Valves - A Case Based Discussion,Department of Anesthesiology the First Affiliated Hospital of Soochow University,JIN XIN,Key words,G3P2 孕3产2 gravida I或primigravida gravida II或secundigravida gravida III或tertigravida para O 未产妇 para 初产妇 para 、,Peripa
2、rtum 围产期 Gestation 怀孕, 酝酿, 妊娠 Thrombosis 血栓形成 Thromboembolism 血栓栓塞 Embryopathy 胚胎病 Osteoporosis 骨质疏松症 Teratogenic 畸形形成的hypoplasia 发育不全,Case Introduction,25 years, G3P2 gestation 6 weeks, 2 children, S.V.Delivery. 1st pregnancy: Dyspnoea(30 weeks), Mitral Regurgitation, Diuretic-Rest-Observation, MVR
3、, Anticoagulation(warfarin). 2nd pregnancy: 2 years later, uneventful, S.V.Delivery.,.to be continued,Risk of Prosthetic Valve Thrombosis,Tissue valve: wearing out and necessitating replacement. Mechanical valve: longevity but life-long anticoagulation. prosthetic valve thrombosis(PVT): 0.76.0% per
4、patient per year(1.3%-obstruction) VS 25% with no anticoagulation. Thromboembolism in pregnant women with prosthetic heart valve: 723% per pt per year.,Factors increasing the risk of PVT,Mechanical Valve Tissue Valve Right Heart Left Heart Mitral Valve Aortic Valve Hypercoagulable state of pregnancy
5、 Interruption to Anticoagulation,Considerations during Anticoagulation,Anticoagulation drugs: 1. Warfarin 2. Unfractionated heparin (UFH) 3. low molecular weight heparin (LMWH),Balance of two risks: 1. Valve thrombosis 2-1. Direct harm to fetus 2-2. Haemorrhage to both mother and fetus,Warfarin,Best
6、 protection in mother, best interest of unborn child. Crossing the placenta: fetal loss, embryopathy. Fetal and neonatal haemorrhage.,Warfarin Embryopathy: skeletal abnormality, taking warfarin in the first trimester (esp. 6th12th wks), indefinite incidence(1.6% of live births), skeletal deformity a
7、nd nasal hypoplasia-10% of babies exposed to warfarin.,Heparin,Neither UFH nor LMWH cross the placenta, no direct harm to fetus, but less protection against PVT. LMWH UFH: thrombocytopenia and osteoporosis, subcutaneous absorption, long T1/2, dose-response effect. Valve thrombosis rate: 8.6%.- 81 pr
8、egnancy in 75 women with mechanical prosthetic heart valves treated with LMWH.,Anticoagulation Management,UFH: 1750020000 units, sc., Bid, throughout pregnancy. a. APTT (6 hour post dosing): twice the control level. b.anti-a level(6 hour post dosing): 0.350.70 IU/ml. LMWH: dalterpain 100units/kg, sc
9、., throughout pregnancy. anti-a level(4 hour post dosing): 1.0IU/ml. UFH or LMWH therapy: as above until 13th week, Warfarin: till the middle of the 3rd trimester, UFH or LMWH therapy: restart until delivery.,NB: warfarin used alone-an embryopathy rate of 6.4%, completely eliminated by use of hepari
10、n prior to 13 weeks of gestation. (A Meta-Analysis),Thrombosis Rate,Warfarin throughout pregnancy- 3.9% Heparin throughout pregnancy- 33% Heparine in 1st trimester then warfarin thereafter-9.2% Aspirin 150mg Qd. is strongly advised.,Warfarin: offering the best protection against thrombosis Heparin(1
11、st trimester): protecting the unborn baby from teratogenic effect of warfarin,As soon as her pregnancy is confirmed: LMWH(tinzaparin): 7500 units Bid., and stopping warfarin. Warfarin: recommenced at 16 wks and stopped at 36 wks. LMWH (enoxaparin): 90mg Bid. Aspirin: 150mg, Qd, together with LMWH.,C
12、ase Introduction,.to be continued,Monitoring LMWH Therapy,UFH: Interacting with AT-: intrinsic pathway of coagulation LMWH: Blocking only Factor a: 1. not required for monitoring of anticoagulation therapy. 2. Dosage: based on BW, adjusted as pregnancy process due to GFR, Vd , and placental heparina
13、se. 3. anti-a level1 IU/ml (4 hours post dosing).,At 38 weeks: a planned induction of labor. Heamatology Department: joined for assistance. Full blood count and anti-a level 1.2 IU/ml Analgesia in labor: opioids, N2O+O2(Entonox). Epidural analgesia24hrs after last LMWH Recommence LMWH 2hrs after Epi
14、. Catheter removal Epidural heamotoma: risk reduced but still in existence Uneventful labor(SVD), healthy boy, discharged home later. Anticoagulation therapy Warfarin: restarted following delivery, INR2.03.0. Enoxaparin: used in pregnacy.,Case Introduction,.to be continued,10 days later: vaginal ble
15、eding, light headed. Vital signs and blood tests: within normal limits. HR: 64bpm, BP:110/72mmHg, RR:14/min. Hb:112g/L, WBC:5.8E9/L, Plt:195E9/L APTT ratio:1.2, Fibinogen:2.8g/dl, anti-a level:1.32 IU/ml,Post-Partum Haemorrhage (PPH),Post-partum haemorrhage (PPH): a. 500ml after V. delivery or 1000m
16、l after C. section. b. Blood loss that makes the patients symptomatic(dizzy, tachycardia, oliguric etc), primarily (24hrs) or secondarily(24h6wks postpartum).,Causes of PPH,1. Tone uterine atony: an over-distended uterus(multiple pregnancy, fetal macrosomia, polyhydramnios), fatigue uterus(prolonged labor/augmented labor, administration of tocolytics), and an obstructed uterus(retained placenta, retained products of conception ). 2. Trauma sustained injuries during d
