1、Management of Pregnant Woman with Mechanical Heart Valves-A Case Based DiscussionlDepartment of Anesthesiologyl the First Affiliated Hospital of Soochow UniversityJIN XIN读书报告机械瓣膜置换术后孕产妇的处理1Key wordslG3P2 孕3产2lgravida I或primigravidalgravida II或secundigravidalgravida III或tertigravidalpara O 未产妇 lpara
2、初产妇lpara、lPeripartum 围产期 lGestation 怀孕,酝酿,妊娠lThrombosis 血栓形成lThromboembolism 血栓栓塞lEmbryopathy 胚胎病 lOsteoporosis 骨质疏松症lTeratogenic 畸形形成的hypoplasia 发育不全 读书报告机械瓣膜置换术后孕产妇的处理2Case Introduction l25 years,G3P2 gestation 6 weeks,2 children,S.V.Delivery.l1st pregnancy:Dyspnoea(30 weeks),Mitral Regurgitation,
3、Diuretic-Rest-Observation,MVR,Anticoagulation(warfarin).l2nd pregnancy:2 years later,uneventful,S.V.Delivery.to be continued读书报告机械瓣膜置换术后孕产妇的处理3Risk of Prosthetic Valve ThrombosislTissue valve:wearing out and necessitating replacement.lMechanical valve:longevity but life-long anticoagulation.lprosthe
4、tic valve thrombosis(PVT):0.76.0%per patient per year(1.3%-obstruction)VS 25%with no anticoagulation.lThromboembolism in pregnant women with prosthetic heart valve:723%per pt per year.读书报告机械瓣膜置换术后孕产妇的处理4Factors increasing the risk of PVTlMechanical Valve Tissue ValvelRight Heart Left HeartlMitral Va
5、lve Aortic ValvelHypercoagulable state of pregnancylInterruption to Anticoagulation读书报告机械瓣膜置换术后孕产妇的处理5Considerations during AnticoagulationAnticoagulation drugs:1.Warfarin2.Unfractionated heparin (UFH)3.low molecular weight heparin (LMWH)Balance of two risks:1.Valve thrombosis2-1.Direct harm to fetu
6、s2-2.Haemorrhage to both mother and fetus读书报告机械瓣膜置换术后孕产妇的处理6WarfarinlBest protection in mother,best interest of unborn child.lCrossing the placenta:fetal loss,embryopathy.lFetal and neonatal haemorrhage.Warfarin Embryopathy:skeletal abnormality,taking warfarin in the first trimester(esp.6th12th wks)
7、,indefinite incidence(1.6%of live births),skeletal deformity and nasal hypoplasia-10%of babies exposed to warfarin.读书报告机械瓣膜置换术后孕产妇的处理7HeparinlNeither UFH nor LMWH cross the placenta,no direct harm to fetus,but less protection against PVT.lLMWH UFH:thrombocytopenia and osteoporosis,subcutaneous absor
8、ption,long T1/2,dose-response effect.lValve thrombosis rate:8.6%.-81 pregnancy in 75 women with mechanical prosthetic heart valves treated with LMWH.读书报告机械瓣膜置换术后孕产妇的处理8Anticoagulation ManagementlUFH:1750020000 units,sc.,Bid,throughout pregnancy.a.APTT(6 hour post dosing):twice the control level.b.an
9、ti-a level(6 hour post dosing):0.350.70 IU/ml.lLMWH:dalterpain 100units/kg,sc.,throughout pregnancy.anti-a level(4 hour post dosing):1.0IU/ml.lUFH 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-
10、an embryopathy rate of 6.4%,completelyeliminated by use of heparin prior to 13 weeks of gestation.(A Meta-Analysis)读书报告机械瓣膜置换术后孕产妇的处理9Thrombosis RatelWarfarin throughout pregnancy-3.9%lHeparin throughout pregnancy-33%lHeparine in 1st trimester then warfarin thereafter-9.2%Aspirin 150mg Qd.is strongl
11、y advised.Warfarin:offering the best protection against thrombosisHeparin(1st trimester):protecting the unborn baby from teratogenic effect of warfarin读书报告机械瓣膜置换术后孕产妇的处理10 As soon as her pregnancy is confirmed:lLMWH(tinzaparin):7500 units Bid.,and stopping warfarin.lWarfarin:recommenced at 16 wks an
12、d stopped at 36 wks.lLMWH(enoxaparin):90mg Bid.lAspirin:150mg,Qd,together with LMWH.Case Introduction .to be continued读书报告机械瓣膜置换术后孕产妇的处理11Monitoring LMWH TherapylUFH:Interacting with AT-:intrinsic pathway of coagulationlLMWH:Blocking only Factor a:1.not required for monitoring of anticoagulation the
13、rapy.2.Dosage:based on BW,adjusted as pregnancy process due to GFR,Vd,and placental heparinase.3.anti-a level 1 IU/ml(4 hours post dosing).读书报告机械瓣膜置换术后孕产妇的处理12lAt 38 weeks:a planned induction of labor.lHeamatology Department:joined for assistance.Full blood count and anti-a level 1.2 IU/mllAnalgesia
14、 in labor:opioids,N2O+O2(Entonox).Epidural analgesia24hrs after last LMWH Recommence LMWH 2hrs after Epi.Catheter removal Epidural heamotoma:risk reduced but still in existencelUneventful labor(SVD),healthy boy,discharged home later.lAnticoagulation therapy Warfarin:restarted following delivery,INR2
15、.03.0.Enoxaparin:used in pregnacy.Case Introduction.to be continued读书报告机械瓣膜置换术后孕产妇的处理13l10 days later:vaginal bleeding,light headed.lVital 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
16、IU/mlPost-Partum Haemorrhage(PPH)Post-partum haemorrhage(PPH):a.500ml after V.delivery or 1000ml after C.section.b.Blood loss that makes the patients symptomatic(dizzy,tachycardia,oliguric etc),primarily(24hrs)or secondarily(24h6wks postpartum).读书报告机械瓣膜置换术后孕产妇的处理14Causes of PPH1.Tone uterine atony:a
17、n 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 delivery3.Tissue retained products o
18、f conception:preventing uterus from adequate contraction,a source of infection.4.Thrombin coagulation disorder,either acquired or inherited.读书报告机械瓣膜置换术后孕产妇的处理15Cause and ManagementlNo birth trauma,no sepsis,INR 2.0 Clinical examination:poor contracted uterus US examination:retained products of conce
19、ption lStopping warfarin,commencing LMWH(enoxaparin 70mg Bid.)lRemoval of products of conception under general anesthesia.lContinuing bleeding(Hb 6.5g/dl)and blood transfusion 4 units.lINR 1.1 at present读书报告机械瓣膜置换术后孕产妇的处理16One surgical option available-placement of an intrauterine balloonlSevere or
20、refractory PPH secondary to uterine atonylSevere PPH due to retained products,continuing to bleed after evacuation.lSevere PPH secondary to coagulopathylPPH following Cesarean deliverylProphylaxis if at very high risk of PPHIn this case,a Rusch balloon is applied first,deflated at 24hrs,however rein
21、serted later for bleeding again.读书报告机械瓣膜置换术后孕产妇的处理17Case Introductionl72 hrs after evacuation of retained products of conceptionlBlood:Hb:92g/L,Plt:162E9/L,INR:1.1,anti-a:1.1 IU/mllSlow bleeding,reversal of anticoagulation(thrombosis),surgical intervention while anticoagulated.lFinal decision:the in
22、terventional radiology service for uterine artery embolisation.to be continued读书报告机械瓣膜置换术后孕产妇的处理18Uterine Artery EmbolisationlA safe,uterine-sparing procedure.lA high success rate(92%)and a low complication -surgical uterine artery ligation,avoiding surgical access.lLocal anesthesia,Unilateral/Bilat
23、eral femoral A.puncture,Microcatheter,Fluoroscopic guidance,Internal Iliac A.,Synthetic compounds.读书报告机械瓣膜置换术后孕产妇的处理19Complications of UAElImmediate:-Groin puncture site problems including haematoma -Contrast reactions -Uterine artery spasm lEarly:-Post-embolisation syndrome(pain,nausea,fever,flu-li
24、ke illness with raised inflammatory markers)-False aneurysm -Arterial thrombosis lLate:-Vaginal discharge(16%at 12 months)-Amenorrhoea(7.3%at 12 months)-Infection:endometritis读书报告机械瓣膜置换术后孕产妇的处理20Outcome of the PatientlUterine artery embolisation procedurelRemove intrauterine balloon the following da
25、y Recommencing warfarin therapy,stopping LMWH lbe discharged home two days later读书报告机械瓣膜置换术后孕产妇的处理21SummarylProsthetic Valve Thrombosis lAnticoagulation therapy lWarfarin EmbryopathylPost-Partum HaemorrhagelPlacement of an intrauterine balloon surgically available lUterine Artery Embolisation better choice for PPHCorrespondence Email：读书报告机械瓣膜置换术后孕产妇的处理22
