DILEMMAS IN MANAGEMENT OF PREGNANT PATIENTS WITH MECHANICAL PROSTHETIC VALVES IN RURALAND SEMI-URBAN NORTH INDIAN POPULATION AT A TERTIARY CARE INSTITUTION.

Abstract

Pregnancy is a prothrombotic stage, and in women with mechanical heart valves, anticoagulation is a challenge to attain an optimal outcome in mother and fetus. The use of combinations coumadin derivatives and various heparins is still in inconclusive stage due to various socioeconomic and demographic situation. In developing countries due to the cost of surgery, and compliance with lifelong anticoagulation there is contradiction for efficient outcome. Hence a safe protocol is necessary for implementation. Objectives: To evaluate the most effective, practical and uniform “Anticoagulation Regimen” suited to rural and semi-urban Indian pregnant women with mechanical heart valves with low socio-economic status and to observe its impact on the pregnancy outcomes. Methodology: Retrospective observational cohort study carried out at tertiary institute, between July 2006 to June 2015. 69 women became pregnant during the period from 2006 to 2015 on 1 or multiple occasions. 21(30.43%) pregnancies ended in early abortions and 46 (66.7%) pregnancies were continued. Anticoagulation protocol that was followed in these women was H-A-H protocol. These pregnancies were managed by obstetric team of tertiary care hospital under same consultant. Outcome measures were analyzed. Data was expressed as mean with standard deviation or frequency with percentage as appropriate. Results: Of 292 women, who underwent valve replacement surgery, 69 pregnancies were reported during this period on 1 or multiple occasions. 46 women had successful deliveries and rest 23 had single or multiple pregnancy failure. Incidence of stillbirth in those who delivered successfully was lower (2.89%). Fetal morbidity was 37.68% and none of the pregnant women had valve thrombosis. In 46 women majority had successful outcome except 6(13.04%) children out of 46 who developed anticoagulation related congenital defects. This was mainly seen in those women who presented late in pregnancy. Conclusion: Our Experience showed that Heparin-Acitrome-Heparin protocol is effective and safe in pregnancy than heparin alone, or acitrome alone regimen. The fetal outcome was good, maternal compliance was better and this protocol is widely recommended.