Thrombo-hemorrhagic complications during pregnancy and after delivery in prostheted cardiac valves patients


DOI: https://dx.doi.org/10.18565/therapy.2020.1.59-68

Irtyuga O.B., Bautin A.E., Vavilova T.V., Karelkina E.V., Dubinina M.V., Bezrukikh V.A., Li O.A., Yakubov A.V., Sukhova I.V., Stepanov E.D., Volodicheva N.S., Zazerskaya I.E., Gordeev M.L., Pervunina T.M., Moiseeva O.M.

V.A. Almazov National medical research center of the Ministry of Healthcare of Russia, St. Petersburg
The aim of the study was to characterize the frequency and identify risk factors for thrombotic and hemorrhagic complications during pregnancy, delivery and the postpartum period in females with prosthetic heart valves (PHV).
Material and methods. In the period from January 2011 to December 2018, in the conditions of a specialized perinatal center of V.A. Almazov National medical research center it was performed a retrospective cohort study which included 44 patients with PHV, 7 patients had repeated pregnancies over this period of time. As a result, the course and outcomes of 51 pregnancies were analyzed. All patients were divided into two groups depending on prosthesis type: mechanical (34 childbirths in 30 patients) and biological prostheses (17 childbirths in 14 patients). The average age of the examined females was 30,3±5,2 years (from 13 years to 41 years).
Results. Valve prosthetics were performed for the cases of mitral insufficiency (27.5%), aortic stenosis (19,6%) and aortic insufficiency (17,7%) on the field of congenital heart defects, infectious endocarditis and chronic rheumatic heart disease: 41,2; 31,4 and 13,7% respectively. The majority of the patients included in the analysis had an aortic prosthesis (37,3%) and mitral valves prosthesis (31,4%). In 8 (23,5%) pregnants with a mechanical valve prosthesis (MVP), prosthetic thrombosis was recorded. In one patient with MVP (2,9%), the course of pregnancy was complicated by an acute cerebral circulation disorder. All cases of prosthetic thrombosis were associated either with the independent cancellation of anticoagulant therapy by patients, or with a lack of control of anti-Xa activity when prescribing low molecular weight heparin. Despite the clinically significant cardiac pathology, most patients managed to prolong the pregnancy to the full time – 37,0±3,2 weeks. In 5 patients, on the background of a change in anticoagulant therapy, pregnancy stopped in the early stages. A high frequency of surgical delivery in both analyzed groups was mentioned: in patients with MVP in 94,1%, in the group of patients with a biological valve prosthesis – in 58,8% of cases. After delivery, new cases of prosthetic thrombosis were not diagnosed, however, 5 patients in the early postpartum period had hemorrhagic complications requiring relaparotomy and blood transfusions. Despite frequent complications both during pregnancy and the postpartum period, no fatal outcomes have been reported.
Conclusion. A multidisciplinary approach and adherence to modern recommendations on the management of patients with PHV minimizes the risk of maternal mortality. However, the presence of MVP is associated with a high frequency of thrombosis and hemorrhagic complications during pregnancy, childbirth and the postpartum period, which requires careful monitoring of the effectiveness and safety of anticoagulant therapy in this category of patients.
Keywords: heart valve prosthesis, cesarean section, anticoagulant therapy, pregnancy
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About the Autors

Olga B. Irtyuga, PhD, associate professor of the Department of cardiology, leading researcher of scientific research laboratory of cardiomyopathies of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (905) 220-72-06. E-mail: olgir@yandex.ru. ORCID: 0000-0002-8656-3191
Andrey E. Bautin, MD, associate professor of the Department of anesthesiology and intensive care, head of the research laboratory of anesthesiology and intensive care of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (921) 753-91-10. E-mail: abautin@mail.ru. ORCID: 0000-0001-5031-7637
Tatyana V. Vavilova, MD, head of the Department of laboratory medicine and genetics of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia, Chief external expert in clinical laboratory diagnostics of the North-West Federal district. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (921) 913-78-10.
E-mail: vavilova_tv@almazovcentre.ru. ORCID: 0000-0001-8537-3639
Elena V. Karelkina, Researcher, research assistant of the laboratory of cardiomyopathies of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (921) 917-60-57. E-mail: ekarelkina@mail.ru. ORCID: 0000-0002-3655-9709
Maria V. Dubinina, clinical intern-cardiologist of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (987) 738-08-88. E-mail: shama93@bk.ru. ORCID: 0000-0001-7980-4279
Vadim A. Bezrukikh, hematologist of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (921) 563-88-92. E-mail: bezrukikh_v@list.ru
Olga A. Lee, PhD., Deputy chief physician for clinical care of FSSTP of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (921) 323-78-74. E-mail: olgalee74@list.ru. ORCID: 0000-0002-1237-6107
Andrey V. Yakubov, assistant professor of the Department of anesthesiology and intensive care, head of the Department of anesthesiology and resuscitation for adults of FSSTP of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (911) 166-56-63.
E-mail: a.v.yakubov@yandex.ru. ORCID: 0000-0002-7226-6284
Irina V. Sukhova, PhD, senior researcher of the research laboratory of clinical angiology of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (950) 008-14-39. E-mail: ivsukhova@mail.ru. ORCID: 0000-0002-7313-5307
Ekaterina D. Stepanovykh, obstetrician-gynecologist of the Department of pregnancy pathology of V.A. Almazov national medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (921) 891-37-31. E-mail: nifredil@list.ru. ORCID: 0000-0002-4043-030X
Natalia S. Volodicheva, cardiologist of the perinatal center of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (921) 327-21-76.
E-mail: degtyareva_ns@rambler.ru
Irina E. Zazerskaya, MD, head of the Department of obstetrics and gynecology of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str.
Tel.: +7 (921) 948-83-40. E-mail: zazera@mail.ru. ORCID: 0000-0003-4431-3917
Mikhail L. Gordeev, MD, professor, chief researcher at the Institute of heart and vascular pathology establishment of Research Institute of cardiothoracic surgery of V.A. Almazov national medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (921) 941-71-27. E-mail: mlgordeev@mail.ru. ORCID: 0000-0002-8199-0813
Tatyana M. Pervunina, PhD, director of the Institute of perinatology and pediatrics surgery of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (921) 799-99-95. E-mail: pervunina_tm@almazovcentre.ru. ORCID: 0000-0001-9948-7303
Olga M. Moiseeva, MD, director of the Institute of heart and vascular pathology, Chief researcher of the research institute of non-coronarogenic heart diseases of surgery of V.A. Almazov National medical research center of the Ministry of Healthcare of Russia. Address: 197341, St. Petersburg, 2 Akkuratova Str. Tel.: +7 (921) 306-82-49.
E-mail: moiseeva@almazovcentre.ru. ORCID: 0000-0002-7817-3847


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