Impact of prosthetic heart valves on pregnancy in Bangladeshi women

Background: This study evaluated pregnancy outcome in women with a prosthetic heart valve, especially with the oral anticoagulation therapy that must be weighed against the risk of intracardiac thrombosis. Methods: This multicenter, retrospective, cohort study was undertaken between January 2012 and June 2017. The principal maternal outcome variables included bleeding and thromboembolic complications, infective endocarditis, prosthetic valve thrombosis and heart failure. However, the main foetal outcome variables included miscarriage, mortality, preterm baby, warfarin embryopathy, low birthweight and the mode of delivery. Results: A total of 265 pregnancies in women with prosthetic heart valves were evaluated in two groups: Group I (n = 182) covers a mechanical valve, while Group II (n = 82) covers a bioprosthetic valve. The mean age of the patients was 25.2 ± 2.5 years and 24.5 ± 5.2 years in Group I and Group II, respectively. Approximately 80% of the patients had normal echocardiography findings. However, Group I (mechanical prostheses) has a higher incidence (11.54%) of thrombus formation in comparison with the bioprostheses. Hemorrhagic complications and spontaneous miscarriage were statistically significant (p⩽0.05) between the study groups. However, normal pregnancy outcome (91.57%) was significantly higher (p⩽0.05) in Group II compared to Group I (61.54%). Mean birthweight and mean APGAR score were found normal in both study groups. Only 2.75% of patients have warfarin embryopathy in Group I. Furthermore, comparison of SF-36 scores for HRQOL (Health-Related Quality of Life) before and after pregnancy were statistically insignificant among the study population. Conclusion: Proper antenatal care and early risk stratification are the fundamental measures to improve the maternal and foetal outcomes in a patient with a prosthetic heart valve.

Warfarin-Associated Diaphragmatic Hernia: An Unusual Diagnosis

Fetal warfarin syndrome is a consequence of maternal intake of warfarin during pregnancy and comprises a wide range of manifestations, including some typical facial dysmorphologic features. The authors report a case of prenatal ultrasonographic diagnosis of warfarin embryopathy in an obese woman on unsupervised warfarin prophylaxis at the 16th week of gestation. The fetus presented with facial dysmorphism, pectus excavatum, diaphragmatic hernia, and pulmonary hypoplasia. To the best of our knowledge, this is the second reported case of warfarin-associated diaphragmatic hernia.

Imatinib and Pregnancy.

Animal studies with imatinib have shown it to be teratogenic, embryotoxic and to result in increased rates of post-implantation loss. As a consequence there are justifiable physician/patient concerns regarding the safety of tyrosine kinase inhibitors during pregnancy. We can now report on 180 mothers (the majority with chronic myeloid leukemia but some treated for other indications) exposed to the drug during pregnancy. Timing of exposure to imatinib by trimester is available for 146 (81%). 71% of these were exposed in the 1st trimester (includes 4 exposed in both 1st and 2nd trimesters), 38 (26%) were exposed in all trimesters and 4 only after the 1st trimester. Outcome data are known for 125/180 (69%). 63 pregnancies resulted in the birth of normal live infants (50% of those with known outcome (KO), 35% of all pregnancies). 35 women (28% of KO or 19.5% of all pregnancies) underwent elective terminations, 3 following identification of fetal defects. The remainder either had no defects or were of unknown status. There were 12 pregnancies with fetal abnormalities (9.6% KO), resulting in 8 live and 1 still birth. 18 pregnancies (14.4% KO) ended in spontaneous abortion. Although within expected limits for the general population (spontaneous abortion rates of 10–15%) these data may be skewed by absent data from 55 cases. In 51 patients whose pregnancies were reported after a known outcome (as opposed to reporting at the time of confirmation of pregnancy) 11 (22%) resulted in spontaneous abortion- a higher rate than expected in the general population which may suggest an abortifacient effect. Abnormalities included one infant with premature closure of the skull sutures (craniosynostosis), one with hypoplastic lungs, exomphalos, left duplex kidney, right absent kidney, hemivertebrae and a right shoulder anomaly, another child with exomphalos, right renal agenesis and hemivertebrae and a fourth with a small exomphalos and scoliosis. These 4 cases are pertinent as in animal models imatinib causes similar bony defects including exencephaly, encephaloceles and deformities of the skull bones. Other severe defects included a child with communicative hydrocephalus, cerebellar hypoplasia, atrial septal defect, over-riding aorta, ascites and pericardial effusion - this infant was born live but later died. A baby with a meningocoele was still born. The remaining cases include cleft palate and polydactyly, 2 cases of hypospadias, 1 case of pyloric stenosis, 1 abnormal ultrasound with raised AFP and 1 case of warfarin embryopathy. Despite this information, balancing the risk to the foetus of continuing imatinib vs. the risk to the mother of stopping it remains difficult. In a recent report of 10 women who interrupted treatment with imatinib due to pregnancy, 6 had an increase in Ph positive metaphases. At a median of 18 months since restarting imatinib only 3/10 have achieved a complete cytogenetic response. Given the above findings the current recommendation to avoid imatinib during pregnancy remains unchanged. In cases of accidental or desired pregnancy, risk/benefit evaluations must be carried out on an individual basis with careful counselling of both parents. As experience with imatinib continues to grow, further information will become available which should clarify the situation. To facilitate this a global pregnancy registry will be established in the near future.