A prosthetic valve patient switch to heparin at which time of pregnancy
Anticoagulantion in Prosthetic valve complicating Pregnancy Critical for women with mechanical prosthetic valves Unfounately, warfarin is the most effective anticoagulant for preventing maternal thromboembolic complications but causes significant fetal morbidity and moality Maternal thromboembolic complications are much higher with heparin Any one of the following anticoagulant regimens is recommended: Adjusted-dose LMWH twice daily throughout pregnancy. The doses should be adjusted to achieve the manufacturer's peak anti-Xa level 4 hours after subcutaneous injection Adjusted-dose UFH administered every 12 hours throughout pregnancy. The doses should be adjusted to keep the midinterval aPTT at least twice control or attain an anti-Xa level of 0.35 to 0.70 U/mL LMWH or UFH as above until 13 weeks' gestation, then warfarin substitution until close to delivery when LMWH or UFH is resumed In women at very high risk of thromboembolism and in whom concerns exist about the efficacy and safety of LMWH or UFH as dosed above warfarin treatment is suggested throughout pregnancy with replacement by UFH or LMWH (as above) close to delivery. In addition, low-dose aspirin--75 to 100 mg daily--should be orally administered If delivery supervenes while the anticoagulant is still effective, and extensive bleeding is encountered, then protamine sulfate is given intravenously Anticoagulant therapy with warfarin and heparin may be restaed 6 hours following vaginal delivery and heparin stopped once INR is adjusted between 2 and 3 The American College of Obstetricians and Gynecologists (2011b) advises resuming unfractionated or low-molecular-weight heparin 6 to 12 hours after cesarean delivery Because warfarin, low-molecular-weight heparin, and unfractionated heparin do not accumulate in breast milk, they do not induce an anticoagulant effect in the infant safe in breast feeding. OR Anticoagulants indicated in cases with CHD Pulmonary HTN Mechanical Hea valve Atrial Fibrillation The patient taking Warfarin should discontinue it as soon as pregnancy is diagnosed and to replace it by Heparin5000 units twice daily SC upto 12weeks LMWH can also be used This is then replace with Warfarin tablet 3mg daily to be taken at the same time each day and continues upto 36wks. Thereafter it replaced with heparin upto 7days postpaum. Heparin should be staed 6-12 hrs postpaum. Wafarin is then to be contnued after 7days. UFH,LMWH and HEPARIN therapy do not contraindicate Breastfeeding. Reference: DC.Duttas textbook of OBG, 9th edition,page 259 Reference: Willam's Obstetrics; 24th edition; Chapter 49
28 weeks
32 weeks
36 weeks
Postpaum
Medical, surgical and gynaecological illness complicating pregnancy