Bian Ce, Qi Xiaorong, Li Li, Zhao Jitong, Liu Xinghui
Department of Obstetrics and Gynecology, Sichuan Provincial Key Laboratory of Gynecologic Oncology, Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Women's and Children's Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.
Arch Gynecol Obstet. 2016 Jan;293(1):69-74. doi: 10.1007/s00404-015-3768-0. Epub 2015 Jun 6.
To investigate the morbidity of complications and pregnancy outcomes in women with mechanical heart valve replacement who received low-dose oral anticoagulation treatment with warfarin throughout the pregnancy, compare the prognosis and complications of patients who were treated with single oral warfarin treatment or the "bridging" therapy treatment, investigate the influence of using vitamin K1 before emergency cesarean section delivery on postoperative warfarin anticoagulant effect and to explore an appropriate anticoagulant regimen during perioperative period for pregnant women with mechanical heart valve replacement.
46 pregnant women with mechanical heart valve replacement who received low-dose oral anticoagulation treatment from October 2008 to October 2014 treated at West China Women's and Children's Hospital were retrospectively reviewed. Eight patients received emergency cesarean section (CS), while 38 patients received selective CS, in which 17 patients received single oral warfarin and 21 patients received "bridging" anticoagulation treatment during postoperative period. Morbidity of complications and the time to achieve the target INR after operation were compared.
The mechanical valves were at the mitral position in 35 (76.09 %) patients, at the aortic position in 2 (4.35 %) patient and at both the mitral and aortic position in 9 (19.57 %) patients. 46 full-term healthy babies were delivered and no maternal thromboembolic was observed during pregnancy. There was no significant difference of the amount of uterine bleeding between single oral warfarin group and "bridging" treatment group during postpartum period. In single oral warfarin group, one valve thrombosis was observed and led to sudden death. No periphery thrombosis, hematoma, general hemorrhage or other sign of over-anticoagulation was observed. The INR increased more slowly in the group who received emergency CS with preoperative application of vitamin K1 than other two groups.
The use of vitamin K1 preoperatively might result in warfarin resistance and discontinuation of warfarin therapy before selective CS might be more appropriate than application of vitamin K1. The "bridging" anticoagulation treatment which combines oral warfarin and subcutaneous LMWH might be more effective and safer than single oral warfarin therapy for patients with mechanical heart valve replacement during postoperative period, no matter selective or emergency CS. The safety of low-dose oral warfarin therapy throughout pregnancy is still under controversy.
探讨孕期全程接受小剂量华法林口服抗凝治疗的机械心脏瓣膜置换术后妇女的并发症发生率及妊娠结局，比较接受单一华法林口服治疗或“桥接”治疗患者的预后及并发症情况，研究急诊剖宫产术前使用维生素K1对术后华法林抗凝效果的影响，并探索机械心脏瓣膜置换术后孕妇围手术期合适的抗凝方案。
回顾性分析2008年10月至2014年10月在华西妇女儿童医院接受小剂量口服抗凝治疗的46例机械心脏瓣膜置换术后孕妇。8例行急诊剖宫产，38例行择期剖宫产，其中17例术后接受单一华法林治疗，21例接受“桥接”抗凝治疗。比较并发症发生率及术后达到目标国际标准化比值（INR）的时间。
35例（76.09%）患者的机械瓣膜位于二尖瓣位置，2例（4.35%）位于主动脉位置，9例（19.57%）位于二尖瓣和主动脉位置。共分娩46例足月健康婴儿，孕期未观察到母体血栓栓塞。产后单一华法林治疗组与“桥接”治疗组的子宫出血量无显著差异。单一华法林治疗组观察到1例瓣膜血栓形成并导致猝死。未观察到外周血栓形成、血肿、全身出血或其他抗凝过度迹象。术前应用维生素K1的急诊剖宫产组INR升高比其他两组更慢。
术前使用维生素K1可能导致华法林抵抗，对于择期剖宫产，停用华法林治疗可能比应用维生素K1更合适。对于机械心脏瓣膜置换术后患者，无论择期还是急诊剖宫产，术后采用口服华法林与皮下注射低分子肝素联合的“桥接”抗凝治疗可能比单一华法林治疗更有效、更安全。孕期全程小剂量口服华法林治疗的安全性仍存在争议。
