386. Care of pregnant women with prosthetic heart valves: Still a formidable challenge in low to middle income countries?

Introduction Patients with mechanical heart valves require lifelong anticoagulation and pregnancy being a pro-thrombotic state poses additional risk of thromboembolic complications. In pregnancy, anticoagulation regimes using Coumadin derivatives or various heparins offers advantage over each other remains inconclusive. Especially in low to middle income countries cost of medication/monitoring and compliance remains a major challenge. We report a single center experience of managing pregnancy in women with prosthetic heart valve from South India. Methods We collected demographic, medical and obstetric details of pregnant women with prosthetic heart valve admitted to a regional tertiary center catering to rural population of South-eastern India from Jan 2011 to March 2018. Outcomes assessed were maternal complications such as maternal mortality, prosthetic valve thrombosis, and perinatal complications such as miscarriages or rates of congenital malformation. Data was expressed as mean with standard deviation or frequency with percentages as appropriate. Results We collected data of 73 pregnancies in 59 women with prosthetic heart valve during the time period. Majority of the women (84%) had valve replacement in mitral position and were replaced with ttk Chitra (titling disc) valve (80%). Five women developed thrombotic complication; three while on unfractionated heparin and two on warfarin therapy. Among three women with prosthetic valve thrombosis, two underwent thrombolysis while one succumbed to the disease. Two third of women were on warfarin therapy in first trimester. One fetus was diagnosed with warfarin-embryopathy and 4 had miscarriages. Cesarean section rates were 16.4%. Hemorrhagic complications occurred in six women in the postpartum period; four of them were on heparin. Conclusion Pregnancy in women with prosthetic mechanical heart valves can lead to life-threatening complications. Anticoagulation regimes should take into consideration fetal risk concerns, cost or treatment/ monitoring which will ensure a better compliance especially in low to middle income countries.