Enoxaparin sodium/low molecular weight heparins/warfarin
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Cardiovascular disorders and fetal death: 9 case reports A clinical study identified nine pregnant women [ages not stated] with mechanical heart valves who developed cardiovascular complications and/or fetal loss while receiving anticoagulation with warfarin and/or low molecular weight heparins (LMWH) [routes not stated; some dosages, durations of treatment to reaction onsets and outcomes not stated]. One woman later died. Patients 1-4 were receiving treatment with aspirin and a LMWH, initially administered at 1 mg/kg twice daily. Enoxaparin sodium was the specified LMWH in patients 1 and 2. Patient 1 started treatment at 5 weeks’ gestation during her fourth pregnancy; she had miscarried her first three pregnancies while receiving warfarin. She presented at 7 weeks’ gestation with a fatal parietal intracerebral haemorrhage, and subsequently miscarried. In patient 2, the enoxaparin sodium dosage was increased from 60mg (1 mg/kg) to 90mg twice daily. At 35 weeks’ gestation, she presented with premature labour with pulmonary oedema secondary to mitral valve thrombosis. An emergent mitral valve replacement was performed following vaginal delivery. Patient 3 delivered at 34 weeks’ gestation due to increasing tricuspid velocities and a new diastolic murmur. A postpartum fluoroscopy disclosed immobile valve leaflets, and she underwent repeat tricuspid valve replacement. The valve was found to have marked pannus ingrowth and an adherent thrombosis. Patient 4 underwent a normal vaginal delivery following induction at 38 weeks’ gestation, but developed a secondary haemorrhage 6 days later. Patient 5 developed primary haemorrhage during each of her three pregnancies while receiving warfarin 5mg. She delivered one fetus vaginally, but miscarried the other two in their first trimesters. Patients 6-9 were receiving combination therapy with a LMWH at an initial dosage of 1 mg/kg twice daily and aspirin, subsequently switched to warfarin for the majority of gestation until 36 weeks; at this point, the LMWH would be resumed. Patient 6 developed a transient ischaemic attack at 9 weeks’ gestation while on LMWH and miscarried 2 weeks after starting warfarin. Patient 7 was induced at 35 weeks’ gestation due to left ventricular function deterioration and a drop in peak velocity across her prosthesis. Her cardiac function improved with supportive care following delivery. Patient 8 developed secondary haemorrhage following a miscarriage at 17 weeks’ gestation while receiving warfarin 10mg. Patient 9 experienced fetal loss at 18 weeks’ gestation while receiving warfarin 13mg. Author comment: "[W]omen with mechanical valves have been advised that the best anticoagulant in terms of preventing maternal complications is warfarin, but at the cost of increased fetal loss. Although LMWH is safe for the fetus, there have been significant concerns regarding maternal safety. . ." Basude S, et al. Low-molecular-weight heparin or warfarin for anticoagulation in pregnant women with mechanical heart valves: What are the risks? A retrospective obse
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