Barnard, Pieter M

Heydenrych, J.J.

English

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15 November 1969 S.A. MEDICAL JOURNAL 1397kept 'on the go' by being topped up, whether the appara-tus was cleansed daily, weekly or hardly ever. and how itwas cleaned. Mixing utensils were examined.Medication given to the infant was inve tigated, parti-cularly that administered within the previous 2 week . asto whether it was obtained from a clinic, medical prac-titioner, shop, herbalist or witchdoctor, and the type ofmedicine, whether laxatives or enemas were given andhow often, on what occasion and of what type. Dummieswere tudied. Information was obtained as to whethermother, grandmother or children looked after the infant,their state of intelligence and cleanliness and their commit-ment to other duties, bearing in mind such unusual cir-cumstances in the Bantu areas as the reversion of aninfant to an often disinterested maternal grandmother be-cause the husband had failed to pay lobola, which tradi-tionally gives him the right to the womb and its issue.Field investigators were requested to record any addi-tional pertinent factors encountered.Control group. Randomly-selected well babies wereused for control purposes. In the Bantu areas the fir t 10clinically normal babies, or a les er number to parallelthe sample group, who presented at the child healthpromotive and preventive clinics of the 5 poly-clinicconducting the field study were selected on each day onwhich sample cases were drawn. The e control case weresubmitted to exactly the ame clinical. domiciliary andlaboratory investigations as the sample cases.(To be continued)MITRAL VALVE PROSTHESIS AND PREG ANCY WITHOUTANTICOAGULATION THERAPY*PIETER M. BARNARD, M.B., CH.B., EA.C.S., M.D. A D J. J. HEYDENRYCH, M.B., CH.B., M.Se., M.MED. (CHIR.). De-partment of Cardiothoracic Surgery, Kart Bremer Hospital and the University of Stellenbosch, AND B. G. LOM-BAARD, M.B., CH.B., B.Sc., General Practitioner, Barkl}" East. CPPatients with mitral valve prostheses are usually advisedagainst becoming pregnant. These patients are usuallymaintained on long-term anticoagulation therapy which,hould pregnancy occur, may pose difficult problems forthe patient, the foetus and the physician.VillaSanta' and Beller' outlined the dangers to the preg-nant patient who is maintained on anticoagulant therapy.Bennett and Oakley' reported the death after caesareanection of the mother in whom a Hammersmith-Alvarezmitral prosthesis had been inserted before pregnancy, andadvised sterilization in such instances.We report here a successful pregnancy with delivery ofa normal child in a primigravida, with a University oftelJenbosch mitral valve prosthesis, in whom anticoagu-lation therapy was not used.We believe that in selected cases where the pregnancyis highly desirable these patients should be granted theopportunity to continue with the pregnancy in the light ofthe improved results now being obtained with the newerdesign of prosthetic heart valve.CASE REPORTThe patient was a 17-year-old Bantu woman who had hadrheumatic fever at tbe age of 14 years. At the age of 16years he developed severe heart failure and pulmonaryoedema due to mitral incompetence that was confirmed bycardiac catheterization studies. These studies also showedthe presence of minimal aortic incompetence.She initially responded well to medical therapy but12 month!; later deteriorated and was thought to haveubacute bacterial endocarditis. Although repeated bloodcultures were negative, the sedimentation rate remainedelevated. and he was treated for bacterial endocarditi .Conge tive heart failure persisted and her mitral valve'Date received: 9 September 1969.was replaced with a 20-mm. University of Stellenboschmitral valve prosthesis (Fig. I). at Karl Bremer Ho pitalon 6 December 1967.She made a remarkable recovery and was discharged 4weeks after the operation. Anticoagulation with warfarinsodium had been started on the third po toperative day.and it was decided to continue the oral anticoagulationfor a period of 3 months. Her medications at the time ofdischarge included digitoxin. 0·1 mg. b.d., and warfarinsodium, 2·5 mg. daily.However, she discontinued all medications of her ownaccord one month after discharge and failed to report toher local physician at Barkly East. She was married with-in a year after her operation and fir t consulted herphysician at 24 weeks' gestation. The pregnancy wanormal in all respects, without any signs of cardiac failure,and it was decided not to use anticoagulation therapy atthat stage. Urinalysis revealed the presence of a urinarytract infection which responded well to antibiotic therapy.The progress of the pregnancy was uncomplicated, andshe was hospitalized at the Cloete-Joubert Hospital inBarkly East on 25 May 1969. On 26 May she was de-livered of a normal 7-lb. baby at term without any com-plications. She breast fed the child. and they were dis-charged on the fifth day after delivery. Mother and childcontinue to do well more than 3 months after delivery.DISCUSSIOThis i the eventh report of pregnancy in a patient whohad undergone prosthetic mitral valve replacement beforepregnancy. Although the first report by Johnson et al"was encouraging, DiSaia' and Kerber et al" reported con-genital malformation of the infants in the form of saddle-nose deformity. bilateral optic atrophy and mental retar-dation that was attributed to the u e of warfarin odiumduring pregnancy. Bennett and Oakley' reported multiple139 S.A. TYD KRIF VIR GENEE KU'DE 15 ovember 1969niversity of Stellenbosch cloth-covered. discpro thesis.systemic emboli and the death of the mother In thepostpartum period due to thrombus formation on theprosthe i .These reports gave cause for concern and re ulted ina policy of advising patients with pro thetic mitral valvesto avoid pregnancy or to undergo sterilization'More recently Bloomfield and Rubinstein' reported aucce ful pregnanc and delivery of a normal infant ina patient with a Starr-Edwards mitral valve prosthesis.The patient took warfarin sodium for 36 weeks and wasgiven heparin parenterally for 18 days before delivery.They believe successful pregnancy and delivery in patientswith mitral valve prostheses is possible when carefulcontrol of anticoagulation is maintained.Finnerty and MacKay and Aaro et al.' also reportedthat, when properly used. oral anticoagulation therapy wasboth safe aMd effective during pregnancy.The use of anticoagulation during pregnancy cannevertheless be potentially hazardous, as oral anticoagu-lants cross the placental barrier with depression of theprothrombin content of the foetal blood.]· Besides mal-formation of the foetus, fatal haemorrhage of tbe bypo-thrombinaemic foetus or newborn occurred when thelimits of the therapeutic range were exceeded or when theoral anticoagulant was not discontinued long enoughbefore labour.7,BVilJaSanta' reviewed 92 cases of pregnant patients re-ported in the literature, who were treated with oral anti-coagulants alone or in conjunction with heparin. In thesepatients, there were 14 stiJJborn infants and 3 neonataldeaths, representing a perinatal mortality of 18'4% or al-most 1 in 5 cases. Furthermore, there were 2 other infantswith congenital anomalies related to defect of coagulation,who lived, but with residua.Ideally, pregnant patients with prosthetic valves shouldnot receive anticoagulant therapy. This, however, shouldbe weighed against the potential danger of systemic embo-lism or thrombotic obstruction of the prosthetic valve.The use of the newer types of prosthetic mitral valves,with cloth covering and subsequent tissue ingrowth intothe prosthesis,"-H has markedly lowered the incidence ofthrombo-embolism. Following our previously reported ex-perimental studies in subhuman primates and initial clini-cal experience," we now use warfarin sodium only duringthe first 3 - 6 postoperative months. We have detected nolate systemic emboli or cases of thrombosis with the Uni-versity of Stellenbosch mitral valve prosthesis for periodsof 3 months to 2 years after valve insertion where anti-coagulant therapy has been discontinued. We thereforefeel justified to continue thi policy also during preg-nancy, so as to avoid the potential hazards of oral orparenteral anticoagulation therapy.SUMMARYAn uncomplicated pregnancy is reported in a l7-year-oldfemale with a University of Stellenbosch mitral valve pros-thesis following rheumatic heart disease and subacute bacterialendocarditis. The patient received no anticoagulant therapyduring pregnancy and delivered a normal, healthy 7-lb. baby.Successful pregnancy and delivery in patients with a Universityof Stellenbo ch mitral valve prosthesis is possible without theuse of anticoagulation. This is believed to be the first reportedcase of a normal pregnancy and delivery of a normal infantfollowing mitral valve replacement and discontinuation ofanticoagulation therapy.REFERE 'CESI. VillaSanla, U. (1965): Amer. J. Obslet. Gynec .• 93. 142.2. Beller. F. K. (196): Clin. Obslet. Gynec., It. 290.3. Bennett. G. G. and Oakley. C. M. (196): Lancel. I. 616.4. Johnson, A. S.. Meyers, M. P., Eckhouse. A. S., Bacher. B. andLimia. A. (1966): Mich. Med., 65. 71 .5. DiSaia, P, J. (1966): Obstet. and Gynec., 28. 469.6. Kerber. I. J., Warr, O. S. and Richardson, C. (1968): J. Amer. Med.Assoc .. 203, 223.7. Bloomfield. D. K. and Rubinstein. L. I. (1969): Lancel. 2. 290.Finnerty. J. 1. and MacKay, B. R. (1962): Obstet. and Gyncc.,19. 405. .9. Aaro. L. A., Johnson. T. R. and Juergens, J. L. (1967): Am.r. J.Obslet. Gynec .. 97, 5t4.10. Quick, A. J. (1946): J. BioI. Chem., 164, 371.11. Gardon, R. R. and Dean, T. (1955): Brit. Med. J .. 2, 719.12. Davila. J. C .. Amongero, F.. Sethi. R. S.. Rincon. ,L.. Pall1XT.T. E. and Lauls<:h, E. V. (1966): Ann. Thomc. Surg., 2, 714.13. Braunwald. . S. and Bonchek, L. I. (1967): J. Thorac. Cardiovasc.Surg., 54. 630.14. Barnard. P. M. and Heydenrych. J. J. (1969): Thorax, 24, 18.

Mitral valve prosthesis and pregnancy without anticoagulation therapy

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Mitral valve prosthesis and pregnancy without anticoagulation therapy

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