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Anesthetic management of a parturient with a mitral mechanical valve

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Mechanical prosthetic heart valve (MPHV) is associated with complications such as thromboembolism and bleeding.1Physiologic changes of pregnancy, therapeutic anticoagulation, and the presence of a MPHV places the parturient at risk for maternal cardiovascular events such as an embolic event, hemorrhage, miscarriage, preterm birth, and fetal complications.2,3
A 39 year-old G3P1 at 37 weeks with a past medical history of mitral valve replacement with a St. Jude valve due to a congenital cleft of the mitral valve, nonsustainedventricular tachycardia (NSVT), and gestational diabetes presented for induction of labor for an anticipated vaginal delivery. Medications prior to admission consisted of a beta blocker, and enoxaparin 80 mg subcutaneously. The plan for labor analgesia included placing an epidural 24 hours   post lovenoxand 2 hours post cessation of heparin drip. Upon admission, enoxaparin was discontinued, and a heparin infusion was initiated.  In regard to her NSVT, cardiac monitoring along with the placement of a code cart outside the labor room was established in the event of cardiac decompensation.Enoxaparin was discontinued 24 h prior, and a normal coagulation profile was obtained 2 h after discontinuation of heparin, an early epidural placement was deemed safe. An atraumatic early labor epidural was placed at the L3-4 level. The heparin drip was restarted one hour after placement of the epidural; adjustments were made to keep the PTT within protocol range. Heparin was stopped when the patient was in active labor. Epidural catheter was removed given normal PTT. The postpartum course consisted of close neurologic and cardiac monitoring, and anticoagulation was progressively transitioned from enoxaparin to a warfarin regimen. The patient was discharged stable on post partum day 3.
When caring for a parturient with an MPHV it is imperative to monitor the patient coagulation profiles to prevent maternal and fetal morbidity and mortality. A multidisciplinary approach is crucial for improving patient and fetal outcomes.In this case an early labor epidural was considered important given her history of NSVT. Anticoagulation places the patient at high risk for spinal epidural hematoma and hemorrhage. Adherence to ASRA guidelines for neuraxial blocks is imperative.
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