Coumadin and pregnancy

[della_anne]

Hey Sherry!
How's it going? Nice to hear from you again. Very sorry to hear about your miscarriage...was it directly due to the effects of Coumadin? It sounds as if proper precautions were taken.
Yes, that is what my cardio has told me in the past...that if I had kids it would be a high risk pregnancy and that I would need to see a high risk obgyn. But that was such a long time ago that I discussed it with my cardio (like within the first year of my new valve replacement, 10 years ago.) I think its time for me to discuss it with my cardio again. And you never know things have changed since 10 years ago...more is possible now. And yes, Sherry, don't worry, I am just doing my homework.
Take care,

Danielle

 

[Guest]

The biggest changes in the past ten years have been:

We now know that weeks 6 to 12 are the worst for the effects on the fetus. Many women successfully take warfarin from week 13 to about week 30. This avoids the bad effects on the bones that long-term heparin has.

The effect on the fetus is probably dose related. Women who are successfully anticoagulated with 4 mg or less of warfarin daily are less likely to have children with birth defects. For a picture of a child with the typical malformed face from warfarin exposure look at http://www.teratology.org/jfs/Warfarin1.jpg

Fixed-dose Lovenox in pregnant women with mechanical heart valves is not a good idea. Whether or not weight-adjusted Lovenox works well in pregnant women with mechanical heart valves is unknown.

 

[della_anne]

allodwick,

I don't think you mentioned week 1 to 6. Is being on Coumadin during these weeks of pregnancy rather safe? Hmmm, Lovanox not safe? My cardio said Lovanox is ok to use during pregnancy...Where did you hear that it is not safe? And why is it not safe?

I am confused now...what my doc has told me and what is posted on here is contradicting...who is right?


Danielle

 

[Guest]

Weeks 1 to 6 do not seem to pose much risk. Perhaps because the face is not being differentiated at that time.

This is an exact copy of the patient package insert for Lovenox
Pregnant Women with Mechanical Prosthetic Heart Valves: The use of Lovenox Injection for thromboprophylaxis in pregnant women with mechanical prosthetic heart valves has not been adequately studied. In a clinical study of pregnant women with mechanical prosthetic heart valves given enoxaparin (1 mg/kg bid) to reduce the risk of thromboembolism, 2 of 8 women developed clots resulting in blockage of the valve and leading to maternal and fetal death. Although a causal relationship has not been established these deaths may have been due to therapeutic failure or inadequate anticoagulation. No patients in the heparin/warfarin group (0 of 4 women) died. There also have been isolated postmarketing reports of valve thrombosis in pregnant women with mechanical prosthetic heart valves while receiving enoxaparin for thromboprophylaxis. Women with mechanical prosthetic heart valves may be at higher risk for thromboembolism during pregnancy, and, when pregnant, have a higher rate of fetal loss from stillbirth, spontaneous abortion and premature delivery. Therefore, frequent monitoring of peak and trough anti-Factor Xa levels, and adjusting of dosage may be needed.

Your cardiologist told you that you would need to work with a high-risk OB doctor. The cardiologist was right about that. The OB would have managed it correctly.

There was an absolute prohibition in the official package insert against using Lovenox in pregnant women for a couple of years. Many of us did not think that was a valid conclusion from the study where the two women died and worked to get the FDA to change this. Eventually they did lift the total prohibition. Your cardiologist probably heard that much but did not realize that there was still a very strong caution.

 

[LUVMyBirman]

I posted the FDA Lovenox article upon discovery. Beleive me....we wanted a second child. Looked high and low, did my homework and decided since we already have one....the risks were too high. If we had not had a child...my views may be very different on the issue.

Al, I am very curious. What is the difference between the Heparin Injections vrs. Lovenox? Have you seen the Heparin injections replacing the Lovenox? Have been very concerned since the FDA made the annoucement on the Lovenox. Especially since I have not been able to find a reverse in lifting the recall. In defense of Lovenox...I used it very frequently post surgery for bridging. It ether did it's magic....or I was just plain lucky.

Looking forward to meeting you in a few short weeks Al!

 

[Guest]

Lovenox is made from heparin. The cut off the part of the molecule that is responsible for most of the problems such as erratic levels that cause heparin to need to be monitored by a blood test every 6 hours until the level stabilizes. Heparin doses are as hard or harder to predict than warfarin doses. This chopping-off of the molecule also makes it less likely to cause osteoporosis in people who must use it long term. There is also less chance of the potentially-fatal allergic reaction called heparin-induced thrombocytopenia (HIT) This is a so-called white clot that causes all of the platelets to clump up together to form gigantic clots. Heparin is not replacing Lovenox, just the opposite Lovenox is growing by leaps and bounds. Heparin has been around for many years and is generic and dirt cheap. Therefore, nobody will ever finance a study of its use for pregnant women because there is no payoff. It is so old that many doctors assume that it has been proven safe but in reality it was around before they knew how to do the studies so there is very little evidence to support its use other than, "we have always used it".

Even as long as it has been around, it was only in the last 10 years or so that HIT was really recognized for what it is -a reaction to heparin

 

[Sherry]

Hey, Danielle, check your PMs. I'm sending you a note discussing the details. Take care.

 

[Guest]

A new review article was just published today. This is the abstract. If you are interested, copy this and take it to a librarian and get a copy.

J Cardiovasc Pharmacol Ther. 2004 Jun;9(2):107-15. Related Articles, Links


Anticoagulation in pregnant women with prosthetic heart valves.

Elkayam U, Singh H, Irani A, Akhter MW.

Division of Cardiovascular Medicine, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California 90033, USA. [email protected]

BACKGROUND: Pregnancy is associated with an increased risk of thrombosis in women with mechanical prosthetic heart valves. Effective anticoagulation is therefore critical in such patients but remains problematic, since oral anticoagulation and both unfractionated and low-molecular-weight heparin may be associated with important fetal and maternal side effects. PURPOSE: To review information related to the use of anticoagulation with both warfarin and heparin and reassess the safety and efficacy of these therapies in pregnant women with mechanical prosthetic heart valves. DATA SOURCE AND SELECTION: A MEDLINE search from 1966 to October 2003 for English and non-English language articles that reported the use of anticoagulation in pregnancy was conducted. Articles were included if they reported use of anticoagulation in pregnancy with emphasis on those that included women with mechanical prosthetic heart valves. CONCLUSIONS: Anticoagulation prophylaxis with both warfarin and heparin (unfractionated heparin and low-molecular-weight heparin) may be associated with important fetal and maternal side effects. Optional regimens for the treatment of low-risk and high-risk patients are proposed to minimize potential complications.

 

[Granbonny]

Daughter adopting from Russia

Daughter adopting from Russia

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[della_anne]

Cardiologist answered my question

Cardiologist answered my question

I just had my semi-annual heart check up and everything is same as usual, which is good, no suprises. I did ask her for more detailed info on high-risk pregnancies...she made it sound like pregnancy for heart patients is very possible and that it is a very routinely done. As far as the Coumadin, she said that if and when I have kids, I would need to be on heprin or lovanox for the first 6 weeks and then go back on Coumadin from the time of the end of the 6 weeks to just before delivery. Then just before delievery, I would need to be on Heprin or Lovanox again. So, there you go...its not that complicated after all!


Danielle

 

[Guest]

The time you stated to be off the warfarin is incorrect. You have to be off of it from weeks 6 to 12. This is the time when the face is forming and when warfarin causes the most damage. Being off warfarin for the last 6 weeks is correct. You need to be able to clot after the baby is born.

It can be done, but before deciding to get pregnant you should already have set up a plan with an OB who specializes in high risk pregnancy.

I have been advising people on this for the past 7 years. I have seen about 25,000 patient visits during that time. For any doctor to have this much experience, they would have to see 1 warfarin patient daily for 50 weeks per year for 100 years.

It is very important that you get everything done in the correct order. I'm not trying to discourage you, just trying to keep you from making an uncorrectable mistake.

 

[Shelba]

Della Anne,

What made my valve choice so difficult for me was the pregnancy issue. Would I be able to have bio children w/ a mechanical valve or not? That was my biggest concern. I searched high and low for people who have first-hand knowledge of mechanical valve pregnancies. I found one woman who has had two mechanical valve pregnancies. One using heparin, and the other using lovenox. She is considering a third pregnancy.

She pointed me to a doctor in the mid-west, who helped manage her pregnancy long-distance. I called this doctor's nurse and he called me right back to discuss the work he has done. He then had one of his partners, a hematologist, who runs a coumadin clinic for women, and this doctor called me to discuss what would be involved with a mechanical valve pregancy. They use lovenox. They were wonderful to take so much time out of their busy schedules to discuss and explain the lovenox/pregnancy study, and explained in detail what a pregnancy would be like for someone like us.

They offered to co-manage (long distance) my pregnancy, should I ever have one. If you're interested, I will e-mail their info to you.

Michele

 

[Guest]

Thanks for sharing this. This is exactly what we need. More doctors who have the knowledge and are willing to share it.