p.31 抽出テキスト

...................................................... 6.5.3.3 Diagnosis and management of valve thrombosis Dyspnoea and/or an embolic event are reasons for immediate transthoracic echocardiography to search for valve thrombosis, usually followed by transoesophageal echocardiography. Additionally, fluoroscopy can be performed with limited foetal risk. Management of valve thrombosis is comparable with management in non-pregnant patients. This includes optimizing anticoagulation with i.v. UFH and the resumption of oral anticoagulation in non-critically ill patients with recent subtherapeutic anticoagulation, and surgery when anticoagulation fails and for critically ill patients with obstructive thrombosis.204 A molecular weight >1000 Da prevents most fibrinolytic items from easily crossing the placenta, though small amounts of streptokinase and fragments of urokinase may pass into the foetal circulation. Alteplase (a recombinant tissue plasminogen activator) has the highest molecular weight and does not cross the placenta. However, the risk of embolization (10%) and subplacental bleeding is a concern, and experience in pregnancy is limited. Fibrinolysis should be applied in critically ill patients when surgery is not immediately available, and it should be considered when the risk of surgery is high.204 Because foetal loss is high (30%) with surgery, fibrinolysis may be considered instead of surgery in non-critically ill patients when anticoagulation fails.231 Fibrinolysis is the therapy of choice in right-sided prosthetic valve thrombosis.204 The mother should be informed about the risks.

6.5.3.4 Delivery Planned delivery is necessary. Vaginal delivery requires a prior switch to i.v. heparin. The use of epidural anaesthesia requires a prolonged interruption of anticoagulant therapy, which may contraindicate its use in women with a mechanical prosthesis. A planned caesarean section may therefore be considered as an alternative, especially in patients with a high-risk of valve thrombosis, to keep the time without VKAs as short as possible. Caesarean section should be performed if labour onset occurs while the patient is still on VKAs.

6.6 Recommendations

Recommendations for the management of native valvular heart disease

Recommendations Classa Levelb

Pre-pregnancy evaluation, including echocardiography, and counselling is recommended for any woman with known or suspected valvular disease. I C

Mitral stenosis In patients with symptoms or pulmonary hypertension, restricted activities and beta-1-selective blockers are recommended.5,204 I B Diuretics are recommended when congestive symptoms persist despite beta-blockers.5 I B Intervention is recommended before pregnancy in patients with MS and valve area <1.0 cm2. I C

Therapeutic anticoagulation using heparins or VKA is recommended in case of atrial fibrillation, left atrial thrombosis, or prior embolism. I C Intervention should be considered before pregnancy in patients with MS and valve area <1.5 cm2. IIa C

Percutaneous mitral commissurotomy should be considered in pregnant patients with severe symptoms or systolic pulmonary artery pressure >50 mmHg despite medical therapy. IIa C

Aortic stenosis

Intervention is recommended before pregnancy in patients with severe aortic stenosis if:

 they are symptomatic I B  OR LV dysfunction (LVEF <50%) is present204 I C  OR when they develop symptoms during exercise testing. I C

Intervention should be considered before pregnancy in asymptomatic patients with severe AS when a fall in blood pressure below baseline during exercise testing occurs. IIa C

Balloon aortic valvuloplasty should be considered during pregnancy in patients with severe aortic stenosis and severe symptoms. IIa C

Chronic regurgitant lesions

Surgical treatment is recommended before pregnancy in patients with severe aortic or mitral regurgitation with symptoms of impaired ventricular function or ventricular dilatation.204 I C

Medical therapy is recommended in pregnant women with regurgitant lesions when symptoms occur. I C

LV = left ventricular; LVEF = left ventricular ejection fraction; MS = mitral stenosis; VKA = vitamin K antagonist. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026