[Pregnancy in patients with rheumatic cardiopathy]

Pregnancy can cause life-threatening complications in women with rheumatic heart disease. Mitral stenosis is the most common valvular lesion found in the gravida. Percutaneous mitral balloon commissurotomy has emerged as a safe and effective procedure in symptomatic pregnant patients. Immediate clinical and hemodynamic improvement was observed in 8 pregnant women treated by the Inoue technique at the Institute. The procedure was well tolerated by the fetus. Thirteen gravid patients with rheumatic valvular disease have undergone open heart surgery at the Institute. Maternal mortality was 15.4% and was related to the critical preoperative condition. Because of the high fetal mortality (38.5%) these procedures should be indicated only in extreme emergencies. The management of women with prosthetic heart valves during pregnancy poses a particular challenge. At the Institute 393 pregnancies have been studied in 304 women with these valves. Patients with mechanical prostheses require anticoagulant therapy to prevent thromboembolic phenomena. Coumarin agents provide adequate protection against these complications but their use was associated in our series with an increased abortion rate (26.7%) and with an incidence of coumarin embryopathy of 4.1%. Different regimens of subcutaneous heparin have not been effective to prevent prosthetic thrombosis (5.2% in our cases). Controversy exists regarding the appropriate treatment of these patients. Patients with bioprostheses may not require anticoagulation. However the limited duration of these valves is a significant disadvantage in these women.