Anticoagulant therapy in a pregnant patient with prosthetic mitral valve-emergency for caesarian section and postoperative bleeding

Pregnant patients with prosthetic valve need anticoagulation therapy during pregnancy to prevent stuck valve. Regarding the thrombosed valve, there is a dilemma between anticoagulation to prevent further thrombus formation and postoperative bleeding after caesarian section until valve replacement surgery. A 35-year-old woman in her 34th weeks of pregnancy with a thrombus on prosthetic mitral valve was scheduled for emergency caesarian section under general anesthesia. Anticoagulation therapy with heparin was started after admission to the intensive care unit targeting the range between 70-100 second of activated partial thromboplastin time to prevent further thrombus formation. Heparin was administered intravenously (25,000 units per day), but APTT was kept over 110 seconds. Abdominal wall hematoma was detected by percutaneous echo next day and surgery for removal of hematoma was performed. Mitral valve replacement surgery was performed on the postoperative third days successfully. Postoperative anticoagulation therapy with heparin should be started carefully in consideration of physiological change of clotting ability after the termination of pregnancy.