Because warfarin, LMWH, and UFH do not accumulate in breast milk, they do not induce an anticoagulant efect in the newborn. hese anticoagulants are compatible with breastfeeding (American College of Obstetricians and Gynecologists, 2017).
Although usually postponed until after delivery, valve replacement or other cardiac surgery during pregnancy may be lifesaving. Several reviews conirm that such surgery is associated with major maternal and fetal morbidity and mortality. At the Mayo Clinic between 1976 and 2009,r21 pregnant women underwent cardiothoracic surgery requiring cardiopulmonary bypass Oohn, 2011). The procedures included valve replacements, myxoma excisions, aneurysm repairs, patent foramen ovale closure, prosthetic aortic valve thrombectomy, and septal myectomy. Median cardiopulmonary bypass time was 53 minutes, with a range of 16 to 185 minutes. One woman died 2 days ater surgery, three fetuses died, and 52 percent were delivered before 36 weeks' gestation. Elassy and associates (2014) described 23 women who underwent urgent open cardiac surgery for severe valve malfunction. Two women and 10 fetuses-all at a gestational age below 28 weeks-died before hospital discharge. Only six fetuses were delivered at term. To optimize outcomes, Chandrasekhar and coworkers (2009) recommend that surgery be elective when possible, pump low rate should remain >2.5 Llmin/m2, normothermic perfusion pressure should exceed 70 mm Hg, and hematocrit should be keptr> 28 volumes percent.
Many successful pregnancies have followed cardiac transplantation (Abdalla, 2014; Vos, 2014). The current recommendations from The International Society of Heart and Lung Transplantation do not discourage pregnancy in stable heart transplant recipients who are more than 1 year posttransplant (Costanzo, 2010). Obviously, a highly specialized level of care with a mul tidisciplinary team is necessary.
he transplanted heart appears to responds normally to preg nancy-induced alterations (Key, 1989; Kim, 1996). Despite this, complications are common during pregnancy (Dashe, 1998). Of 53 pregnancies in 37 heart recipients, almost half developed hypertension, and 22 percent sufered at least one rejection episode during pregnancy (Armenti, 2002; Miniero, 2004). They were delivered-usually by cesarean-at a mean of 37 to 38 weeks' gestation. hree fourths of neonates were liveborn. At follow-up, at least ive women had died more than 2 years postpartum. Another analysis of 25 such women with 42 pregnancies found no maternal deaths. Major complica tions included two rejections during the early puerperium, two cases of renal failure, and 11 spontaneous abortions (Estensen, 2011). Five women died 2 to 12 years after delivery. And from the United Kingdom, Mohamed-Ahmed and colleagues (2014) identiied 14 women with transplants between 2007 and 2011r.
Graft rejections occurred in two women, one of whom died.
Rheumatic fever is uncommon in the United States because of less crowded living conditions, penicillin availability, and evolution of nonrheumatogenic streptococcal strains. Still, it remains the chief cause of serious mitral valvular disease in women of childbearing age in the nonindustrialized world (Nanna, 2014; Roeder, 2011) .