Managing a Pregnant Patient With a Mechanical Heart Valve and Subchorionic Hematomas

BACKGROUND: Balancing thrombotic and bleeding risks is a significant challenge when managing anticoagulation in pregnant patients with mechanical heart valves and severe left ventricular dysfunction. CASE REPORT: This report describes a G2P1 26-year-old woman with this complex history, including a mechanical aortic valve after an arterial switch operation for dextro-transposition of the great arteries and coexisting severe left ventricular dysfunction. At 22 weeks, she developed large subchorionic hematomas despite therapeutic anti-Xa levels on low-molecular-weight heparin. Her low-molecular-weight heparin dose was cautiously titrated to a lower therapeutic target. This approach successfully stabilized the hematomas and culminated in a planned cesarean section at 37 weeks. TAKE-HOME MESSAGES: For high-risk pregnant patients with mechanical valves, modifying anticoagulation targets is a viable strategy to manage bleeding complications without stopping therapy. Titrating anticoagulation to a lower, yet still therapeutic, anti-Xa target can successfully balance the risk of bleeding with the need to prevent catastrophic valve thrombosis.