Critical uterine bleeding after miscarriage in a warfarin-anticoagulated patient with mechanical heart valve: a case report

BACKGROUND: Patients with mechanical heart valves require lifelong oral anticoagulation with vitamin K antagonists such as warfarin to prevent valve-associated thromboembolism. Bleeding complications during this therapy pose significant clinical challenges and necessitate expert management. In particular, heavy uterine bleeding following miscarriage represents a high-risk and emergent situation. The management of uterine bleeding is challenging, due to the need to balance anticoagulation with hemostatic control. This report presents a case of severe and prolonged bleeding caused by retained product of conception in a patient with mechanical heart valves receiving vitamin K antagonist therapy. CASE PRESENTATION: We describe the case of a 28-year-old African woman with mechanical double heart valve prosthesis maintained on warfarin therapy who initially underwent vacuum curettage for a missed abortion. Two weeks later, she presented with heavy vaginal bleeding. Despite initial expectant management, recurrent bleeding episodes necessitated multiple interventions including repeat curettage, off-label intrauterine tamponade, blood transfusions, and bridging with unfractionated heparin. Persistent hemorrhage led to attempted endometrial ablation, followed by successful uterine artery embolization, which effectively controlled hemorrhage and preserved the uterus. The patient was closely monitored from both a cardiologic and hemostatic perspective, and anticoagulation therapy was resumed with stable prosthetic valve function observed at discharge. CONCLUSIONS: The management of miscarriage-associated bleeding in patients receiving warfarin anticoagulation for mechanical heart valves is complex and necessitates interdisciplinary collaboration. A stepwise multimodal approach incorporating gynecological, hematological, radiological, and cardiological expertise can achieve hemorrhage control while maintaining an appropriate balance between thrombotic and bleeding risks. Organ-preserving interventions such as uterine artery embolization may offer viable alternatives to hysterectomy in selected cases.