Terapi Antikoagulan pada Kehamilan Trimester Pertama pada Pasien dengan Riwayat Penggantian Katup Mitral Mekanik
DOI:
https://doi.org/10.36408/mhjcm.v7i1.435Keywords:
kehamilan trimester pertama, bedah jantung penggantian katup mital mekanik, antikoagulan, warfarin, heparin, LMWHAbstract
Penggantian katup jantung mekanik memerlukan terapi antikoagulan seumur hidup. Sementara itu, risiko trombosis pada katup mekanik diketahui meningkat pada saat kehamilan. Risiko ini menurun dengan terapi antikoagulan pada dosis yang adekuat. Guideline merekomendasikan penggunaan antagonis vitamin K (VKA) seperti warfarin. Namun warfarin memiliki efek teratogenik sehingga kadangkala terapi antikoagulan dialihkan ke heparin karena preparat ini tidak menembus sawar plasenta. Namun penggunaan heparin diketahui kurang efektif dibandingkan warfarin sehingga memungkinkan meningkatnya risiko kejadian trombosis. Guideline menyebutkan dosis warfarin <5 mg/24 jam sebagai alternatif terapi pada trimester pertama. Kasus ini memaparkan pasien dalam kondisi hamil trimester pertama dengan riwayat penggantian katup mitral mekanik. Antikoagulan VKA dipilih untuk tetap diberikan pada kehamilan trimester pertama dengan dosis <5 mg/24 jam disertai pemeriksaan INR setiap dua minggu untuk mencapai target adekuat (2.5-3.5 menurut AHA 2014). Kondisi janin diketahui baik yang dipantau melalui pemeriksaan USG fetal yang dilakukan berkala.
Kesimpulan : Kehamilan paska MVR meningkatkan risiko trombosis dan secara mutlak memerlukan terapi antikoagulan dengan dosis adekuat. Terapi VKA pada berbagai kajian sistematik diketahui aman dilanjutkan pada kehamilan trimester pertama, jika diberikan dengan dosis <5 mg/24 jam.
Kata kunci : kehamilan trimester pertama, bedah jantung penggantian katup mital mekanik, antikoagulan, warfarin, heparin, LMWH
Heart valve replacement with a mechanical valve requires lifelong anticoagulation. The risk of valve thrombosis is markedly increased during pregnancy. The risk is lower with adequate dosing of anticoagulant therapy. Guidelines currently recommend using a vitamin K antagonist (VKA) such as warfarin. Given the teratogenic effects of VKAs, it is often favorable to switch to heparin derived therapies in pregnant patients since they do not cross the placenta. However, these therapies are known to be less effective anticoagulants subjecting the pregnant patient to a higher chance of a thrombotic event. Guidelines currently recommend pregnant women requiring more than 5 mg a day of warfarin be switched to alternative therapy during the first trimester. This case report highlights a patient who was in her first pregnancy after mechanical mitral valve replacement, she continued to use warfarin in her first trimester with daily dose 3 mg/24 hours. Vitamin K antagonist prefer to be given in first trimester of pregnancy with daily dose less than 5 mg and with monitoring of International Normalized Ratio 2.5-3.5 (AHA Guideline 2014). Fetus condition is observed in good condition with fetal ultrasonography.
Conclusions : Pregnant women with a mitral valve replacement (MVR) are at a heightened risk of a thrombotic event, and their absolute need for adequate anticoagulation. Vitamin K antagonist based on many systematic reviews is safe for first trimester of pregnancy if prescribed with daily dose less than 5 mg.
Keywords : first trimester of pregnancy, mitral valve replacement, anticoagulant, warfarin, heparin, low molecular weight heparin
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