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Anticoagulation in Pregnancy with Mechanical Valve — EECC MCQ

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ModerateGeneral CardiologyAnticoagulation in Pregnancy with Mechanical ValveEECC

A 30-year-old woman with Marfan syndrome and a mechanical aortic valve is planning pregnancy. She is currently on warfarin with stable INR 2.5-3.0. Her warfarin dose is 3.5 mg daily. Her ascending aorta is 38 mm (stable on serial imaging). According to the 2025 ESC CVD in Pregnancy Guidelines, what is the anticoagulation recommendation during the first trimester?

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Correct answer: D — Warfarin may be continued throughout the first trimester as the dose is ≤5 mg daily, which is associated with a lower risk of embryopathy

The 2025 ESC CVD in Pregnancy Guidelines recommend that for women with mechanical valves requiring warfarin ≤5 mg/day, continuation through the first trimester may be considered (Class IIa), as the risk of warfarin embryopathy is dose-dependent and significantly lower at ≤5 mg. For warfarin doses >5 mg, switching to LMWH during weeks 6-12 (the critical period for embryopathy) is recommended (Class IIa). DOACs are absolutely contraindicated with mechanical valves in pregnancy. The decision should be made pre-conception as part of a documented anticoagulation plan developed by the pregnancy heart team. This patient's dose of 3.5 mg falls below the 5 mg threshold.

Reference: ESC (2025): Guidelines for CVD in Pregnancy