Τρίτη, 16 Ιουλίου 2019

Figure 1: Coarctation and hypertension in pregnancy

Pregnancy complicated with severe aortic coarctation,

Maryam Moshkani Farahani, Zahra Pour Jafar

Archives of Cardiovascular Imaging 2017 5(2):35-36

Coarctation of the aorta (COA) is a congenital disease with significant stenosis of the aorta which is associated with some complications such as hypertension. A 37-year-old pregnant woman was referred to our Cardiology Department for control of hypertension. She was in the 26th week of her gestation and she had another uneventful pregnancy 4 years ago. Echocardiography before delivery showed significant coarctation with pressure gradient (PG)= 120 mmHg and cesarean section was done without any abnormal event. Six months later, stenting of aortic stenosis was done with a patient in a good condition. Coarctation (repaired or nonrepaired) is an important clinical condition during pregnancy which needs full investigation. 

Background Top

Hypertension is the most common medical problem in pregnancy and is a well-recognized risk factor for increasing maternal mortality and morbidity, and it could be evaluated in three major categories as follows: (a) chronic hypertension which is diagnosed before 20 weeks of gestation (essential and secondary causes should be included), (b) gestational hypertension that is new hypertension after the 20th week of pregnancy, and (c) Preeclampsia (Hypertension after 20th weeks of gestation with proteinuria, liver involvement, neurologic complications, fetal growth restriction, or placental abruption.[1]

Coarctation of the aorta (COA) is a congenital disease with significant stenosis of the aorta which can occur anywhere along the aorta but mainly occurs after the subclavian artery is one of the causes of secondary hypertension which needs special attention. Other associated anomalies with this disease are bicuspid aortic valve, patent ductus arteriosus, and ventricular septal defect. There is a male dominance with a prevalence of 6%–8%.[2] Most of the patients are diagnosed during childhood, but it can be lately diagnosed in adulthood. Complications of this disease consist of hypertension, coronary artery disease, renal failure, cerebral aneurysm, and dissection of the aorta. Multimodality imaging such as echocardiography, magnetic resonance imaging, computed tomography angiography, and catheterism can be used for the evaluation of the coarctation.[1]

  Case Report Top

A 37-year-old pregnant woman was referred to our Cardiology Department for control of hypertension. She was in the 26th week of her gestation and she had another uneventful pregnancy 4 years ago. Her blood pressure was 170/90 mmHg on admission and she had a history of poorly controlled hypertension from 7 years ago with poor adherent to medical therapy. In physical examination, there was systolic murmur and femoral pulses were weak. Electrocardiography showed left ventricle hypertrophy. Chest X-ray was not done, and in echocardiography, mild left ventricle enlargement with hypertrophy and mild systolic dysfunction were noticed. This patient was discussed in our cardiology group and we decided to notice her about the hazard of this disease during pregnancy and she decided to continue the pregnancy. Because of failure to respond to previous drugs, finally, she was treated with atenolol and amlodipine, and blood pressure was about 150–160/80 mmHg during her pregnancy. Fortunately, she had no symptoms during this course. Another echocardiography before delivery showed significant coarctation with PG = 120 mmHg, and elective cesarean section was done (without any complications and 24 h after delivery careful monitoring was done), and the baby was examined by pediatric physician and was healthy. The mother and her girl were discharged in a normal condition. Six months later, stenting of aortic stenosis was done with the patient in good condition.

  Discussion Top

Each woman with congenital heart disease, who decides for, should be fully evaluated to assess its disease severity. COA may be detected for the first time during pregnancy. It may present with severe maternal hypertension or other complications such as aortic dissection. In most of the time when hypertension is optimally controlled, the pregnancy is well tolerated. Aneurysm formation is one of the dangerous complications and can be life-threatening. Because estrogen is responsible for weakening the arterial walls during pregnancy, so the chance of impending rupture increases, so epidural anesthesia to avoid straining during labor is recommended. The patient with unrepaired coarctation is predisposed to complications, and careful echocardiographic evaluation should be done during pregnancy and after delivery, especially along the first 6 weeks of postpartum.[3],[4]

Treatment is based on the patient condition and gradient either conservative or intervention. Surgical repair is simple with minimal mortality, and primary stenting in coarctation has shown favorable results.[3]

The mode of delivery is based on patient condition, both vaginal delivery and elective caesarian section can be performed. Vaginal delivery with low-dose epidural analgesia and instrumental delivery without maternal pushing in the second stage, to avoid valve maneuvers, are recommended.[5]

Not only the elective cesarean section usually under general anesthesia seems to be safe for many women with cardiac diseases but also vaginal delivery with regional analgesia in expert hands is a preferred method. The elective cesarean section may be recommended in the occasional patients with coarctation who experienced uncontrolled and labile systemic hypertension, significant aortic root dilatation, and severe coarctation.[6] In our patient, the elective cesarean section with regional spinal anesthesia was done with no complication and was referred to cardiac care unit for close monitoring, and no hypertension crisis or other complications reported.

In review of literature, there are some cases of coarctation and mostly are treated conservatively during pregnancy. Yavuz et al. reported a case of significant recoarctation with thoracic aorta aneurysm that was managed medically, and after cesarean section by spinal anesthesia, endovascular aortic stenting was done after 6 months.[7] We recommend this algorithm for pregnant women with suspected coarctation in [Figure 1].
Figure 1: Coarctation and hypertension in pregnancy

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Conflicts of interest

There are no conflicts of interest.

  References Top

Zipes D, Libby P, Bonow RO, Mann DL, Tomaselli GF. Braunwald Heart Disease A Textbook of Cardiovascular Medicine. Philadelphia: Elsevier Health Sciences. 2019, page:1792  Back to cited text no. 1
Anderson RH, Baker EJ, Redington A, Rigby ML, Penny D, Wernovsky G. Paediatric Cardiology. Churchill Livingstone: Expert consult-online and print; 2009.  Back to cited text no. 2
Mann DL, Zipes DP, Libby P, Bonow RO. Braunwald's Heart Disease E-Book: A Textbook of Cardiovascular Medicine. Elsevier Health Sciences 2014;2136:861-71.  Back to cited text no. 3
Matsui H, Gardiner H. Coarctation of the Aorta: Fetal and postnatal diagnosis and outcome. Expert Rev Obstet Gynecol 2009:4:191-200.   Back to cited text no. 4
Dob D, Yentis S. UK registry of high-risk obstetric anaesthesia: Report on cardiorespiratory disease. Int J Obstet Anesth 2001;10:267-72.  Back to cited text no. 5
Beauchesne LM, Connolly HM, Ammash NM, Warnes CA. Coarctation of the aorta: Outcome of pregnancy. J Am Coll Cardiol 2002;3:96.  Back to cited text no. 6
Yavuz C, Soydinc HD, Takbas G, Karahan O. Pregnancy complicated with severe recurrent aortic coarctation:A case report. Case Rep Vasc Med. 2012; p.3. Doi:10.1155/4012/865035.  Back to cited text no. 7

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