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Nagao T, Inoue M, Ito Y, Kunihara T, Kawame H, Samura O, Okamoto A. Loeys-Dietz syndrome with a novel in-frame SMAD3 deletion diagnosed as a result of postpartum aortic dissection: A case report. Taiwan J Obstet Gynecol 2024; 63:225-228. [PMID: 38485319 DOI: 10.1016/j.tjog.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 03/19/2024] Open
Abstract
OBJECTIVE Loeys-Dietz syndrome (LDS) is a rare, autosomal dominant connective tissue disorder which can aggressively affect the aortic vasculature. Limited information is available regarding its impact on pregnancy and postpartum outcomes. CASE REPORT A pregnant 38-year-old nulliparous woman with mild aortic regurgitation and family history of aortic aneurysms presented with an aortic root measuring 49 mm. Despite concerns of an underlying connective tissue disorder, a definitive diagnosis was not reached. She delivered under strict blood pressure control, developed intractable uterine atony, and underwent uterine artery embolization. On the second postpartum day, aortic dissection was incidentally diagnosed, and aortic root replacement surgery was performed. Genetic testing revealed a novel in-frame SMAD3 deletion [NM_005902.4: c.703_708del, (p.Ile235_Ser236del)], leading to a diagnosis of LDS type 3. CONCLUSION This case highlights the high postpartum aortic dissection risk in women with LDS, emphasizing the importance of early diagnosis in pregnant women with few clinical symptoms.
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Affiliation(s)
- Takeshi Nagao
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Momoko Inoue
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Ito
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan; Department of Clinical Genetics, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroshi Kawame
- Department of Clinical Genetics, The Jikei University School of Medicine, Tokyo, Japan
| | - Osamu Samura
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan; Department of Clinical Genetics, The Jikei University School of Medicine, Tokyo, Japan
| | - Aikou Okamoto
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
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Gouda P, Kay R, Habib M, Aziz A, Aziza E, Welsh R. Clinical features and complications of Loeys-Dietz syndrome: A systematic review. Int J Cardiol 2022; 362:158-167. [PMID: 35662564 DOI: 10.1016/j.ijcard.2022.05.065] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Loeys-Dietz syndrome (LDS) is a connective tissue disorder that arises from mutations altering the transforming growth factor β signalling pathway. Due to the recent discovery of the underlying genetic mutations leading to LDS, the spectrum of characteristics and complications is not fully understood. METHODS Our search included five databases (Pubmed, SCOPUS, Web of Science, EMBASE and google scholar) and included variations of "Loeys-Dietz Syndrome" as search terms, using all available data until February 2021. All study types were included. Three reviewers screened 1394 abstracts, of which 418 underwent full-text review and 392 were included in the final analysis. RESULTS We identified 3896 reported cases of LDS with the most commonly reported features and complications being: aortic aneurysms and dissections, arterial tortuosity, high arched palate, abnormal uvula and hypertelorism. LDS Types 1 and 2 share many clinical features, LDS Type 2 appears to have a more aggressive aortic disease. LDS Type 3 demonstrated an increased prevalence of mitral valve prolapse and arthritis. LDS Type 4 and 5 demonstrated a lower prevalence of musculoskeletal and cardiovascular involvement. Amongst 222 women who underwent 522 pregnancies, 4% experienced an aortic dissection and the peripartum mortality rate was 1%. CONCLUSION We observed that LDS is a multisystem connective tissue disorder that is associated with a high burden of complications, requiring a multidisciplinary approach. Ongoing attempts to better characterise these features will allow clinicians to appropriately screen and manage these complications.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Robert Kay
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Marina Habib
- Flinders University, School of Medicine, Adelaide, Australia
| | - Amir Aziz
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Eitan Aziza
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Robert Welsh
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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Cauldwell M, Steer PJ, Curtis S, Mohan AR, Dockree S, Mackillop L, Parry H, Oliver J, Sterrenburg M, Bolger A, Siddiqui F, Simpson M, Walker N, Bredaki F, Walker F, Johnson MR. Maternal and fetal outcomes in pregnancies complicated by the inherited aortopathy Loeys-Dietz syndrome. BJOG 2019; 126:1025-1031. [PMID: 30811810 DOI: 10.1111/1471-0528.15670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Pregnancies in women with Loeys-Dietz syndrome (LDS) are rare and are typically documented in case reports only. Early reports suggested high rates of maternal complications during pregnancy and the puerperium, including aortic dissection and uterine rupture, but information on fetal outcomes was very limited. DESIGN A retrospective cohort study. SETTING Eight specialist UK centres. SAMPLE Pregnant women with LDS. METHODS Data was collated on cardiac, obstetric, and neonatal outcomes. MAIN OUTCOME MEASURES Maternal and perinatal outcomes in pregnancies complicated by LDS. RESULTS Twenty pregnancies in 13 women with LDS were identified. There was one miscarriage, one termination of pregnancy, and 18 livebirths. In eight women the diagnosis was known prior to pregnancy but only one woman had preconception counselling. In four women the diagnosis was made during pregnancy through positive genotyping, and the other was diagnosed following delivery. Five women had a family history of aortic dissection. There were no aortic dissections in our cohort during pregnancy or postpartum. Obstetric complications were common, including postpartum haemorrhage (33%) and preterm delivery (50%). In all, 14/18 (78%) of deliveries were by elective caesarean section, at a median gestational age at delivery of 37 weeks. Over half the infants (56%) were admitted to the neonatal unit following delivery. CONCLUSION Women with LDS require multidisciplinary specialist management throughout pregnancy. Women should be referred for preconception counselling to make informed decisions around pregnancy risk and outcomes. Early elective preterm delivery needs to be balanced against a high infant admission rate to the neonatal unit. TWEETABLE ABSTRACT Pregnancy outcomes in women with Loeys-Dietz syndrome.
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Affiliation(s)
- M Cauldwell
- Academic Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, London, UK
| | - P J Steer
- Academic Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, London, UK
| | - S Curtis
- Adult Congenital Heart Disease Service, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - A R Mohan
- Department of Obstetrics, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - S Dockree
- Women's Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - L Mackillop
- Women's Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - H Parry
- Department of Adult Congenital Heart Disease, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - J Oliver
- Department of Adult Congenital Heart Disease, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - M Sterrenburg
- Department of Human Development and Health, Princess Anne Hospital, University of Southampton, Southampton, UK
| | - A Bolger
- Department of Adult Congenital Heart Disease, Glenfield Hospital, Leicester, UK
| | - F Siddiqui
- Department of Obstetrics, Royal Leicester Infirmary, Leicester, UK
| | - M Simpson
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, UK
| | - N Walker
- Department of Obstetrics, University College Hospital, London, UK
| | - F Bredaki
- Department of Adult Congenital Heart Disease, Bart's Heart Centre, London, UK
| | - F Walker
- Department of Adult Congenital Heart Disease, Bart's Heart Centre, London, UK
| | - M R Johnson
- Academic Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, London, UK
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Chetty S, Norton ME. Obstetric care in women with genetic disorders. Best Pract Res Clin Obstet Gynaecol 2017; 42:86-99. [PMID: 28392223 DOI: 10.1016/j.bpobgyn.2017.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/07/2017] [Accepted: 03/10/2017] [Indexed: 01/04/2023]
Abstract
The management of pregnant women who are themselves affected with genetic diseases is an increasingly relevant and important issue. Improvements in early diagnosis and management of genetic disease, as well as advances in assisted reproductive technology have impacted pregnancy rates in a cohort of women who may not have otherwise been able to conceive. A multidisciplinary approach is key to the management of pregnant women with complex health conditions, including genetic diseases. Pertinent issues should be addressed in the preconception, antepartum, intrapartum and postpartum periods to optimize maternal and fetal health. Additionally, counseling regarding risk of inheritance in offspring and options for prenatal diagnosis should be reviewed if available. This reviews aims to help provide background and insight into the management strategies for various commonly encountered and complex genetic conditions in the setting of pregnancy.
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Affiliation(s)
- Shilpa Chetty
- Department of Obstetrics, Gynecology and Reproductive Sciences, 550 16th St, 7th Floor, University of California, San Francisco, CA 94143, USA.
| | - Mary E Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, 550 16th St, 7th Floor, University of California, San Francisco, CA 94143, USA
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Byard RW. Manifestations and Medicolegal Significance of Loeys-Dietz Syndrome. J Forensic Sci 2017; 62:1512-1515. [DOI: 10.1111/1556-4029.13466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/13/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Roger W. Byard
- Forensic Science SA; 21 Divett Place Adelaide SA 5000 Australia
- Discipline of Anatomy and Pathology; The University of Adelaide; Frome Road Level 3 Medical School North Building Adelaide SA 5005 Australia
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Loeys-Dietz syndrome and pregnancy: The first ten years. Int J Cardiol 2016; 226:21-25. [PMID: 27780078 DOI: 10.1016/j.ijcard.2016.10.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 10/07/2016] [Accepted: 10/09/2016] [Indexed: 12/14/2022]
Abstract
The physiological and haemodynamic changes that occur in pregnancy and the postpartum period increase the risk of aortic dissection. Loeys-Dietz syndrome results from mutations in the genes encoding components of the TGF-β signalling pathway; aortic pathology is of particular concern in this condition but other vascular abnormalities can also be present. Significant maternal morbidity and mortality has been described in patients with Loeys-Dietz syndrome, but successful and uncomplicated pregnancies are still possible. Nevertheless, all patients with this condition should, at present, be treated as very high risk in pregnancy and the postpartum period, until reliable risk prediction tools become available. This review summarises the recent advances in the understanding of the pathophysiology of this condition, and the management strategies currently advocated.
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