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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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2
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Dey S, Cheikhali R, Frishman WH, Aronow WS. Genetic Problems, Diagnosis, and Cardiovascular Manifestations of Loeys-Dietz Syndrome. Cardiol Rev 2023:00045415-990000000-00104. [PMID: 37126428 DOI: 10.1097/crd.0000000000000544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Loeys-Dietz Syndrome (LDS) is an autosomal dominant connective tissue disorder with multisystem involvement of wide spectrum, found to be associated with transforming growth factor-β pathway. LDS is characterized by craniofacial, skeletal, cutaneous, vascular abnormalities along with aortic aneurysm and aortic dissection contributing to mortality and morbidity at a young age. Therefore, timely diagnosis and intervention in patients with LDS is vital. Several gene mutations have been described as contributing factors of LDS, causing widespread and aggressive vascular disease. Based on these gene mutations, 5 types of LDS have been described so far. Besides aortic aneurysm and dissection, some of the other cardiac manifestations of LDS involve cardiomyopathy, valvular abnormality, atrial fibrillation, patent ductus arteriosus, atrial septal defects, etc. Routine imaging of patients' vasculatures and aggressive medical and surgical management are key factors in managing patients with LDS.
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Affiliation(s)
- Subo Dey
- From the Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Ryan Cheikhali
- From the Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - William H Frishman
- From the Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
- Departments of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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3
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Baeza-Velasco C, Rodriguez N, Parra L, Gutiérrez-Rosado T. Adjustment to disease and quality of life in people with vascular Ehlers-Danlos and Loeys-Dietz syndromes: A mixed-method study. Front Psychol 2023; 14:1019863. [PMID: 36925590 PMCID: PMC10011476 DOI: 10.3389/fpsyg.2023.1019863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/30/2023] [Indexed: 03/08/2023] Open
Abstract
Background Vascular Ehlers-Danlos (vEDS) and Loeys-Dietz syndromes (LDS) are hereditary disorders of connective tissue having severe vascular complications (HDCTv) which lead to an increased risk of premature death. Little is known about the impact of the disease in patient's daily life. Method Sixteen HDCTv patients (vEDS = 9 and LDS = 7), 16 age and sex-matched hypermobile Ehlers-Danlos syndrome patients (hEDS) and 18 healthy subjects (HS), responded to self-questionnaires assessing psychosocial adjustment, quality of life (QoL), anxiety, depression, pain, fatigue and sleep problems. Patients with HDCTv were also interviewed in order to explore qualitatively their experience with the disease. Results Compared with HS, patients with HDCTv scored significantly higher on anxiety, depression, fatigue, sleep problems, and lower on QoL. Most HDCTv patients (93.8%) have optimal psychosocial adjustment. In addition, HDCTv patients scored higher on QoL and psychosocial adjustment, but lower in pain, fatigue, sleep problems, and depressive symptoms than hEDS patients. Four main themes were identified in qualitative analyses: living with HDCTv, knowledge/ignorance of the disease, health behaviors/self-care and coping strategies. Conclusion Our results suggest that despite the negative impact of HDCTv on the patients' daily lives, overall, they present an optimal disease adjustment which points to appropriate coping strategies. More research in psychosocial aspects of people with these rare diseases are needed to confirm these results and better understand their needs.
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Affiliation(s)
- Carolina Baeza-Velasco
- Laboratoire de Psychopathologie et Processus de Santé (LPPS UR4057), Université Paris Cité, Boulogne-Billancourt, Paris, France.,Department of Emergency Psychiatry and Acute Care, CHU Montpellier, Montpellier, France.,Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | | | - Laura Parra
- Laboratoire de Psychopathologie et Processus de Santé (LPPS UR4057), Université Paris Cité, Boulogne-Billancourt, Paris, France
| | - Teresa Gutiérrez-Rosado
- Department of Clinical and Health Psychology, University Autonomous of Barcelona, Barcelona, Spain
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4
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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: 18] [Impact Index Per Article: 9.0] [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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5
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Sayama S, Iriyama T, Takeda N, Yamauchi H, Toshimitsu M, Seyama T, Sone K, Kumasawa K, Nagamatsu T, Fujii T, Osuga Y. Proposed Management Policy for Pregnant Women with Loeys-Dietz Syndrome Following Prophylactic Aortic Root Replacement Based on Experience from a Tertiary Care Center. Int Heart J 2022; 63:176-179. [DOI: 10.1536/ihj.21-341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Seisuke Sayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Takayuki Iriyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Norifumi Takeda
- Department of Cardiovascular Medicine, Faculty of Medicine, The University of Tokyo
| | - Haruo Yamauchi
- Department of Cardiac Surgery, Faculty of Medicine, The University of Tokyo
| | - Masatake Toshimitsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Takahiro Seyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Kenbun Sone
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Takeshi Nagamatsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
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6
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Rajasekaran P, Gandhi P, Idhrees M, Velayudhan BV. Aortic complications in pregnancy: the less remembered chapter—a narrative review. EXPLORATION OF MEDICINE 2021. [DOI: 10.37349/emed.2021.00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Pregnancy increases the risk of common vascular events and also the rarer events like aortic dissection (AD)/aortic rupture and this is even more pronounced in patients with predisposing aortopathies. AD was found to occur in 0.0004% of all pregnancies, and it is more pronounced in patients with underlying connective tissue disorders. The normal hemodynamic changes on a weak aorta will lead to AD and/or rupture, more so with increase in the period of gestation. Hence the haemodynamic and hormonal changes during pregnancy make pregnancy itself a risk factor for AD. It is advised that women with Marfan syndrome who are planning pregnancy should go through prophylactic aortic repair if the diameter of the ascending aorta exceeds 4 cm. Pre-pregnancy counselling is very important in these patients and must include complete history taking, including family history, physical examination and advanced aortic imaging. There is a general consensus among various authors advising against surgery during pregnancy in stable patients due to increased maternal and fetal morbidity but it is justified if the condition is refractory to medical management or in life threatening stage like acute AD. Though the incidence of aortopathy in pregnancy is rare, there is a high maternal and fetal mortality associated with this condition.
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Affiliation(s)
- Preetha Rajasekaran
- Department of Obstetrics and Gynaecology, Vihaa Hospitals, Anna Nagar, Chennai-600102, India
| | - Praveena Gandhi
- Department of Obstetrics and Gynaecology PPN Hospital, Palani-624601, India
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Diseases, SIMS hospital, Chennai-600026, India
| | - Bashi V. Velayudhan
- Institute of Cardiac and Aortic Diseases, SIMS hospital, Chennai-600026, India
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7
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Grewal J, Windram J, Bottega N, Sermer M, Spears D, Silversides C, Siu SC, Swan L. Canadian Cardiovascular Society: Clinical Practice Update on Cardiovascular Management of the Pregnant Patient. Can J Cardiol 2021; 37:1886-1901. [PMID: 34217807 DOI: 10.1016/j.cjca.2021.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022] Open
Abstract
The number of women of childbearing age with cardiovascular disease (CVD) is growing due to increased survival of children with congenital heart disease (CHD). More women are also becoming pregnant at an older age, which is associated with increased co-morbidities including hypertension, diabetes and acquired CVD. Over the last decade the field of cardio-obstetrics has significantly advanced with the development of multidisciplinary cardio-obstetric programs (COPs) to address the increasing burden of CVD in pregnancy. With the introduction of formal COPs, pregnancy outcomes in women with heart disease have improved. COPs provide preconception counseling, antenatal and postpartum cardiac surveillance, labor and delivery planning. Pre-pregnancy counseling by a COP should be offered to women with suspected CVD who are of child bearing age. In those women who present while pregnant, counseling should be performed by a COP as early as possible in pregnancy. The purpose of counseling is to reduce the risk of pregnancy to the mother and fetus whenever possible. This is done through accurate maternal and fetal risk stratification, optimizing cardiac lesions, reviewing safety of medications in pregnancy, and making a detailed plan for the pregnancy, labor and delivery. This Clinical Practice Update highlights the COP approach to pre-pregnancy counseling, risk stratification, and management of commonly encountered cardiac conditions through pregnancy. We highlight "red flags" that should trigger a more timely assessment by a COP. We also describe the approach to some of the cardiac emergencies that the care provider may encounter in a pregnant woman.
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Affiliation(s)
- Jasmine Grewal
- Division of Cardiology, St.Paul's Hospital, University of British Columbia, Vancouver, B.C., Canada.
| | - Jonathan Windram
- Department of Cardiology, Mazankowski Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Natalie Bottega
- Department of Cardiology, Royal Victoria Hospital-Glen Site, McGill University, Montréal, QC, Canada
| | - Mathew Sermer
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto ON
| | - Danna Spears
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Candice Silversides
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiology Department of Medicine Mount Sinai Hospital and University Health NetworkUniversity of Toronto Canada
| | - Samuel C Siu
- Division of Cardiology Department of Medicine Mount Sinai Hospital and University Health NetworkUniversity of Toronto Canada; Maternal Cardiology Program Division of Cardiology Department of Medicine Schulich School of Medicine and Dentistry London Ontario Canada
| | - Lorna Swan
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiology Department of Medicine Mount Sinai Hospital and University Health NetworkUniversity of Toronto Canada
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8
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Lindley KJ, Bairey Merz CN, Asgar AW, Bello NA, Chandra S, Davis MB, Gomberg-Maitland M, Gulati M, Hollier LM, Krieger EV, Park K, Silversides C, Wolfe NK, Pepine CJ. Management of Women With Congenital or Inherited Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 2/5. J Am Coll Cardiol 2021; 77:1778-1798. [PMID: 33832605 DOI: 10.1016/j.jacc.2021.02.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/19/2021] [Accepted: 02/12/2021] [Indexed: 01/15/2023]
Abstract
Maternal morbidity and mortality continue to rise in the United States, with cardiovascular disease as the leading cause of maternal deaths. Congenital heart disease is now the most common cardiovascular condition encountered during pregnancy, and its prevalence will continue to grow. In tandem with these trends, maternal cardiovascular health is becoming increasingly complex. The identification of women at highest risk for cardiovascular complications is essential, and a team-based approach is recommended to optimize maternal and fetal outcomes. This document, the second of a 5-part series, will provide practical guidance from pre-conception through postpartum for cardiovascular conditions that are predominantly congenital or heritable in nature, including aortopathies, congenital heart disease, pulmonary hypertension, and valvular heart disease.
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Affiliation(s)
- Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Anita W Asgar
- Division of Cardiology, Institut de Cardiologie de Montreal, Universite de Montreal, Montreal, Quebec, Canada
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sonal Chandra
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mardi Gomberg-Maitland
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Martha Gulati
- Department of Medicine (Cardiology), University of Arizona-Phoenix, Phoenix, Arizona, USA
| | - Lisa M Hollier
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Eric V Krieger
- Seattle Adult Congenital Heart Service, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ki Park
- Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Candice Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Natasha K Wolfe
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Carl J Pepine
- Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
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9
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Keir M, McClure RS, Fedak PWM. Commentary: How to save and improve the lives of families with heritable aortic diseases. J Thorac Cardiovasc Surg 2021; 163:49-50. [PMID: 33781592 DOI: 10.1016/j.jtcvs.2021.02.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Michelle Keir
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - R Scott McClure
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul W M Fedak
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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10
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Rimmer L, Mellor S, Harky A, Gouda M, Bashir M. Pernicious pregnancy: Type B aortic dissection in pregnant women. J Card Surg 2021; 36:1232-1240. [PMID: 33533078 DOI: 10.1111/jocs.15354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/22/2020] [Accepted: 10/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Type B aortic dissection (TBAD) occurs seldomly, particularly in pregnancy, but has disastrous consequences for both mother and fetus. The focus of immediate surgical repair of type A aortic dissection due to higher mortality of patients is less clear in its counterpart, TBAD, in which management is controversial and debated. This article collates knowledge so far on this rare event during pregnancy. METHODS A comprehensive literature search was performed in PubMed, Scopus, Google Scholar, Embase, and Medline. Key search terms included "type B aortic dissection," "pregnancy," and corresponding synonyms. Non-English papers were excluded. RESULTS Risk factors for TBAD include aortic wall stress due to hypertension, previous cardiac surgery, structural abnormalities (bicuspid aortic valve, aortic coarctation), and connective tissue disorders. In pregnancy, pre-eclampsia is a cause of increased aortic wall stress. Management of this condition is often conservative, but this is dependent on a number of factors, including gestation, cardiovascular stability of the patient, and symptomology. In most cases, a cesarean section before intervention is carried out unless certain indications are present. CONCLUSIONS Due to a scarce number of cases across the decades, it is difficult to determine which management is optimal. The gold-standard management of TBAD has traditionally been the medical treatment for uncomplicated cases and open surgery for those needing urgent intervention, but with the advent of techniques, such as thoracic endovascular aortic repair, the management of these group of patients continues to develop.
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Affiliation(s)
- Lara Rimmer
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Sophie Mellor
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Amer Harky
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Mohamed Gouda
- Vascular & Endovascular Surgery, Mataria Teaching Hospital, Cairo, Egypt
| | - Mohamad Bashir
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
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11
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Shitara R, Iriyama T, Sayama S, Takeda N, Nagamatsu T, Osuga Y, Fujii T. Postpartum Stanford type B aortic dissection in a woman with Loeys-Dietz syndrome who underwent a prophylactic aortic root replacement before conception: A case report. Taiwan J Obstet Gynecol 2021; 60:145-147. [PMID: 33494990 DOI: 10.1016/j.tjog.2020.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Loeys-Dietz syndrome (LDS) is associated with a higher risk of aortic dissections (ADs) during pregnancy and postpartum. However, there is limited evidence about the perinatal management of LDS patients who have undergone prophylactic aortic root replacements (ARRs) before conception. CASE REPORT We present the case of a 28-year-old nulliparous pregnant woman with LDS with a pathogenic variant within exon 5 of TGFBR2 (c.1379G > T, p.[Arg460Leu]), who underwent an ARR at 20 years of age. Cardiac echocardiography did not show any significant changes in the aorta during pregnancy, and her blood pressure remained normal. She had a cesarean section at 37 weeks of gestation. She developed an acute Stanford type B AD extending from the aortic arch to the infrarenal aorta 8 days postpartum and underwent a total arch replacement. CONCLUSION This case report suggests that patients with LDS after prophylactic ARRs still possess a risk for Stanford type B ADs.
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Affiliation(s)
- Rieko Shitara
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan; Departments of Obstetrics & Gynecology, Japan Community Health Care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Takayuki Iriyama
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan.
| | - Seisuke Sayama
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Norifumi Takeda
- Department of Cardiovascular Medicine, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Takeshi Nagamatsu
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Tomoyuki Fujii
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
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12
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Avila WS, Alexandre ERG, Castro MLD, Lucena AJGD, Marques-Santos C, Freire CMV, Rossi EG, Campanharo FF, Rivera IR, Costa MENC, Rivera MAM, Carvalho RCMD, Abzaid A, Moron AF, Ramos AIDO, Albuquerque CJDM, Feio CMA, Born D, Silva FBD, Nani FS, Tarasoutchi F, Costa Junior JDR, Melo Filho JXD, Katz L, Almeida MCC, Grinberg M, Amorim MMRD, Melo NRD, Medeiros OOD, Pomerantzeff PMA, Braga SLN, Cristino SC, Martinez TLDR, Leal TDCAT. Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease - 2020. Arq Bras Cardiol 2020; 114:849-942. [PMID: 32491078 PMCID: PMC8386991 DOI: 10.36660/abc.20200406] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Walkiria Samuel Avila
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Marildes Luiza de Castro
- Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas gerais (UFMG),Belo Horizonte, MG - Brasil
| | | | - Celi Marques-Santos
- Universidade Tiradentes,Aracaju, SE - Brasil.,Hospital São Lucas, Rede D'Or Aracaju,Aracaju, SE - Brasil
| | | | - Eduardo Giusti Rossi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Felipe Favorette Campanharo
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil.,Hospital Israelita Albert Einstein,São Paulo, SP - Brasil
| | | | - Maria Elizabeth Navegantes Caetano Costa
- Cardio Diagnóstico,Belém, PA - Brasil.,Centro Universitário Metropolitano da Amazônia (UNIFAMAZ),Belém, PA - Brasil.,Centro Universitário do Estado Pará (CESUPA),Belém, PA - Brasil
| | | | | | - Alexandre Abzaid
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Antonio Fernandes Moron
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Carlos Japhet da Mata Albuquerque
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil,Hospital Barão de Lucena, Recife, PE – Brazil,Hospital EMCOR, Recife, PE – Brazil,Diagnósticos do Coração LTDA, Recife, PE – Brazil
| | | | - Daniel Born
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Fernando Souza Nani
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Flavio Tarasoutchi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - José de Ribamar Costa Junior
- Hospital do Coração (HCor),São Paulo, SP - Brasil.,Instituto Dante Pazzanese de Cardiologia,São Paulo, SP - Brasil
| | | | - Leila Katz
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil
| | | | - Max Grinberg
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Nilson Roberto de Melo
- Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP – Brazil
| | | | - Pablo Maria Alberto Pomerantzeff
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
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13
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Ramlakhan KP, Ahmed I, Johnson MR, Roos-Hesselink JW. Congenital heart disease and family planning: Preconception care, reproduction, contraception and maternal health. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2020. [DOI: 10.1016/j.ijcchd.2020.100049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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14
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Demo E, Rigelsky C, Rideout AL, Graf M, Pariani M, Regalado E, MacCarrick G. Genetics and Precision Medicine: Heritable Thoracic Aortic Disease. Med Clin North Am 2019; 103:1005-1019. [PMID: 31582001 DOI: 10.1016/j.mcna.2019.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Heritable thoracic aortic disease (HTAD) can have life-threatening consequences if not diagnosed early. Affected individuals and at-risk family members benefit from both cardiology and genetic evaluations, including genetic testing. Important information can be obtained through family history, medical history, and genetic testing to help guide management and assess risk. A genetic diagnosis can guide cardiovascular management (type and frequency of vascular imaging, timing of surgical intervention), risk assessment for arterial aneurysm/dissection, evaluation of nonvascular features, and familial testing.
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Affiliation(s)
- Erin Demo
- Sibley Heart Center Cardiology, 2835 Brandywine Road, Suite 300, Atlanta, GA 30341, USA
| | - Christina Rigelsky
- Genomic Medicine Institute, Cleveland Clinic, 9500 Euclid Avenue, NE50, Cleveland, OH 44195, USA
| | - Andrea L Rideout
- IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada
| | - Madeline Graf
- Stanford Health Care, 900 Blake Wilbur Drive, 3rd floor, Stanford, CA 94305, USA
| | - Mitchel Pariani
- Stanford School of Medicine, 300 Pasteur Drive, 2nd Floor, Room H2157, Stanford, CA 94305, USA
| | | | - Gretchen MacCarrick
- Johns Hopkins School of Medicine, Blalock 1008, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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15
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Thomas KE, Hogan J, Pitcher A, Mackillop L, Blair E, Frise CJ. Loeys-Dietz syndrome in pregnancy. Obstet Med 2019; 14:42-45. [PMID: 33995573 DOI: 10.1177/1753495x19852819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 05/03/2019] [Indexed: 11/17/2022] Open
Abstract
Loeys-Dietz syndrome is a recently described condition which causes cardiovascular, craniofacial, neurocognitive and skeletal abnormalities due to mutations in components of the transforming growth factor-β signalling pathway. Associated vascular abnormalities include vessel tortuosity and an increased incidence of vascular dissection. Pregnancy increases the risk of aortic dissection compared to non-pregnant individuals and an underlying condition such as Loeys-Dietz syndrome increases this further. While aortic dissection is well described in pregnancy in Loeys-Dietz syndrome, some women can have uncomplicated deliveries, particularly when the risks of the condition are actively managed. Such pregnancies should be considered high-risk, and women should be counselled and managed accordingly. Here we describe two pregnancies in one woman, both with successful outcomes, followed by a summary of the key management principles.
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Affiliation(s)
| | - Jennifer Hogan
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Alex Pitcher
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lucy Mackillop
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Edward Blair
- Oxford Centre for Genomic Medicine, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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16
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Bashari H, Brooks A, O'Brien O, Brennecke S, Zentner D. Maternal Loeys-Dietz syndrome (transforming growth factor ligand 2) in a twin pregnancy: Case report and discussion. SAGE Open Med Case Rep 2019; 7:2050313X19852539. [PMID: 31191903 PMCID: PMC6542112 DOI: 10.1177/2050313x19852539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/30/2019] [Indexed: 01/16/2023] Open
Abstract
Loeys–Dietz syndrome is a rare autosomal dominant connective tissue disorder. Pregnant women with Loeys–Dietz syndrome are at increased risk of serious vascular and visceral complications, including aortic dissection and uterine rupture. Multidisciplinary tertiary management aims to mitigate such complications by preconception counselling and vascular assessment, medical therapy, regular echocardiography in pregnancy and joint decision-making re-mode and timing of delivery. We report an in vitro fertilisation twin pregnancy in a woman with Loeys–Dietz syndrome first seen at our institution at 26 weeks’ gestation. After monitoring via serial echocardiograms, caesarean delivery occurred at 30 + 1 weeks’ gestation to allow planned delivery with suspected fetal growth restriction before uterine distension was considered an indication. The patient was discharged on Day 9 with a planned early aortic root replacement due to an increase in diameter from 39 to 43 mm, followed by the discharge of twin boys at term equivalent.
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Affiliation(s)
- Homira Bashari
- Maternity Services, The Royal Women's Hospital, Melbourne, VIC, Australia
| | - Alexandra Brooks
- Maternity Services, The Royal Women's Hospital, Melbourne, VIC, Australia.,Department of Maternal Fetal Medicine, The Royal Women's Hospital, Melbourne, VIC, Australia
| | - Orla O'Brien
- Maternity Services, The Royal Women's Hospital, Melbourne, VIC, Australia
| | - Shaun Brennecke
- Maternity Services, The Royal Women's Hospital, Melbourne, VIC, Australia.,Department of Maternal Fetal Medicine, The Royal Women's Hospital, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne and The Royal Women's Hospital, Melbourne, VIC, Australia
| | - Dominica Zentner
- Departments of Cardiology and Genetic Medicine, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne and Royal Melbourne Hospital Clinical School, Melbourne, VIC, Australia
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17
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Li J, Lu C, Wu W, Liu Y, Wang R, Si N, Meng X, Zhang S, Zhang X. Application of next-generation sequencing to screen for pathogenic mutations in 123 unrelated Chinese patients with Marfan syndrome or a related disease. SCIENCE CHINA-LIFE SCIENCES 2019; 62:1630-1637. [PMID: 31098894 DOI: 10.1007/s11427-018-9491-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/25/2019] [Indexed: 01/08/2023]
Abstract
Marfan syndrome (MFS) is a systemic connective tissue disease principally affecting the ocular, skeletal and cardiovascular systems. This autosomal dominant disorder carries a prevalence of 1:3,000 to 1:5,000. This study aims to define the mutational spectrum of MFS related genes in Chinese patients and to establish genotype-phenotype correlations in MFS. Panel-based targeted next-generation sequencing was used to analyze the FBN1, TGFBR1 and TGFBR2 genes in 123 unrelated Chinese individuals with MFS or a related disease. Genotype-phenotype correlation analyses were performed in mutation-positive patients. The results showed that 97 cases/families (78.9%; 97/123) harbor at least one (likely) pathogenic mutation, most of which were in FBN1; four patients had TGFBR1/2 mutations; and one patient harbored a SMAD3 mutation. Three patients had two FBN1 mutations, and all patients showed classical MFS phenotypes. Patients with a dominant negative-FBN1 mutation had a higher prevalence of ectopia lentis (EL). Patients carrying a haploinsufficiency-FBN1 mutation tended to have aortic dissection without EL. This study extends the spectrum of genetic backgrounds of MFS and enriches our knowledge of genotype-phenotype correlations.
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Affiliation(s)
- Jiacheng Li
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100005, China
| | - Chaoxia Lu
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100005, China.
| | - Wei Wu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100730, China
| | - Yaping Liu
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100005, China
| | - Rongrong Wang
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100005, China
| | - Nuo Si
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100005, China
| | - Xiaolu Meng
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100005, China
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100730, China
| | - Xue Zhang
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100005, China.
- Laboratory of Clinical Genetics, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100730, China.
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18
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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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19
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Fetal and placental anatomy visualized with cinematic rendering from volumetric CT data. Radiol Case Rep 2017; 13:281-283. [PMID: 29487668 PMCID: PMC5826733 DOI: 10.1016/j.radcr.2017.09.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 09/22/2017] [Accepted: 09/25/2017] [Indexed: 11/23/2022] Open
Abstract
Avoiding unnecessary radiation exposure in children, including fetuses or embryos, is of paramount importance. However, emergent clinical situations will arise that necessitate the use of ionizing radiation-based modalities, such as computed tomography (CT), in this patient population. In such circumstances, the use of advanced visualization methods may provide optimum diagnostic utility. We present the case of a pregnant patient with Loeys-Dietz syndrome who was evaluated with CT angiography to rule out an acute aortic syndrome. The CT data from the fetus and placenta were reconstructed using the new cinematic rendering technique that allows for photorealistic display. The potential advantages of cinematic rendering relative to traditional volume rendering are discussed.
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20
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Kapoor R, Mann DG, Mossad EB. Perioperative Anesthetic Management for Cesarean Delivery in a Parturient With Type IV Loeys-Dietz Syndrome. ACTA ACUST UNITED AC 2017; 9:182-185. [DOI: 10.1213/xaa.0000000000000561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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