Peripartum anesthetic management of patients with Takayasu’s arteritis: case series and review

Systemic vasculitis diagnosed during the post-partum period: case report and review of the literature

INTRODUCTION

The vasculitis diagnosed specifically in the post-partum period are less well known. We report here such a case followed by a descriptive review of the literature.

CASE REPORT

A 25 year-old French nurse reported abrupt-onset musculoskeletal pain 15 days after delivery of her first infant. Her first pregnancy was uneventful. The physical examination yielded only bilateral conjunctivitis and purpuric eruption of lower limbs, and complementary investigations evidenced pulmonary renal syndrome in connection with the diagnosis of Granulomatosis with Polyangiitis.

METHODS

We screened previous articles in Medline database using keywords (i) "post-partum" or "puerperium" (ii)"peripartum" (iii) "pregnancy" associated with "vasculitis". Full texts were obtained from case reports or cases series whose title or abstract included keywords of interest (or synonyms). These references were secondarily excluded if the diagnosis of vasculitis was not confirmed or made before or more than 6 months after delivery and if vasculitis occurred only in the new born or affected only the cerebral vasculature or the retina.

RESULTS

Fifty-six cases of vasculitis diagnosed in the post-partum period were included, 50 (89.3%) were secondary to an immunological process and 44 corresponded to primary vasculitis, 4 were secondary to Systemic Lupus Erythematosus, 1 to cryoglobulinaemia and 1 to cryoglobulinaemia associated with inflammatory bowel disease. The main primary vasculitis diagnosed were Takayasu Arteritis (n = 10), Eosinophilic granulomatosis with polyangiitis (n = 9), Granulomatosis with Polyangiitis (n = 7), Periarteritis Nodosa (n = 5) and Behcet's disease (n = 4). The first symptom occurred before delivery in 26 (59.1%) and maternal death occurred in 4 (9.1%) out of the 44 primary vasculitis cases.

CONCLUSION

The vasculitis diagnosed in the post-partum period were mainly primary vasculitis among patients in whom the diagnosis had not been made during pregnancy. In less than half of cases and as described in ours, there were no reported symptoms before delivery. Therefore, the physicians should pay attention to symptoms and keep a high degree of suspicion for vasculitis before as well as after delivery.

Anesthetic management of cesarean section in a patient with Takayasu's arteritis: a case report

BACKGROUND

Takayasu's arteritis (TA) is a chronic, progressive, inflammatory arteritis. We presented the case of cesarean section in a patient with TA.

CASE PRESENTATION

A 31-year-old pregnant woman with TA underwent a planned cesarean section at 34 weeks of pregnancy. She had stenosis of the cerebral and coronary arteries and heart failure due to aortic regurgitation. Spinal anesthesia was performed. In addition to standard monitoring, arterial blood pressure in the dorsalis pedis artery and regional cerebral tissue oxygen saturation were monitored. Intraoperative arterial blood pressure was maintained using continuous infusion of noradrenaline with a careful intermittent bolus infusion of phenylephrine. All the procedures were successfully performed without significant complications.

CONCLUSIONS

In a pregnant woman with TA, severe stenosis of the cerebral and coronary arteries, and heart failure due to valvular heart disease, careful anesthetic management by selecting catecholamines and assessing the perfusion pressure for critical organs is important.

Combined Spinal-Epidural Anaesthesia for Caesarean Delivery in Takayasu's Arteritis: A Viable Alternative

Takayasu's arteritis (TA), also known as “pulseless disease”, is a nonspecific inflammatory arteritis of large and medium caliber arteries of unknown aetiology with a predilection for young women of childbearing age. Although the evolution of the disease is not affected during pregnancy, it can result in uncontrolled hypertension, multiple organ dysfunction, and stenosis that hinder regional blood flow. Associated pregnancy, therefore, poses an increased risk to the mother and foetus due to the many cardiovascular complications that can occur in the course of the disease, making anaesthesia for caesarean delivery especially challenging to the anaesthesiologist. We report the successful anaesthetic management of a case of TA undergoing caesarean section in view of a previous caesarean delivery. We also engage in a brief review of the related literature.

Pregnancy issues in Takayasu arteritis

Takayasu arteritis (TAK) is a chronic inflammatory vasculitis of unknown origin affecting large vessels, predominantly the aorta and its main branches. TAK usually affects young women and the management of pregnancy during this vasculitis may be a challenging situation. After a review of the literature, we analysed the data of 505 pregnancies in 373 TAK patients. We discuss main results to clarify if the pregnancy outcome is affected by TAK, especially during disease clinical onset or disease activity. We also discuss the potential impact of pregnancy on TAK prognosis. Disease activity of TAK appears independently associated with a poor pregnancy outcome. More than 5% of pregnant women with TAK develop a life-threatening maternal cardiovascular complication. A good control of TAK disease activity and arterial hypertension before conception and during pregnancy is critical to improve both maternal and foetal outcomes. Pregnancies in the setting of TAK should be considered high-risk, requiring a close collaboration between specialists involved in the care of TAK and obstetricians.

Management and evaluation of pregnant women with Takayasu arteritis

PURPOSE

To evaluate the clinical characteristics, obstetric/neonatal outcomes, and pregnancy complications of pregnant women with Takayasu arteritis (TA).

METHODS

We retrospectively evaluated the data of 22 pregnancies of 11 patients with TA between January 1 2000, and December 31 2017. Patient characteristics, severity of disease, obstetric outcomes, pregnancy complications, mode of delivery, and neonatal outcomes were evaluated.

RESULTS

Based on the angiographic classification, four, two, one, three, and one patient were classified into groups I, IIa, III, IV, and V, respectively. Based on Ishikawa criteria, five, two, two, and two patients were classified into groups 2a, 1, 2b, and 3, respectively. Sixteen and five pregnancies resulted in live births and spontaneous abortion, respectively. One pregnancy was terminated due to prenatally diagnosed trisomy 21. Relapse of TA was observed in five pregnancies. Mean age at diagnosis was 24.54 ± 6.23 years, and mean age at conception was 30.30 ± 4.80 years. There were two multiple pregnancies (one twin and one triplet) and 19 newborns were delivered alive. Rates of hypertensive disorders of pregnancy, preterm birth, intrauterine growth retardation, oligohydramnios, and intrauterine fetal demise were 36.4, 18.2, 13.6, 13.6, and 0%, respectively. Mean gestational age at birth was 37.25 ± 2.40 weeks and mean birthweight was 2682.10 ± 176.82 g. Median APGAR score was 8. Cesarean section rate was 50%. Regional anesthesia/analgesia was administered during 62.5% of the deliveries. Ten neonates were admitted to neonatal intensive care unit and eight neonates had neonatal respiratory complications.

CONCLUSION

Appropriate management of pregnant women with TA within the framework of antenatal care programs and adopting a multidisciplinary approach are key to ensure successful outcomes.

Successful spinal anaesthesia for caesarean section in an African patient with Takayasu's arteritis

Takayasu's arteritis (TA) is a rare chronic inflammatory disease affecting mainly the aorta and its main branches. We report a case of a 24-year-old primigravida, an African patient, with TA planned for caesarean section at 37 weeks of gestation. Clinically, she has involvement of aortic arch and its branches and abdominal aorta. She underwent caesarean section and delivered an alive baby boy under successful spinal anaesthesia with insignificant complications. Although it is rare in the African continent, anesthesiologists should be up-to-date with the knowledge of perioperative anesthetic management of TA in pregnant cases requiring operative delivery.

Takayasu's Arteritis in Pregnancy: A Rare Case Report from a Tertiary Care Infirmary in India

Background. Takayasu's arteritis (TA) is a rare, chronic, inflammatory, progressive, idiopathic arteriopathy, afflicting young women of reproductive age group, causing narrowing, occlusion, and aneurysms of systemic and pulmonary arteries, especially the aorta and its branches. During pregnancy, such patients warrant special attention. An interdisciplinary collaboration of obstetricians, cardiologists, and neurologists is necessary to improve maternal and fetal prognosis. Here a case is reported where a patient with diagnosis of TA, complicated by neurological sequelae, successfully fought the vagaries of the condition twice to deliver uneventfully. Case. 25-year-old G2P1L1 presented at 34 weeks of gestation, with chronic hypertension, with TA, with epilepsy, and with late-onset severe IUGR. Following a multidisciplinary approach, she delivered an alive born low birth weight baby (following induction). Her postpartum course remained uneventful. Conclusion. Pregnancy with TA poses a stringent challenge to an obstetrician. Despite advancements in cardiovascular management and advent of new-fangled drugs, the optimal management for pregnant patients with this disease still remains elusive.

Combined Spinal-Epidural for Vaginal Delivery in a Parturient With Takayasu's Arteritis

Takayasu's arteritis is a rare, progressive panendarteritis involving all layers of the arterial wall. This disease includes variable involvement of the aorta and its major branches. The most common complication with this condition is severe, uncontrolled hypertension, often leading to end organ dysfunction. We describe the management of a 27-year-old woman diagnosed with Takayasu's arteritis that presented in labor with intense pain and underwent a combined spinal-epidural for anesthetic management. Per literature review, a combined spinal-epidural technique for planned vaginal delivery has not been described for a laboring Takayasu patient. Our technique, utilizing intrathecal opioids and a low-dose local anesthetic-opioid epidural infusion, provided adequate analgesia while maintaining hemodynamic stability throughout labor augmentation and successful vaginal delivery.

Regional cerebral oxygen saturation guided cerebral protection in a parturient with Takayasu's arteritis undergoing cesarean section: a case report

The objective of this case report is to present the successful use of regional cerebral oxygen saturation (rScO2) monitoring guided cerebral protection for cesarean delivery in a parturient with Takayasu's arteritis at 38weeks' gestation. The parturient presented with impaired cerebral and renal perfusion. Titrated epidural anesthesia was performed. During the procedure, we used rScO2 guided cerebral protection strategies, which helped to optimize cerebral oxygen delivery and prevent cerebral complications.

Maternal and Neonatal Outcomes in 89 Patients with Takayasu Arteritis (TA): Comparison Before and After the TA Diagnosis

Objective.

To evaluate maternal and neonatal outcomes in patients before and after a diagnosis of Takayasu arteritis (TA).

Methods.

Patients diagnosed with TA according to the American College of Rheumatology criteria were selected from the Vasculitis Outpatient Clinic of the Rheumatology Division. Healthy female staff members of this hospital of similar age and educational level were selected as the controls. The disease data were obtained from an ongoing electronic database protocol. A standardized questionnaire, emphasizing gestational history, was applied to both groups. The prevalence of fetomaternal complications and disease variables were evaluated between the groups and a statistical analysis was performed.

Results.

A total of 89 patients with TA (156 pregnancies) and 89 healthy controls (181 pregnancies) were evaluated. There were 75.6% pregnancies that occurred before the TA diagnosis (pre-TA group) and 24.3% after (post-TA group). In the pre-TA group, higher rates of hypertension (HTN; 27.1% vs 3.9%, p < 0.001), low birth weight (16.8% vs 6.5%, p = 0.012), and perinatal mortality (7.9% vs 0.7%, p = 0.003) were observed compared with healthy controls. The frequency of abortions and the average number of children were similar in both groups (p > 0.05). Further comparison of the pre- and post-TA groups revealed similar rates of HTN, abortion, and low birth weight, and higher rates of Cesarean delivery (p = 0.002), prematurity (p < 0.001), and infection (p = 0.045) in the latter group.

Conclusion.

Our study identified that patients with TA, even before the disease diagnosis, have a worse fetal outcome that is most likely associated with high rates of HTN. TA was identified as an additional differential diagnosis for HTN in pregnancy.

Application of cerebral oximetry for a parturient with Takayasu's arteritis undergoing cesarean section -a case report-

Takayasu's arteritis (TA) is a chronic inflammatory disease involving the aorta. Because TA sometimes involves cerebral arteries, anesthetic debates focus on cerebral monitoring. There is limited evidence as to which cerebral monitoring method is most adequate. Furthermore, there is insufficient evidence to determine which anesthetic technique is better for TA parturients. We experienced the case of a TA parturient who developed transient cerebral ischemia during cesarean section. The patient's TA involved her cerebral arteries, and her regional cerebral oxygen saturation (rSO₂) was lower in the left side than in the right side. She complained of speech impairment, tinnitus, and stiffness of the posterior neck when the rSO₂ levels dropped. The FloTrac/Vigileo™ system did not correlate with clinical symptoms, but the cerebral oximeter displayed the low oxygen saturation. We recommend the cerebral oximetry for cerebral monitoring in TA parturients who undergo cesarean sections, especially in hemodynamically unstable patients under regional anesthesia or unconscious patients under general anesthesia.

Takayasus's arteritis in pregnancy. Case report and literature review

BACKGROUND AND OBJECTIVES

Takayasus's Arteritis (TA) is a chronic, inflammatory, progressive, idiopathic disease that causes narrowing, occlusion, and aneurysms of systemic and pulmonary arteries affecting especially the aorta and its branches. During pregnancy, one should pay special attention to these patients. The objective of this report was to present the peripartum anesthetic care of a patient with TA and a review of the literature.

CASE REPORT

This is a 31-year old gravida who underwent exchange of the aortic arch and placement of a metallic aortic valve for TA four years ago. She had no complications during pregnancy, and she was admitted at 34 weeks of pregnancy for anticoagulation management. Elective cesarean section was performed at 39 weeks with continuous epidural anesthesia. Fractionated doses of local anesthetic were administered to guarantee slow installation of the blockade. The patient remained hemodynamically stable and was transferred to the ICU in the postoperative period.

CONCLUSIONS

Several complications can affect gravidas with TA. Careful patient evaluation, treatment of TA complications, and anestheticsurgical planning are fundamental. Maintenance of perfusion is the main concern in these patients, and neuraxial blocks may be used without harming the mother and fetus. In patients with compensated TA complications, monitoring does not differ from that routinely used in cesarean sections. Continuous epidural anesthesia with slow installation maintains hemodynamic stability and allows monitoring cerebral perfusion through the level of consciousness. To avoid postoperative hypoperfusion or hypertensive complications patients should be monitored in an intensive or semi-intensive care unit for 24 hours.

[Treatment of large vessel vasculitis]

Large vessels vasculitis: Giant cells arteritis (GCA), and Takayasu's arteritis (TA) are a pair of systemic chronic inflammatory diseases characterized by specific involvement of large caliber, elastic-layered arteries. Presently, and derived from the paucity of clinical controlled trials approaching the issue, the management of GCA and TA is largely based on the clinical judgment of the treating physician. Glucocorticoids and immunosuppressive drugs are used when clear evidence of inflammatory activity is observed. The traditional management approach is to start with systemic glucocorticoid therapy at immunosuppressive dose, followed by cytotoxic immunosuppressive drugs (methotrexate, azatioprine, cyclophosphamide or mycofenolate mofetil) aimed at maintaining remission and decreasing corticosteroid therapy time. Recently, based on the potential pathogenic role of tumor necrosis factor α in these diseases, a series of reports addressing the benefic effect of αTNF-blockers in patients who have been resistant to the traditional management approach have been published. Non- reversible vascular lesions (such as occlusion or stenosis) may require surgical treatment (stent or bypass), however this must be done only when a complete control of the inflammatory activity has been reached.

Takayasu aortoarteritis with dilated cardiomyopathy: anesthetic management of labor analgesia

Takayasu aortoarteritis in a pregnant patient is often associated with severe life-threatening complications. The coexistence of associated dilated cardiomyopathy can further complicate the pregnancy, particularly during parturition and at the time of delivery. We describe the management of labor analgesia in a symptomatic parturient suffering from advanced Takayasu aortoarteritis with dilated cardiomyopathy and a recent episode of congestive cardiac failure. The patient was man-aged with graded epidural analgesia instituted early in labor. Intermittent boluses of 0.0625% bupivacaine with 2 microg/mL fentanyl were administered epidurally, which provided adequate analgesia without impaired hemodynamic status.