Outcome of pregnancy following intervention for coarctation of the aorta

High prevalence of pre-eclampsia in women with coarctation of the aorta

Aims

The aim was to study pregnancy outcomes in women with coarctation of the aorta (CoA) and associations to hypertensive disorders of pregnancy. Maternal morbidity and mortality are higher in women with heart disease and pre-eclampsia. Chronic hypertension, frequently encountered in CoA, is a risk factor for pre-eclampsia.

Methods and results

Clinical data from the National Unit for Pregnancy and Heart Disease database was reviewed for pregnant women with CoA from 2008 to 2021. The primary outcome was hypertensive pregnancy disorders. The secondary outcomes were other cardiovascular, obstetric, and foetal complications. Seventy-six patients were included, with a total of 87 pregnancies. Seventeen (20%) patients were treated for chronic hypertension before pregnancy. Fifteen (20%) patients developed pre-eclampsia, and 5 (7%) had pregnancy-induced hypertension. Major adverse cardiac events developed in four (5%) patients, with no maternal or foetal mortality. Maternal age at first pregnancy [odds ratio (OR) 1.37], body mass index before first pregnancy (OR 1.77), and using acetylsalicylic acid from the first trimester (OR 0.22) were statistically significantly associated with pre-eclampsia. At follow-up (median) 8 years after pregnancy, 29 (38%) patients had anti-hypertensive treatment, an increase of 16% compared to pre-pregnancy. Five (7%) patients had progression of aorta ascendens dilatation to >40 mm, seven (9%) had an upper to lower systolic blood pressure gradient >20 mmHg, and six (8%) had received CoA re-intervention.

Conclusion

Pre-eclampsia occurred in 20% of women with CoA in their first pregnancy. All pre-eclamptic patients received adequate anti-hypertensive treatment. All CoA patients were provided multi-disciplinary management, including cardiologic follow-up, to optimize maternal-foetal outcomes.

Coarctation of the Aorta: Diagnosis and Management

Coarctation of the aorta (CoA) accounts for approximately 5-8% of all congenital heart defects. Depending on the severity of the CoA and the presence of associated cardiac lesions, the clinical presentation and age vary. Developments in diagnosis and management have improved outcomes in this patient population. Even after timely repair, it is important to regularly screen for hypertension. Patients with CoA require lifelong follow-up with a congenital heart disease specialist as these patients may develop recoarctation and complications at the repair site and remain at enhanced cardiovascular risk throughout their lifetime.

Pregnancy outcomes in women with aortic coarctation

OBJECTIVE

Pregnancy in women with aortic coarctation (CoA) has an estimated moderately increased risk (mWHO II-III) of adverse cardiovascular, obstetric or fetal events, but prospective data to validate this risk classification are scarce. We examined pregnancy outcomes and identified associations with adverse outcomes.

METHODS

Pregnancies in women with CoA were selected from the worldwide prospective Registry of Pregnancy and Cardiac Disease (ROPAC, n=303 out of 5739), part of the European Society of Cardiology EURObservational Research Programme. The frequency of and associations with major adverse cardiac events (MACE) and hypertensive disorders (pregnancy-induced hypertension, (pre-)eclampsia or haemolysis, elevated liver enzymes and low platelets syndrome) were analysed.

RESULTS

Of 303 pregnancies (mean age 30 years, pregnancy duration 39 weeks), 9.6% involved unrepaired CoA and 27.1% were in women with pre-existing hypertension. No maternal deaths or aortic dissections occurred. MACE occurred in 13 pregnancies (4.3%), of which 10 cases were of heart failure (3.3%). Univariable associations with MACE included prepregnancy clinical signs of heart failure (OR 31.8, 95% CI 6.8 to 147.7), left ventricular ejection fraction <40% (OR 10.4, 95% CI 1.8 to 59.5), New York Heart Association class >1 (OR 11.4, 95% CI 3.6 to 36.3) and cardiac medication use (OR 4.9, 95% CI 1.3 to 18.3). Hypertensive disorders of pregnancy occurred in 16 (5.3%), cardiac medication use being their only predictor (OR 3.2, 95% CI 1.1 to 9.6). Premature births were 9.1%, caesarean section was performed in 49.7% of pregnancies. Of 4 neonatal deaths, 3 were after spontaneous extreme preterm birth.

CONCLUSIONS

The ROPAC data show low MACE and hypertensive disorder rates during pregnancy in women with CoA, suggesting pregnancy to be more safe and better tolerated than previously appreciated.

Significant infrarenal aortic stenosis in pregnancy: a case report

Background

Hypertension is common in pregnant women presenting with aortic coarctation or Takayasu’s arteritis. Uncontrolled hypertension leads to increased adverse maternal and neonatal events.

Case presentation

A 36-year-old gravida 2, para 1 Caucasian woman presented at 9 weeks of gestation with headaches but normal blood pressure. She had a past medical history of an in vitro fertilization pregnancy complicated by preeclampsia at 27 weeks of gestation (birth weight 1900 g) and infrarenal aortic stenosis. In the current pregnancy, she received aspirin and calcium as preeclampsia prophylaxis, remained normotensive throughout pregnancy, and was delivered by elective cesarean section at 37 weeks without complications.

Conclusions

This case demonstrates a significant chronic aortopathy in pregnancy with normal fetal growth and uterine blood flow through collateral supply from the internal mammary and epigastric arteries.

Electronic supplementary material

The online version of this article (10.1186/s13256-019-2057-0) contains supplementary material, which is available to authorized users.

Adult Congenital Heart Disease with Pregnancy

The number of women with congenital heart disease (CHD) at risk of pregnancy is growing because over 90% of them are grown-up into adulthood. The outcome of pregnancy and delivery is favorable in most of them provided that functional class and systemic ventricular function are good. Women with CHD such as pulmonary hypertension (Eisenmenger syndrome), severe left ventricular outflow stenosis, cyanotic CHD, aortopathy, Fontan procedure and systemic right ventricle (complete transposition of the great arteries [TGA] after atrial switch, congenitally corrected TGA) carry a high-risk. Most frequent complications during pregnancy and delivery are heart failure, arrhythmias, bleeding or thrombosis, and rarely maternal death. Complications of fetus are prematurity, low birth weight, abortion, and stillbirth. Risk stratification of pregnancy and delivery relates to functional status of the patient and is lesion specific. Medication during pregnancy and post-delivery (breast feeding) is a big concern. Especially prescribing medication with teratogenicity should be avoidable. Adequate care during pregnancy, delivery, and the postpartum period requires a multidisciplinary team approach with cardiologists, obstetricians, anesthesiologists, neonatologists, nurses and other related disciplines. Caring for a baby is an important issue due to temporarily pregnancy-induced cardiac dysfunction, and therefore familial support is mandatory especially during peripartum and after delivery. Timely pre-pregnancy counseling should be offered to all women with CHD to prevent avoidable pregnancy-related risks. Successful pregnancy is feasible for most women with CHD at relatively low risk when appropriate counseling and optimal care are provided.

Changes in echocardiographic parameters and hypertensive disorders in pregnancies of women with aortic coarctation

OBJECTIVES

Pregnancy can be well tolerated after the repair of aortic coarctation. However, a higher incidence of hypertensive disorders during these pregnancies was reported. We analyzed the perinatal changes in echocardiographic parameters in women with aortic coarctation and investigated the risk factors of gestational hypertension (GH).

METHODS

We retrospectively identified 15 pregnancies in nine Japanese women with aortic coarctation between 1982 and 2015. We categorized the patients according to the presence/absence of GH as the group with GH(n=3) and that without GH(n=12). The echocardiographic parameters were compared between groups.

RESULTS

Our analysis revealed that a pre-pregnancy Doppler-measured pressure gradient≥20mmHg and a left ventricular mass index≥95g/m² were significant risk factors for GH. The left ventricular end-diastolic diameters at the first and the third trimesters, the left ventricular end-systolic diameters at the first trimester, and the left ventricular ejection fraction at the third trimester were also significantly higher in the pregnancies with GH. All of these findings had been obtained before the patients' GH occurred.

CONCLUSIONS

Hypertrophy of the left ventricle with a lower ejection fraction and a high pressure gradient across the coarctation were risk factors for GH in the patients with aortic coarctation. Thus, serial measurements using echocardiography are important for predicting GH in women with aortic coarctation. However, further research investigating this finding with a larger sample size is needed.

Ruptured sinus of valsalva aneurysm and coarctation of aorta in a woman at early postpartum period

Coarctation of aorta and sinus of Valsalva aneurysm are frequently missed congenital cardiac defects that their diagnosis might be delayed. To our knowledge, coincidence of these cardiac defects is unusual and has not been reported in the literature before. Here, we present a patient with coarctation of aorta and ruptured noncoronary sinus of Valsalva aneurysm leading to aorto-right atrial fistula in the early postpartum period and our management of this unusual case.

Pregnancy complicated with severe recurrent aortic coarctation: a case report

A 23-year-old primigravida was referred to our clinic for evaluation of high blood pressure (BP) in her 16th week of gestation. She had an operation to repair congenital aortic coarctation and patent ductus arteriosus 8 years ago. On physical examination the blood pressure in upper extremity was 155/95 and in lower extremity was 90/55 mmHg, and heart rate was 93 beats/min. Transthoracic echocardiography showed narrowing of the descending aorta, the diameter of the aortic arch was 10.60 mm and an echocardiographic gradient was 96 mmHg. During the pregnancy (from 16 weeks to 38 weeks) BP was regulated with metoprolol. Cesarean section delivery was applied at 38 weeks of gestation. There was no complication in postpartum period. Spinal anesthesia application was used for caesarean section intervention and healthy female baby was delivered with the APGAR scores of 10/10. Herein the diagnosis of aortic coarctation is reviewed and the management when found during pregnancy is discussed.

Comparison of risk of hypertensive complications of pregnancy among women with versus without coarctation of the aorta

Hypertension is a common consequence of coarctation of the aorta. The frequency of hypertensive complications of pregnancy in women with coarctation in the general population is undefined. In this study, we used the 1998 to 2007 Nationwide Inpatient Sample, a nationally representative data set, to identify patients admitted to an acute care hospital for delivery. The frequency of hypertensive complications of pregnancy was compared between women with and without coarctation. Secondary outcomes, including length of stay, hospital charges, Caesarean delivery, and adverse maternal outcomes, were also assessed. There were an estimated 697 deliveries among women with coarctation, compared to 42,601,409 deliveries by women without coarctation. The frequency of hypertensive complications of pregnancy was 24.1 ± 3.3% for women with coarctation compared to 8.0 ± 0.1% for women without coarctation (multivariate odds ratio [OR] 3.6, 95% confidence interval [CI] 2.5 to 5.2). Preexisting hypertension complicating pregnancy (10.2 ± 2.5% vs 1.0% ± 0.02%, multivariate OR 10.8, 95% CI 5.9 to 19.8) and pregnancy-induced hypertension (13.9 ± 3.0% vs 7.0% ± 0.1%, multivariate OR 2.1, 95% CI 1.3 to 3.3) were more common in women with coarctation. Women with coarctation were more likely to deliver by Caesarean section (41.6 ± 3.3% vs 26.4% ± 0.2%, multivariate OR 2.0, 95% CI 1.4 to 2.8), have adverse cardiovascular outcomes (4.8 ± 2.2% vs 0.3 ± 0.01%, multivariate OR 16.7, 95% CI 6.7 to 41.5), have longer hospital stays, and incur higher hospital charges (both p values <0.0001) than women without coarctation. In conclusion, women with coarctation are more likely to have hypertensive complications of pregnancy, deliver by Caesarean section, have adverse cardiovascular outcomes, have longer hospitalizations, and incur higher hospital charges than women without coarctation.

Anaesthetic management for caesarean section in a parturient with uncorrected coarctation of the aorta

We present the case of a woman who refused RMI examination to diagnose a coarctation of her aorta before her third pregnancy. At term of 34 weeks of gestation the caesarean delivery was scheduled under spinal-epidural anaesthesia. Despite the use of a titrated regional anaesthesia, an important arterial hypotension occurred, restored with low doses of vasopressive agents.

An Unusual Cause of Hypertension in Pregnancy

Aortic coarctation is an unusual cause of hypertension in pregnancy. We report the case of a 34-year-old woman with severe hypertension after surgical repair of aortic coarctation in childhood. An MRI showed a residual stenosis of the aortic arch and a small aneurysm. Pregnant postcoarctectomy patients are at an increased risk for developing hypertension during pregnancy due to residual aortic gradients and abnormal vascular reactivity of the precoarctation vessels. Women after repair of aortic coarctation should be closely monitored for blood pressure during pregnancy.

[Management of heart diseases in pregnancy: rheumatic and congenital heart disease, myocardial infarction and post partum cardiomyopathy]

Heart disease is present in 0.5-1% of all pregnancies. It is the leading non-obstetric cause of maternal mortality accounting for about 10-15% of all maternal death. Over the last decades the underlying cardiac disease has changed. Also new therapeutic options have been developed. In western industrial countries the incidence of acquired rheumatic heart disease has declined. In contrast, as a result of neonatal corrective or palliative surgery, congenital heart disease has become an increasing and challenging problem. Maternal older age and the increase in women's smoking habits amplify the likelihood of coronary artery disease. Multiple therapeutic options including percutaneous interventions are available and novel therapeutic concepts are emerging i.e. for peripartum cardiomyopathy. Management of pregnancy, labor and delivery requires accurate diagnosis of the underlying cardiac disorder. Hemodynamic changes physiologically occurring during pregnancy have a different impact depending on the type and severity of cardiac anomalies. Management of these patients requires teamwork of obstetricians, neonatologists, cardiologists, anesthetists and sometimes cardiac surgeons.

Pregnancy: Maternal and Fetal Heart Disease

Cardiac disorders complicate less than 1% of all pregnancies. Physiologic changes in pregnancy may mimic heart disease. In order to differentiate these adaptations from pathologic conditions, an in-depth knowledge of cardiovascular physiology is mandatory. A comprehensive history, physical examination, electrocardiogram, chest radiograph, and echocardiogram are sufficient in most cases to confirm the diagnosis. Care of women with cardiac disease begins with preconception counseling. Severe lesions should be taken care of prior to contemplating pregnancy. Management principles for pregnant women are similar to those for the non-pregnant state. A team approach comprised of a maternal fetal medicine specialist, cardiologist, neonatologist, and anesthesiologist is essential to assure optimal outcome for both the mother and the fetus. Although fetal heart disease complicates only a small percentage of pregnancies, congenital heart disease causes more neonatal morbidity and mortality than any other congenital malformation. Unfortunately, screening approaches for fetal heart disease continue to miss a large percentage of cases. This weakness in fetal screening has important clinical implications, because the prenatal detection and diagnosis of congenital heart disease may improve the outcome for many of these fetal patients. In fact, simply the detection of major heart disease prenatally can improve neonatal outcome by avoiding discharge to home of neonates with ductal-dependent congenital heart disease. Fortunately, recent advances in screening techniques, an increased ability to change the prenatal natural history of many forms of fetal heart disease, and an increasing recognition of the importance of a multidisciplinary, team approach to the management of pregnancies complicated with fetal heart disease, together promise to improve the outcome of the fetus with congenital heart disease.

Outcome of pregnancy in women with congenital heart disease: a literature review

A search of peer-reviewed literature was conducted to identify reports that provide data on complications associated with pregnancy in women with structural congenital heart disease (CHD). This review describes the outcome of 2,491 pregnancies, including 377 miscarriages (15%) and 114 elective abortions (5%). Important cardiac complications were seen in 11% of the pregnancies. Obstetric complications do not appear to be more prevalent. In complex CHD, premature delivery rates are high, and more children are small for gestational age. The offspring mortality was high throughout the spectrum and was related to the relatively high rate of premature delivery and recurrence of CHD.

Biopsychosocial experiences of adults with congenital heart disease: review of the literature

BACKGROUND

Approximately 1% of all newborns display some form of congenital heart disease (CHD). Successful medical and surgical management of CHD has allowed 85% of these children to survive into adulthood and produced a new set of challenges for both patients and doctors with an emphasis on quality of life and psychosocial functioning.

METHODS

The current paper has 3 aims: (1) to summarize the research literature examining the emotional adjustment among this population, (2) to detail the psychological, social, and quality-of-life factors that might result in an increased risk of psychological maladjustment, and (3) to provide clinical management strategies to optimize health outcomes.

RESULTS

Current empirical evidence has suggested that compared with same aged reference norms in US studies, adults with CHD had scores indicative of worse emotional functioning as assessed by both clinical interviews and self-report measures. Similar European studies have generally not demonstrated such differences. Additional research suggests that areas of functioning that may be particularly affected include neurocognitive functioning, body image, social and peer relationships, and mild delays in developmental functioning.

CONCLUSIONS

These studies suggest that patients with CHD are successfully engaging in full adult responsibilities and roles but do experience specific psychosocial challenges that may impact emotional functioning, self-perception, and peer relationships. Lifestyle considerations in young adulthood are significant and impinge on pregnancy considerations and exercise capabilities. Clinical management strategies include increased awareness and dialogue between patients with CHD and physicians regarding psychosocial concerns.

Pregnancy in women with congenital heart disease

Congenital heart disease is the most common form of structural heart disease affecting women of childbearing age in developed countries. Pregnancy in these patients is associated with an increased risk to both mother and fetus. Appropriate prepregnancy evaluation and counseling is recommended to assess the pregnancy-related maternal and fetal risk and to identify patients who should avoid pregnancy. Once pregnancy occurs, cardiovascular reevaluation is generally recommended; the frequency is individualized. Monitoring during delivery may be necessary and the postpartum period is a concern in select individuals. Data regarding the outcome of pregnancy in patients with operated congenital cardiac defects are available. Individualized care is mandatory.

Outcome of pregnancy in patients after repair of aortic coarctation

AIMS

Nowadays, most women born with aortic coarctation reach childbearing age. However, data on outcome of pregnancy in women after repair of aortic coarctation are scarce. The aim of this study was to report on maternal and neonatal outcome of pregnancy in women after aortic coarctation repair.

METHODS AND RESULTS

The CONCOR national registry on congenital heart disease in The Netherlands was reviewed for women of childbearing age (> or =18 years old) with a history of aortic coarctation repair. Medical history and maternal, obstetrical, and neonatal outcome were determined. Fifty-four of the 100 women included had a history of pregnancy. The 54 women had 126 pregnancies resulting in 98 successful pregnancies, 22 miscarriages, and six abortions. The success rate was estimated as 0.778 (SE 0.002) including abortions and 0.817 (SE 0.002) excluding abortions. There were 85 vaginal deliveries, seven vaginal deliveries with epidural analgesia, and six caesarean sections. There were two neonatal deaths. A total of 26 pregnancies were complicated by a hypertensive disorder of pregnancy. There were 21 pregnancies in 14 women complicated by hypertension and five pregnancies in four women complicated by pre-eclampsia. The hypertension- and pre-eclampsia-probabilities were estimated as 0.183 (SE 0.285) and 0.061 (SE 0.211), respectively. During pregnancy, five patients had an increase > or =15 mmHg across the site of repair at echocardiography, but only one patient required reintervention for recoarctation after delivery. Four of the 98 children (4%) had a congenital heart defect.

CONCLUSION

Pregnancy is well tolerated in women after repair of aortic coarctation. However, an excess of miscarriages and hypertensive disorders of pregnancy were found.

Hepatic ischemia associated with coarctation of the aorta in pregnancy: key issues in differential diagnosis

BACKGROUND

Hepatic ischemia associated with coarctation of the aorta has not previously been reported in an adult; pregnancy increases the pressure gradient across a coarctation.

CASE

A young woman with known coarctation of the aorta developed severe hepatic ischemia in pregnancy. A pregnancy-induced increase in the mean pressure gradient across the coarctation, from 18 mm Hg before pregnancy to 40 mm Hg in the third trimester, predisposed to critical hepatic hypoperfusion in the setting of dehydration.

CONCLUSION

This case documents an association between coarctation of the aorta and hepatic ischemia, precipitated by pregnancy and dehydration in combination. It emphasizes the need in the assessment of patients with liver disease in pregnancy to consider not only "traditional" pregnancy-related conditions such as acute fatty liver and the hemolysis, elevated liver enzymes, low platelets syndrome, in which delivery may be necessary as a clinical emergency, but also those in which the circulatory and metabolic demands of pregnancy may precipitate liver injury.

Anaesthetic management of aortic coarctation in pregnancy

We report two cases of aortic coarctation in pregnancy. The first was a 20-year-old nulliparous woman who underwent an aortic coarctation repair when she was 23 weeks old and subsequently developed an aneurysm at the site of initial repair. The second was a 20-year-old nulliparous woman with a severe uncorrected congenital aortic coarctation and upper body hypertension, who became pregnant whilst awaiting transcatheter dilatation of the coarctation. Antenatal care involved a multidisciplinary approach with obstetric, anaesthetic and cardiology input. Both parturients were delivered by elective caesarean section. A cautious, incremental regional anaesthetic technique was used, with no associated maternal or neonatal morbidity. Perioperative management focused on minimising haemodynamic disturbances. The management is discussed, together with the potential maternal and fetal complications of aortic coarctation in pregnancy.

Coarctation of the aorta: outcome of pregnancy

OBJECTIVES

The study sought to determine the outcome of pregnancy in women with coarctation of the thoracic aorta.

BACKGROUND

Patients with coarctation of the thoracic aorta are expected to reach childbearing age, but data on the outcome of pregnancy in this population are limited.

METHODS

The Mayo Clinic database was reviewed for women of childbearing age (> or =16 years old) with a diagnosis of aortic coarctation evaluated from 1980 to 2000. Spectrum of cardiovascular disease, surgical history, and obstetrical and neonatal outcomes were determined.

RESULTS

Fifty women with coarctation had pregnancies: 30 had coarctation repair before pregnancy, 10 had repair after pregnancy, 4 had repair both before and after pregnancy, and 6 had no history of repair. The 50 women had 118 pregnancies resulting in 106 births. There were 11 miscarriages (9%), 4 premature deliveries (3%), and 1 early neonatal death; 38 deliveries (36%) were by cesarean section. Of the 109 offspring, 4 (4%) had congenital heart disease. A patient with Turner syndrome died of a Stanford type A dissection at 36 weeks of pregnancy. Nineteen women (38%) were known to have hemodynamically significant coarctation during pregnancy (gradient > or =20 mm Hg). Fifteen women (30%) had hypertension during their pregnancy, 11 of whom (73%) had hemodynamically significant coarctation during that time (8 with native and 3 with residual/recurrent coarctation).

CONCLUSIONS

Major cardiovascular complications were infrequent but continue to be a source of concern for patients with coarctation who become pregnant. Systemic hypertension during pregnancy was common and related to the presence of a significant coarctation gradient.

Management of the critically ill cardiac patient

The decline in rheumatic fever has made heart disease in pregnancy an uncommon problem in the developed world but it remains an important cause of maternal morbidity and mortality in developing countries. Pregnancy is particularly dangerous in the presence of cyanotic congenital heart disease, Eisenmenger's syndrome, primary pulmonary hypertension, Marfan's syndrome, dilated cardiomyopathy and significant mitral stenosis. Severe stenosis is often complicated by pulmonary hypertension and atrial fibrillation. Maternal disease status should be determined using echocardiography to define cardiac anatomy, assess ventricular function and estimate intracardiac pressure gradients. Patients in the New York Heart Association functional classes 1 and 2 generally have a favourable outcome. Closed mitral commissurotomy is safe and effective in relieving stenosis across the mitral valve in selected patients. More recently the technique of percutaneous balloon mitral valvotomy has successfully been used in the treatment of mitral stenosis. Termination of pregnancy is advised in patients with severe pulmonary hypertension, including Eisenmenger's syndrome.

Axillofemoral bypass for recurrent atypical coarctation of the thoracic aorta. Woman in childbearing age

Various surgical techniques for recurrent atypical coarctation have been described, and extra-anatomic bypass with a thoracotomy or a sternotomy approach has been widely recommended. We report a case where axillofemoral bypass has been used to treat a 28-year-old woman with recurrent atypical coarctation. Ordinarily, she had not suffered greatly from hypertension, but she experienced repeated miscarriages most probably owing to uncontrolled hypertension over 200 mmHg during pregnancy. We chose an axillofemoral bypass for extra-anatomic bypass to manage intractable hypertension during pregnancy. Postoperatively, her hemodynamics improved substantially, particularly during pregnancy, and two children were successfully delivered. The patient remains in excellent condition 74 months after operation. We suggest that an axillofemoral bypass will become an option among surgical techniques for recurrent coarctation under individual circumstances.