Aortic coarctation diagnosed after hypertension in pregnancy

"Mind Your Arch"-An Unusual Cause of Systemic Hypertension in Pregnancy

•CoA must be considered in a young patient with severe uncontrolled hypertension. •Presentation may be delayed due to extensive collateral circulation. •Multimodality imaging is often necessary for preprocedural planning. •Despite treatment there is continued risk for long-term vascular disease.

Aortopathy in pregnancy

Up to half of all aortic dissections and ruptures in women younger than 40 years are associated with pregnancy. In pregnancy, women with aortic disease such as arteritis and aortitis are at significant risk of aneurysmal formation and dissection with potential for catastrophic outcomes. Pregnancy places predisposed women at an increased risk of dissection due to physiological and hormonal changes that occur, particularly those with connective tissue disorders, genetic syndromes, congenital heart disease, and other heritable and acquired conditions involving the aorta. Thus, preconception counseling and preparation are advised to determine which patients may cautiously pursue pregnancy, to optimize medical management prior to conception (antihypertensive medications and anticoagulants in the setting of mechanical valves), to identify women in whom aortic root repair should occur prior to pregnancy, and lastly, those in whom pregnancy is contraindicated. Additionally, discussion of the heritable nature of many aortic conditions and associated syndromes is indicated. Preconception and genetic counseling, management by a multidisciplinary team, along with close echocardiographic surveillance and medical management, are recommended if precursors of dissection are identified.

A Pregnant Patient with Native Aortic Coarctation and Aneurysm

Uncorrected coarctation is rare and is known to cause hypertension in adult patients. Retrospective observational studies showed hypertension and occasionally aortic dissection to be the principal risks during pregnancy after correction of aortic coarctation. We present a case of a patient with known hypertension, who presented at 32 weeks of gestation. A saccular aortic aneurysm of 4.5 × 8.8 cm was found by echocardiogram and confirmed with a chest X-ray. She delivered a healthy girl by caesarean section. After delivery a CT-angiography was performed showing a stable situation. Two months postpartum she was successfully operated. We present images of echocardiography, X-ray, CT and the surgical procedure. We discus the literature on native coarctation and the management choices in this difficult case.

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.

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.