Indications for peripartum aortic pressure monitoring in Takayasu's disease. A patient with past history of intrapartum cerebral hemorrhage

Pregnancy and Takayasu arteritis: a single centre experience from North India

AIM

Takayasu's syndrome is a chronic inflammatory arteriopathy of unknown origin which primarily affects women of reproductive age. We report the course and outcome of 37 pregnancies in 15 women with Takayasu arteritis during the period 1999-2008.

METHODS

A retrospective analysis of 9 years was carried out in a tertiary hospital in Northern India. The effect of disease on the course of pregnancy, complications during pregnancy and perinatal outcome were analyzed.

RESULTS

Hypertension was the most common presenting feature (27%). In the majority of the patients, vessels involved were the subclavian artery and arch of the aorta. Superimposed preeclampsia complicated 62% of pregnancies while 16% of pregnancies had intrauterine growth retardation. Six patients had preterm delivery and one had preeclampsia and placental abruption. The mean gestational age at delivery was 36 +/- 3 weeks. The majority of the patients had a vaginal delivery. There was one maternal death due to accelerated hypertension and its complications.

CONCLUSION

Adequate control of blood pressure during pregnancy, planning the timing and mode of the delivery and vigilant monitoring during intrapartum period with special reference to management of blood pressure and its complications is essential for an optimum outcome.

Takayasu's arteritis in pregnancy: review of literature and discussion

Takayasu's arteritis (TA) is a rare inflammatory disease of the arteries that affects women of childbearing age. The optimal management for pregnant patients with this disease has not yet been defined. The course of disease seems to be neither affected nor worsened by pregnancy. We could not find reported maternal deaths directly related to pregnancy. However, many authors report maternal as well as fetal unfavorable events in the course of pregnancy. We describe a 25-year-old primigravida of Turkish-Greek origin who presented at 30 weeks of pregnancy with active TA. In the 37(th) week, intrauterine fetal death occurred. Our patient did not show high blood pressure or aortic inflammation. The course of her disease was stable. Whether a newly diagnosed TA during pregnancy should be regarded as an indication for premature delivery is discussed. An interdisciplinary collaboration of rheumatologists, nephrologists and obstetricians is necessary to improve maternal and fetal prognosis.

Pregnancy and vasculitis

Until recently, the prognosis associated with many forms of systemic vasculitis was quite grim. Advances in this field have allowed us to begin to focus on issues related to quality of life such as fertility, conception, and pregnancy among women with vasculitis. Because the systemic vasculitides are rare diagnoses, many important questions remain unanswered. Overall, it seems that women who have inactive vasculitis may not be subject to unusual complications during pregnancy, but our understanding of the interaction between pregnancy and specific forms of vasculitis continues to evolve.

Pregnancy in vasculitis

Little is known about pregnancy in patients with vasculitis because of the nature of these diseases and the potential for infertility to occur from effective treatments. However, with the expanding armamentarium of therapeutic options that do not affect reproductive function, it is anticipated that more vasculitis patients will entertain the possibility of conception and consider the outcomes of pregnancy. Relevant issues include the effects of the vasculitis on pregnancy, the effects of the pregnancy on vasculitic disease activity, and the impact of medications used during the peripartum period. Although available data are limited and fall short in many regards, there is support for successful outcomes of pregnancy when conception occurs in disease remission. Maternal and fetal outcome is optimized by the establishment of a multidisciplinary team that can provide preconception evaluation and counseling followed by frequent monitoring throughout the pregnancy and the postpartum period.

Outcome of pregnancy in Takayasu arteritis

Of 124 patients with Takayasu arteritis studied over a period of 20 years (1979-1999), 12 female patients experienced 24 pregnancies. The mean age was 23.6+/-3.6 years. The presenting features during pregnancy were severe hypertension (11 patients), congestive heart failure (two patients) and unequal pulses (one patient). Aortography revealed that abdominal aorta was involved in 11 patients and renal arteries in nine patients. Of 17 live babies born, intrauterine growth retardation was present in five babies and premature deliveries were encountered in four patients. Pregnancies resulted in abortion in two patients and intrauterine death in five patients. Maternal complications included superimposed pre-eclampsia in four patients, congestive heart failure and progression of renal insufficiency in two patients each and post partum sepsis in one patient. All patients with poor perinatal outcome had abdominal aortic involvement and a significant delay in seeking medical attention.