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Trajkovski AV, Reiner K, Džaja N, Mamić G, Mažar M, Peršec J, Gluncic V, Lukic A. Anesthetic management for cesarean section in two parturient with ascending aortic aneurysm: a case-based discussion. BMC Anesthesiol 2024; 24:169. [PMID: 38711027 DOI: 10.1186/s12871-024-02553-2] [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] [Received: 11/09/2023] [Accepted: 04/30/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND The anesthetic management of parturients with ascending aortic aneurysm for cesarean section can be particularly challenging, primarily because of increased risk for aortic dissection or aneurysm rupture. CASE PRESENTATION We present some aspects of the anesthetic management of two parturients with ascending aortic aneurysm for cesarean sections; amongst, the use of remifentanil with its effects on patient and newborn. We emphasize the importance of a cardio-obstetric team in the context of preoperative planning of such patients. Also, we reviewed some literature on the anesthetic management with its effect on peri-operative hemodynamic stability. CONCLUSION Maintaining hemodynamic stability is paramount in the prevention of the rupture or dissection of ascending aortic aneurysm during labor of parturient.
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Affiliation(s)
- Ana Vuzdar Trajkovski
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Krešimir Reiner
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Nikolina Džaja
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Gloria Mamić
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Mirabel Mažar
- Department of Anesthesiology and Intensive Care in Cardiac and Vascular Surgery, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Jasminka Peršec
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, University Clinical Hospital Dubrava, Avenija Gojka Šuška 6, Zagreb, 10000, Croatia
| | - Vicko Gluncic
- Department of Anesthesia, Advocate Illinois Masonic Medical Center, 836 W Wellington Ave, Chicago, IL, 60657, USA
| | - Anita Lukic
- Department of Anesthesia, Intensive Medicine, and Reanimation, Varazdin General Hospital, 1 I. Mestrovica Street, Varazdin, 42 000, Croatia.
- University North, Ul. 104. Brigade 3, Varazdin, 42 000, Croatia.
- Bjelovar University of Applied Sciences, Nursing Studies, 4 Eugena Kvaternika Square, Bjelovar, HR-43000, Croatia.
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Moirano J, Khoury J, Yeisley C, Noor A, Voutsinas N. Interventional Radiology and Pregnancy: From Conception through Delivery and Beyond. Radiographics 2023; 43:e230029. [PMID: 37440450 DOI: 10.1148/rg.230029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
Interventional radiology (IR) plays a unique and often invaluable role in the care of pregnant patients. Special considerations regarding radiation exposure and medication choice must be taken into account when evaluating a pregnant patient for an interventional procedure. In addition, the physiologic changes that occur during pregnancy can pose special challenges for an interventionalist when treating this patient population and should be appropriately recognized. Still, the majority of standard IR procedures can be safely performed in the pregnant population, often with additional precautions and proper patient education about the risks, benefits, and alternatives. In many cases, interventional radiologists can provide lifesaving and fertility-preserving alternatives to more invasive surgical intervention. The authors summarize radiation exposure effects and guidelines and medication choice during pregnancy. The physiologic changes that occur during pregnancy are discussed, with specific interest in the pathologic consequences that can be treated with IR. The authors also describe a wide variety of minimally invasive image-guided procedures offered by IR in pregnant, peripartum, or postpartum patients. The areas where IR can help in the treatment of pregnant patients include venous access, biopsies, genitourinary and biliary interventions, venous thromboembolism treatments, ectopic pregnancy management, aneurysm intervention, and management of trauma patients. IR is also involved in management during the peripartum or postpartum periods, with roles in treatment of invasive placenta spectrum, postpartum hemorrhage after vaginal delivery, and postcesarean delivery complications. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Joseph Moirano
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr, Manhasset, NY 11030 (J.M.); Department of Radiology, Division of Vascular and Interventional Radiology, Northwell Health, Manhasset, NY (J.K., C.Y.); Department of Radiology, Division of Vascular and Interventional Radiology, NYU Grossman School of Medicine, New York, NY (A.N.); and Department of Radiology and Radiologic Sciences, Division of Vascular and Interventional Radiology, Vanderbilt University School of Medicine, Nashville, Tenn (N.V.)
| | - Joe Khoury
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr, Manhasset, NY 11030 (J.M.); Department of Radiology, Division of Vascular and Interventional Radiology, Northwell Health, Manhasset, NY (J.K., C.Y.); Department of Radiology, Division of Vascular and Interventional Radiology, NYU Grossman School of Medicine, New York, NY (A.N.); and Department of Radiology and Radiologic Sciences, Division of Vascular and Interventional Radiology, Vanderbilt University School of Medicine, Nashville, Tenn (N.V.)
| | - Christopher Yeisley
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr, Manhasset, NY 11030 (J.M.); Department of Radiology, Division of Vascular and Interventional Radiology, Northwell Health, Manhasset, NY (J.K., C.Y.); Department of Radiology, Division of Vascular and Interventional Radiology, NYU Grossman School of Medicine, New York, NY (A.N.); and Department of Radiology and Radiologic Sciences, Division of Vascular and Interventional Radiology, Vanderbilt University School of Medicine, Nashville, Tenn (N.V.)
| | - Amir Noor
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr, Manhasset, NY 11030 (J.M.); Department of Radiology, Division of Vascular and Interventional Radiology, Northwell Health, Manhasset, NY (J.K., C.Y.); Department of Radiology, Division of Vascular and Interventional Radiology, NYU Grossman School of Medicine, New York, NY (A.N.); and Department of Radiology and Radiologic Sciences, Division of Vascular and Interventional Radiology, Vanderbilt University School of Medicine, Nashville, Tenn (N.V.)
| | - Nicholas Voutsinas
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr, Manhasset, NY 11030 (J.M.); Department of Radiology, Division of Vascular and Interventional Radiology, Northwell Health, Manhasset, NY (J.K., C.Y.); Department of Radiology, Division of Vascular and Interventional Radiology, NYU Grossman School of Medicine, New York, NY (A.N.); and Department of Radiology and Radiologic Sciences, Division of Vascular and Interventional Radiology, Vanderbilt University School of Medicine, Nashville, Tenn (N.V.)
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Thakkar A, Hameed AB, Makshood M, Gudenkauf B, Creanga AA, Malhamé I, Grandi SM, Thorne SA, D'Souza R, Sharma G. Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity. JACC. ADVANCES 2023; 2:100275. [PMID: 37560021 PMCID: PMC10410605 DOI: 10.1016/j.jacadv.2023.100275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 08/11/2023]
Abstract
Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.
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Affiliation(s)
- Aarti Thakkar
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Afshan B. Hameed
- Department of Obstetrics & Gynecology, Department of Medicine, University of California-Irvine, Irvine, California, USA
| | - Minhal Makshood
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brent Gudenkauf
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Isabelle Malhamé
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sonia M. Grandi
- Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara A. Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Wang X, Liu X, Liao E, Ge N, Hu Y. Pregnancy complicated with aortic dissection: Two cases report. Medicine (Baltimore) 2022; 101:e31487. [PMID: 36343070 PMCID: PMC9646651 DOI: 10.1097/md.0000000000031487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
RATIONALE This study aims to investigate the characteristics of pregnancy complicated with aortic dissection (AD), diagnosis and treatment plan, and maternal and infant outcomes. PATIENT CONCERNS Two pregnant women suffered persistent back pain were admitted to Hubei Maternal and Child Health Hospital from December 2019 to December 2020. DIAGNOSIS Pregnant women with chest and back pain and especially hypertension should be highly suspected of AD. However, to confirm diagnosis results, laboratory tests such as D-dimer, fibrinogen and white blood cells, and even some Special examination, cardiac ultrasound, computed tomographic angiography (CTA), magnetic resonance angiography (MRA), are required. Early diagnosis and intervention can improve maternal and infant outcomes. INTERVENTIONS Cesarean sections were performed in both patients. Case 1 underwent thoracic aortic stent implantation one day after the onset of AD symptoms. Case 2 received endovascular repair of AD 4 days after the onset of AD symptoms. OUTCOMES In these two cases, good maternal and infant outcomes were obtained through effective early identification and treatment. LESSONS AD is characterized with an acute onset, and the rates of misdiagnosis and missed diagnosis are high, which seriously endangers the life of mother and child. Hypertension is one of the high-risk factors causing AD. Good maternal and infant outcomes can be achieved by early identification, multidisciplinary collaboration and timely cardiac surgical intervention.
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Affiliation(s)
- Xiaoli Wang
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xi Liu
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - E. Liao
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Ge
- Radiology Department, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yaping Hu
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * Correspondence: Yaping Hu, Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, No. 745, Wuluo Road, Hongshan District, Wuhan 430070, China (e-mail: )
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Chin JM, Bartholomew ML. Aortic aneurysm and dissection in pregnancy: A case report. Case Rep Womens Health 2020; 28:e00261. [PMID: 33083238 PMCID: PMC7554023 DOI: 10.1016/j.crwh.2020.e00261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022] Open
Abstract
We describe a 24-year-old pregnant woman at 34 weeks of gestation who presented to a community hospital with sharp chest pain radiating to her back. She was found to have a 6 cm ascending aortic aneurysm despite not having any established risk factors. She was transported by air ambulance to a tertiary-care hospital. She delivered a live female neonate via cesarean delivery. Her postpartum course was notable for multiple episodes of chest pain and multiple imaging studies that were read as negative for aortic dissection. Definitive valve surgery was postponed by the cardiothoracic surgeons to allow for recovery from severe preeclampsia, treatment of endometritis, and due to concerns for uterine bleeding while on anticoagulation during cardiopulmonary bypass. She was eventually transferred to another hospital in another state for valve-sparing surgery. During transport, she developed a pulmonary embolism, and after arrival an aortic dissection was confirmed. She received a mechanical aortic valve replacement and the aneurysm was repaired. She returned home and recovered without complication. A gene panel revealed a heterozygous pathogenic variant of the Filamin A gene. Aortic aneurysms during pregnancy are rare, and aortic dissections are more rare. We recommend expeditious surgical treatment, a heightened index of suspicion, and testing for a genetic cause of aneurysm when diagnosed in a pregnant or postpartum woman with no known risk factors. Aortic aneurysm in pregnancy is rare and mortality is high. Genetic testing should be performed with a new diagnosis of aortic aneurysm. Multidisciplinary care is essential for aortic aneurysm in pregnancy.
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Affiliation(s)
- Jennifer M Chin
- University of Hawaii, Department of Obstetrics, Gynecology, and Women's Health, 1319 Punahou St, Ste 824, Honolulu, HI 96826, USA
| | - Marguerite L Bartholomew
- University of Hawaii, Department of Obstetrics, Gynecology, and Women's Health, 1319 Punahou St, Ste 824, Honolulu, HI 96826, USA
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6
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Rimmer L, Heyward-Chaplin J, South M, Gouda M, Bashir M. Acute aortic dissection during pregnancy: Trials and tribulations. J Card Surg 2020; 36:1799-1805. [PMID: 32996191 DOI: 10.1111/jocs.15068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Type A acute aortic dissection (TAAD) during pregnancy is a life-threatening event for both the mother and the unborn baby. Pregnancy has been recognized as an independent risk factor for TAAD, postulated to be due to physiological changes that cause hyperdynamic circulation. This review seeks to outline the current controversies around this unique group. METHODS A comprehensive literature search was carried out across large databases to assimilate relevant papers regarding acute aortic dissection in pregnant women. RESULTS The presentation can be atypical in many cases and further concern from clinicians of fetal radiation exposure can result in missed or delayed diagnoses. Investigation via the quickest form of imaging, whether computed tomography, magnetic resonance imaging, or transesophageal echocardiography, should be carried out promptly due to the high risk of mortality. Surgical management of TAAD in pregnancy revolves primarily around the decision to deliver the fetus concomitantly or to perform the aortic repair with the fetus in utero. CONCLUSIONS Management of this group includes rapid and dynamic assessment without delay. From conception to postpartum, there are multiple stages in which to manage these women. Challenges in carrying out management in the form of operative techniques and cardiopulmonary bypass place the fetus at risk and must be approached with caution, particularly as there is little evidence-base for many of these decisions. Further research into reducing maternal and fetal mortality is necessary.
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Affiliation(s)
- Lara Rimmer
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Jessica Heyward-Chaplin
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Matthew South
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Mohamed Gouda
- Department of Vascular and Endovascular Surgery, Mataria Teaching Hospital, Cairo, Egypt
| | - Mohamad Bashir
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
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Makatsariya A, Radetskaya L, Bitsadze V, Khizroeva J, Khamani N, Makatsariya N. Prenatal care and labor in patients with mesenchimal dysplasias (Marfan syndrome, Ehlers-Danlos syndrome, hereditary hemorrhagic telangiectasia). J Matern Fetal Neonatal Med 2018; 33:373-379. [PMID: 29938556 DOI: 10.1080/14767058.2018.1493102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Mesenchymal dysplasias or inherited connective tissue diseases are the group of diseases with deficiency of various components of connective tissue. Connective tissue disorders can affect different organs: skeleton, sight organ, skin, lungs, heart. But the most dangerous is vascular wall insufficiency leading to high risk of hemorrhage, especially during pregnancy and delivery due to hemodynamic and hormonal effects on the walls of the modified vessels.Aim: To evaluate the risk of complications during the pregnancy and delivery in patients with mesenchymal dysplasias.Study design: Fifty-six pregnancies in patients with mesenchymal dysplasias, including subclinical forms of diseases: 23 with Marfan syndrome (I group), 22 with Ehlers-Danlos syndrome (II group), and 11 with Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia) (III group) of the age from 18 to 36. The study included retrospective analysis (for the period from 1993 to 2005) and prospective study. Results of study showed high risk of life-threatening complications during pregnancy and delivery, especially the risk of hemorrhage and cardiovascular complications. In all the patients, we observed the progression of bleeding or development of bleeding in new localizations (epistaxis in 27 patients, easy brushing in 22, skin and mucosa telangiectasia in 20, gastrointestinal bleedings in 4, hemoptysis in 4, hematomas for minor traumas in 14, conjunctivas hemorrhages in 5).Conclusion: The pathogenesis of bleeding in such patients has mixed pattern: besides vascular wall pathology coagulation deficiency plays some role. The preferred delivery method for such patients is caesarean section. Deep vaginal ruptures and serious hemorrhage accompany vaginal delivery.
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Affiliation(s)
- Alexander Makatsariya
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Lyudmila Radetskaya
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Viktoriya Bitsadze
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Jamilya Khizroeva
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Nadin Khamani
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Natalya Makatsariya
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Keepanasseril A, Thendral N, Dorairajan G, Subbaih M, Pillai AA, Sai Chandran BV. Management of aortic aneurysm presenting during pregnancy: A case report. Obstet Med 2018; 13:37-40. [PMID: 32284731 DOI: 10.1177/1753495x18782627] [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: 03/06/2018] [Accepted: 05/18/2018] [Indexed: 11/15/2022] Open
Abstract
Aortic aneurysm in pregnancy is associated with higher risk of complications due to the stress induced by the physiologic changes in pregnancy. Many of the reports are concentrated on those with catastrophic outcomes or who underwent surgical repair during pregnancy/puerperium. We report a case of aortic aneurysm, who presented during the second trimester and had a successful pregnancy outcome, and discuss the various issues concerning the management during pregnancy.
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Affiliation(s)
- Anish Keepanasseril
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - N Thendral
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Gowri Dorairajan
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Murali Subbaih
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Ajith Ananthakrishna Pillai
- Department of Cardiology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - B V Sai Chandran
- Department of Cardio-Thoracic & Vascular Surgery, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
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