Aortic regurgitation in pregnancy
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Isolated aortic insufficiency in pregnant patients can be managed with combination of diuretics and vasodilators[1]. ACE inhibitors are contraindicated in pregnancy. Patients with signs and symptoms of left ventricular failure should be monitored throughout labor and delivery with strict attention to volume status and blood pressure.
Risk Stratification[2]
High risk: Aortic insufficiency associated with NYHA class III to IV symptoms, Marfan syndrome or left ventricular ejection fraction of less than 40%. Such patients ideally should undergo definitive surgical therapy before pregnancy. If patient is already pregnant, termination of pregnancy is recommended.
Low risk: Aortic insufficiency associated with NYHA class I to II symptoms. Such women generally tolerate pregnancy without complications and the natural fall in systolic blood pressure during pregnancy may be beneficial in reducing the regurgitant volume.
Aortic root dilatation in pregnant patients with Marfan syndrome are at increased risk of developing aortic dissection or rupture which usually occur in third trimister or near time of delivery. Patients are at high risk if aortic root diameter is greater than 40mm with approximately 10% probability of developing aortic dissection[3] [2]. Women with marfan syndrome should be counseled against pregnancy and should undergo screening transthoracic echocardiogram to assess the aortic root dimensions. However, replacement of aortic root and ascending aorta may be considered if the aortic diameter exceeds 40 mm in women with marfan syndrome who are contemplating pregnancy[4]. Beta blockers can be used prophylactically throughout pregnancy with labetalol or metoprolol being the preferred drugs [2]. As per AHA/ACC 2006 guidelines, serial transthoracic echocardiogram and regular monitoring of blood pressure throughout the pregnancy with providing adequate analgesia during labor are recommended. Shortening of second stage of labor using various obstetric techniques may be beneficial. In patients with an aortic root diameter greater than 40 mm, severe aortic regurgitation, heart failure or aortic dissection, cesarean delivery with general anesthesia is preferred as it allows optimal hemodynamic control.[4] [5]
References
- ↑ Sheikh F, Rangwala S, DeSimone C, Smith HS, O'Leary AM (1995). "Management of the parturient with severe aortic incompetence". Journal of Cardiothoracic and Vascular Anesthesia. 9 (5): 575–7. PMID 8547563. Retrieved 2011-03-25. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 2.2 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved 2011-03-25. Unknown parameter
|month=ignored (help) - ↑ "Expert consensus document on management of cardiovascular diseases during pregnancy". European Heart Journal. 24 (8): 761–81. 2003. PMID 12800857. Retrieved 2011-03-25. Unknown parameter
|month=ignored (help) - ↑ 4.0 4.1 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780. Retrieved 2011-03-25. Unknown parameter
|month=ignored (help) - ↑ Elkayam U, Ostrzega E, Shotan A, Mehra A (1995). "Cardiovascular problems in pregnant women with the Marfan syndrome". Annals of Internal Medicine. 123 (2): 117–22. PMID 7778824. Retrieved 2011-03-27. Unknown parameter
|month=ignored (help)