Another pregnancy after a previous aortic dissection in pregnancy?
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- Muriel Peters
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1 Another pregnancy after a previous aortic dissection in pregnancy? Dr Leisa Freeman GUCH & Maternal Cardiology Unit Norfolk & Norwich University Hospital UK
2 Arterial wall changes & haemodynamic effects occur in every pregnancy so why not more Aortic Dissection? Pregnancy promotes dilatation aorta, renal & placental resistance vessels Oestrogen receptors seen in fresh aortic tissue associated with: fragmentation of reticular fibres, diminished acid mucopolysaccarides, loss normal corrugation of elastic tissue Immer et al Ann Thorac Surg 2003:76; x
3 International Registry Aortic Dissection Braverman et al Jacc 2012:59(13) Suppl E /3712 AD in pregnancy 11 had full data Mean age 33 (20-40) 7/11 post partum 1/11 1 st Trimester 3/11 3 rd Trimester Type A 5 (surgical rep) Type B - 6 (2/6 surgery) Underlying cause in all Marfan = 4 BiAV = 1, EDIV = 1 L-D = 1; FHAoA = 1 Hypertension = 3 Mean AoD Type A = 5.2cm( ) Mean AoD Type B = 3.3cm ( ) Immer review AD in pregnancy: Type A pre 5 post; Type B 6 pre 4 post
4 Risk Factors Aortic Dissection in Pregnancy Increasing age Multiparity Trauma Coarctation Bicuspid Aortopathy Systemic hypertension Collagen vascular e.g. Marfan, ED IV, Loeys- Dietz, Turner Circulation 2010;121:e266-e369
5 Case History #1 28 PE teacher no FH nil else. P1 G0 32/40 acute dissection. Successful LCCS then AVR + root replacement Wants another baby Full genetic screen negative; no family history, normotensive always Includes Type B dissection to femoral bifurcation
6 Case History # 2 NW P2 G2 (twins) Asc ao Dissection 38/40 LCCS both twins alive Asc Ao root replacement - still type B dissection to bifurcation. Interval surveillance no inc in size Still alive 5 yrs on. No FH, negative genetics (Marfan/EDIV, LD etc) Normotensive
7 Level of evidence IIIC Level of Evidence 1C
8 Questions Is pregnancy an initiator of arterial degeneration whose effects are additive with subsequent pregnancies and women should be counselled absolutely against further pregnancy. Alternatively these women have identified themselves as having an unrecognised genetic aortopathy and should be counselled against further pregnancy OR Future pregnancy might be considered with caveats and concomitant medication, intense cardiological surveillance with early elective delivery
9 MRI assessment 51 women comparing high parity with none or 1 pregnancy Low parity (n = 23) High parity (n = 28) P Age, years (SD) 43.2 (11.9) 46.0 (12.9) White Race, n (%) 16/23 (69.6%) 21/28 (75%) Pregnancies (number) < BSA, m 2 (SD) 1.67 (0.18) 1.72 (0.16) BMI, kg/m 2 (SD) 24.9 (5.2) 25.6 (4.2) 0.592* Systolic blood pressure, mm Hg (SD) Diastolic blood pressure, mm Hg (SD) Ascending aortic diameter, cm (SD) Descending aortic diameter, cm (SD) (16.4) (13.8) 0.356* 72.9 (9.7) 69.3 (7.5) 0.147* 2.39 (0.34) 2.67 (0.48) (0.23) 1.88 (0.28) Multiparous women had 13% bigger Asc Aorta and 10% Desc Ao cf low parity Multivariate analysis age and parity associated with bigger Asc Ao Age and BSA correlated with bigger desc Ao (parity less so) Gutin et al Int J Cardiol 2013:165(2); 383
10 Long term FU type B dissections Desc Ao size increases mostly due to increase in false lumen (6.5mm cf 0.79mm/yr true lumen)* Desc Ao increase only seen in 59% of 191pts predictors of no expansion female sex, use of CCH, intramural haematoma** Partial thrombosis of false lumen predicts late mortality *** Blount et al AJR 2009;192(5) W222 ;**Jonker et al Ann Thor Surg 2012:94(4): *** Tsai et alnejm 2007:357(4)345
11 TEVAR for Type B dissection Instead Trial (BMT vs stent graft) 2 yr n.s. Instead XL FU 2-5 yrs post Type B BMT saw inc size false lumen & rupture Thoracic EVAR significantly reduced late adverse events 90% had stability & Ao remodelling. Nienaber et al 2013 ahajournals.org/circinterventions/ A Booher, A m J M126, ( 8), 730.e19-e24
12 Literature cases Haemashield Asc Ao graft + AV repair 1998 Type B dissection stable 2005 pregnant meticulous BP control regular US then MRI No increase in descending Ao Dimension post delivery Tutarel et al Int J Cardiol 2007:114(2)E36-7 Composite asc Ao graft Type B dissection Successful pregnancy but dissection extended post partum successfully treated (died 2 yrs later endocarditis) Rossiter et al Am J Obstet Gynaecol 1995; 173:
13 Extension into iliac arteries may compromise uterine BF Type B dissection 2o BP R iliac compression by false lumen infarcted kidney tx percutaneos Subsequent R.R.T Subsequent pregnancy regular doppler u/s to monitor uterine aa flow LCCS 31/40 Demant A W et al. Nephrol. Dial. Transplant. 2004;19: true lumen; 2 false lumen; 3 kidney; R infarcted; 4 atrophic L kidney
14 Comments and Questions? Another pregnancy after a previous aortic dissection in pregnancy? Probably not but?? after TEVAR McDermott, Colleen D., International Journal of Cardiology, Volume 120, Issue 3,
15 Thank you
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18 (A) Thoracic CT scan of the aortic dissection. Nephrol Dial Transplant Vol. 19 No. 6 ERA-EDTA 2004; all rights reserved Demant A W et al. Nephrol. Dial. Transplant. 2004;19:
19 Predictors Mortality type B Tsai et al NEJM 2007:357(4): following type B dissection 3 yr mortality 114 (56.7%) patent false lumen % 68 (33.8%) partial thrombosis % 19 (9.5%) complete thrombosis % Independent predictors late mortality : Partial thrombosis false lumen (RR 2.69) Hx Ao aneurysm Hx atherosclerosis
20 Blount et al AJR 2009:192(5): W222-9 Serial imaging type B dissection 19 pts Aortic diameter type B dissection increases over time primarily due to increase in size of false lumen. Max Ao diameter increased by 7mm/yr False lumen diameter 6.5mm/yr cf true lumen diameter only 0.79mm/yr
21 Predictors of Aortic expansion post Type B dissection 191 pts; annual aortic expansion = mm/yr only seen in 59% Predictors for expansion white race AoD = 4cm Predictors for no expansion intramural haematoma, female sex, use of CCB Jonker et al Ann Thor Surg 2012:94(4):1223-9
22 Acute Ao dissection without risk factors in 3 rd trimester Kinney-Ham et al West J Emerg Med 2011;12(4);571-4 Congenital Hrt Dis Volach et al 2006:4:184-8 Asc Ao replacement and preserved AoV successful pregnancy.
23 Computed tomographic sagittal oblique image of thorax and abdomen showing distal thoracic and abdominal aortic dissection as well as gravid uterus with twin gestation. Aortic dissection complicating pregnancy following prophylactic aortic root replacement in a woman with Marfan syndrome McDermott, Colleen D., International Journal of Cardiology, Volume 120, Issue 3, Copyright 2006 Elsevier Ireland Ltd
24 34 yr old athletic woman type A dissection no risk factors in 3 rd trimester J Em Med 2014:46(1) e13-17 Beirer et al
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