Arterial dissections associated with pregnancy

Nolte, James E.; Rutherford, Robert B.; Nawaz, Samia; Rosenberger, Alan; Speers, Wendell C.; Krupski, William C.

doi:10.1016/s0741-5214(95)70296-2

Cited by 107 publications

(81 citation statements)

References 15 publications

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“…Therapeutic options are anticoagulant therapy, endovascular stenting and surgical repair. 36,37 Nolte et al 9 reported one postpartum case of dissection and rupture of both iliac arteries. The authors suggested that pregnancy and hormone excess are initiators of arterial degeneration.…”

Section: 22mentioning

confidence: 99%

Maternal mortality attributable to vascular dissection and rupture in the Netherlands: a nationwide confidential enquiry

Chapelle¹,

Schutte

Schuitemaker

et al. 2011

BJOG

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Objective To determine the incidence of maternal deaths attributable to vascular dissection and rupture in the Netherlands, and to assess clinical features, risk factors and the frequency of substandard care in the cases identified.Design Confidential enquiry into the causes of maternal deaths.Setting Nationwide in the Netherlands. Results A total of 23 maternal deaths attributable to vascular dissection and rupture were reported. In most cases the location was aortic (n = 13), followed by coronary (n = 4) and splenic (n = 3) arteries. Clinical features were various, but most women presented with sudden unexplainable pain. Risk factors were present in 14 cases (61%), with hypertension being most frequently reported in ten cases (43%). Substandard care was determined to have been received in 13 cases (56%), inadequate assessment of complaints and a delay in diagnosis being the most frequent problems identified.Conclusions Vascular dissection and rupture in pregnancy, although rare, carry a high risk of maternal and fetal morbidity and mortality. Because of the rarity of this condition and its variety in presentation, diagnosis is easily missed. A high index of suspicion when a woman presents with suggestive complaints, leading to an early diagnosis, may improve the prognosis for the woman and her child.Keywords Aneurysm, aortic dissection, carotid artery dissection, coronary dissection, hepatic artery dissection, iliac artery dissection, maternal mortality, pregnancy-related, splenic artery dissection, substandard care, vascular dissection, vascular rupture.Please cite this paper as: la Chapelle C, Schutte J, Schuitemaker N, Steegers E, van Roosmalen J on behalf of the Dutch Maternal Mortality Commitee. Maternal mortality attributable to vascular dissection and rupture in the Netherlands: a nationwide confidential enquiry. BJOG 2012;119:86-93.

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Section: 22mentioning

confidence: 99%

Maternal mortality attributable to vascular dissection and rupture in the Netherlands: a nationwide confidential enquiry

Chapelle¹,

Schutte

Schuitemaker

et al. 2011

BJOG

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“…• Only in tamponade, or diagnostic • Echocardiographic guidance to avoid fetal radiation exposure whenever pericardiocentesis in critically ill possible patients Pericardioscopy and epicardial/ • Only in vital indications [48,49] • Fetal radiation exposure similar as during cardiac catheterization pericardial biopsy a estimated radiation to the uterus is low (0.2-43.0 mrad) [21] but is best avoided in pregnancy b safety has not been fully established [47] c high dose of radiation (~ 500 mrad to the conceptus, even with an appropriate pelvic shield) [50] d when cardiac decompensation occurs during pregnancy in patients with constrictive pericarditis, particularly if cardiac surgery is being considered, cardiac catheterization is required: (1) to confirm the diagnosis, and (2) to exclude accompanying coronary artery disease in patients with several risk factors for coronary artery disease and an age > 35 years been reported [9][10][11]. The incidence is increased among multiparous women, > 30 years of age with coarctation of the aorta, Marfan's syndrome, or hypertension.…”

Section: Pericardiocentesismentioning

confidence: 99%

Pericardial Disease in Pregnancy

Ristić

Seferović

Ljubić³

et al. 2003

Herz

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Most pericardial disorders are managed during pregnancy as in nonpregnant patients (i.e., nonsteroidal antiinflammatory drugs for acute, antibiotics and drainage for purulent pericarditis, and corticosteroids for systemic autoimmune disorders). However, colchicine is contraindicated in pregnancy, and pericardiocentesis should be performed only for very large effusions causing clinical signs of cardiac tamponade or if presence of suppurative, tuberculous or neoplastic pericardial effusion is suspected. Echocardiographic guidance of pericardiocentesis is preferred to fluoroscopic guidance in order to avoid fetal X-ray exposure. Pericardiectomy should be reserved for significant pericardial constriction and resistant bacterial infections. Delivery of normal infants in term after pericardiocentesis or pericardiectomy is expected, whenever natural history of causative disease allows. Pericardiectomy itself is not a contraindication for subsequent successful pregnancies.

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“…1 The combination of increased blood flow and pregnancy-induced structural changes in the aorta are likely to contribute to this increased risk. 10 The precise mechanism remains unclear, as the structural changes in the aorta specifically and in the maternal systemic vascular bed during pregnancy in general have not been studied in any detail. This increased risk of dissection during pregnancy is even greater in women with pre-existing heart conditions such as Marfan syndrome, bicuspid aortic valve with ascending aortopathy, coarctation of the aorta 11 and perhaps tetralogy of Fallot.…”

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confidence: 99%

Heart disease – why is maternal mortality increasing?

Gelson

Gatzoulis

Steer

et al. 2009

BJOG

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Please cite this paper as: Gelson E, Gatzoulis M, Steer P, Johnson M. Heart disease -why is maternal mortality increasing ? BJOG 2009;116:609-611. The most recent triennial confidential enquiry confirmed that heart disease is the most common cause of maternal death in the UK. The maternal mortality rate associated with heart disease is 2.27 per 100,000 maternities double that reported in 1990. 1 The incidence of heart disease during pregnancy in the UK has remained constant at 0.9% over several decades. 2 However, the severity of heart disease and the risk it poses during pregnancy appear to be increasing in a wide range of healthcare settings. This commentary examines why mortality rates have risen and makes recommendations as to how this trend can be reversed.Ischaemic heart disease is now the most common cause of cardiac death in the pregnant population in the developed world. This is likely due to increased maternal age; smoking; the adoption of a sedentary lifestyle and poor diet leading to greater rates of obesity, diabetes and hypertension. 3-6 Acute myocardial infarction accounts for the majority of deaths and is most commonly due to coronary atherosclerosis, but coronary artery dissection and consequent occlusion are also relatively frequent. There is a high incidence of recognised risk factors for atherosclerosis in pregnant women suffering an acute myocardial infarction during pregnancy and the postpartum period, which should be targeted both for intervention and for identification. 6 Hyperlipidaemia, hypertension and diabetes should be optimally controlled preconception and smoking cessation and weight loss strongly encouraged. Women with multiple risk factors should be identified, alerting obstetricians to the possibility of ischaemic heart disease and lowering thresholds for the investigation of symptoms. When myocardial infarction is suspected or diagnosed, cardiac catheterisation with acute phase intervention (thrombolysis and/or coronary angioplasty) should not be withheld; these procedures are relatively safe in the pregnancy, 7 although larger studies are required to determine their specific risk to benefit ratios. Following the acute phase, secondary prevention (such as optimal blood pressure control, aspirin and statins [see below]) should be instituted. Many cardiac medications can be used without undue risk in pregnancy, for example beta blockers, digoxin, aspirin, diuretics and hydralazine. ACE inhibitors are known to have teratogenic effects in the first trimester and should therefore best be avoided during early pregnancy. 8 Exposure in the second and third trimesters can lead to marked fetal hypotension and decreased fetal renal blood flow. Where ACE inhibitors must be continued, the lowest possible dose should be used and amniotic fluid levels and fetal growth should be monitored carefully. Statins have been identified as potential teratogens on the basis of theoretical considerations. However, epidemiological data suggest this to be unfounded. Given the scarcity of available data,...

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Arterial dissections associated with pregnancy

Cited by 107 publications

References 15 publications

Maternal mortality attributable to vascular dissection and rupture in the Netherlands: a nationwide confidential enquiry

Maternal mortality attributable to vascular dissection and rupture in the Netherlands: a nationwide confidential enquiry

Pericardial Disease in Pregnancy

Heart disease – why is maternal mortality increasing?

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