AORTOARTERITIS IN PREGNANCY

INTRODUCTION

This peculiar arteritis was first noted in 1908 by Japaneas Ophthalmologist Takayasu. It is defined as a nonspecific inflammatory process of unknown aetiology affecting segmentally the aorta and its main branches. This disease entity has been described by a variety of terms including aortic arch syndrome, pulseless disease, reversed coarctation occlusive aortopathy, young female arteritis.

CASE REPORT

A 30 year old female G4 P2 L1A1 with 30 weeks of gestation with previous LSCS came to OPD for ANC registration on 5/8/2000.

There was No H/o Headache/giddiness/epigastric pain

No H/o abdominal pain/Leaking/bleeding P/V

Menstrual History

LMP - 3/1/2000EDD 10/10/2000

Obstetric History

She had one preterm FSB in 1996.

FT. LSCS done for Foetal distress 1 1/2 yrs back.

Patient was diagnosed as known case of Myocarditis with Aortoarteritis (1987)

In 1994 2D ECHO report - LA - 3 cms.

LV - 3.7 cm.

Aorta - 1.6 cm.

At the time of admission patient’s general condition was fair, afebrile, P - 60/min., BP - 240/140, CVS/RS - NAD P/A Ut 32 weeks.

FHS + regular 136 per min. Cephal floting, Ut Relaxed.

P/V - Os closed.

Investigations

Routine investigations within normal limit.

ECG LVH by voltage LVEF - 50%

2D Echo - LA 3.2 cm Concentric LVH

Impression - LVH cardiomegaly

Patient was treated with Tab. Aldomet, Depin, Minipress and Aten. NST done at 34 weeks was Non-reactive.

Emergency LSCS with TL done. Female Child 1.75 Kg. delivered cried immediately after birth. Baby sent to NICU and was on full feeds. Intraop BP 200/120 mm post op period was uneventful. Patient discharged on Day 9. Patient was given NTG drip and NTG patch post operatively. Doses of Tab. Aldomet and Depin titrated ever 4 hours of patch to maintain diastrolic BP of 100 mm.

Post operatively day 2 onwards BP was 160/100 on antihypertensive.

DISCUSSION

It is defined as a non-specific inflammatory process of unknown aetiology affecting segmentally the aorta and its main branches.

Type I - Involvement localized to aortic archand its branches.

Type II - Thoraco abdominal aorta and its branches sparing the arch.

Type III - Contains features of type I and II.

Type IV - Pulmonary arterial involvement.It is mainly a disease of young females F:M 3:1 in India.

Initial illness : After a latent period of variable duration signs and symptoms referable to the obliterative and inflammatary changes in the vessels develop. Diminished or absent pulse in 96% Bruits in 94%, Hypertension in 74%, Heart failure in 28% Hypertension in this disease due to

Renal artery stenosis - 35 to 85% of cases.
Involvement of baroreceptors by aortitis.
Loss of elasticity of aorta.
Coarctation like lesion.
Aortic regurgitation.

Although the exact mechanism behind this damage is unknown, research suggests that TA is triggered by alterations in the body’s immune response. Most probably, TA is an autoimmune disorder, meaning that immune defenses mistakenly attack the body’s own cells rather than protecting them from outside invaders. Maternal morbidity may be high, since pregnancy increases the risk of aortic rupture or dissection, as well as of cerebral haemorrhage from rupture of an aneurysm of the circle of willis. Surgical repair before conception reduces the risk of aortic complications during pregnancy, and also decreases the incidence of foetal complications, such as IUGR or congenital heart disease. The outcome of pregnancy is also influenced by coexistence of other malformations, such as biscuspid aortic valve which leads to infective endocarditis. In uncomplicated coarctation, pregnancy and delivery are usually uneventful. Cesarean section is done mainly for obstetric indications.

Investigations : Increased ESR, leucocytosis, mild anaemia, C reactive protein increased.

Antistreptolysin titres - increased.Rheumatoid factors - present.ANA and fibrinogen levels - increased.

Chest X-ray - shows rim of calcification in walls of arteries.

Arteriography : Irregular intimal surface with stenosis of aorta. Post stenotic dilatation, sacular aneurysms even complete occlusion of vessels.

Cause of death : Heart failure, Encephalopathy, Renal failure, Rupture of aneurysm, cerebral haemorrhage.

Treatment : Treatment usually begin with glucocorticoid medications, such as prednisone. If glucocorticoids alone are not effective, then stronger cytotoxic drugs may be added, including methotrexate, azathioprine or cyclophosphamide. Blood pressure medications may also be necessary to control hypertension.

If TA has caused significant stenosis of an artery, the narrowed segment may need to be widened or repaired. Depending on the specific artery affected, this can be done using traditional open surgery, percutaneous transluminal balloon angioplasty or percutaneous placement of a stent (an implanted device that keeps the narrowed vessel open).

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