Author
Information
Dalvi P*, Parulekar SV**, Mirchandani AM***.
(*
First Year Resident, ** Professor and Head, *** Assistant Professor. Department
of Obstetrics and Gynecology, Seth GS Medical
College & KEM Hospital , Mumbai ,
India
Abstract
Takayasu’s
arteritis is a rare inflammatory disease of unknown origin affecting the
arteries in women of childbearing age. Its optimal management during pregnant
patients with this disease has not yet
been defined. Its course is not affected by pregnancy. It can have
serious complications during pregnancy. A case of aneurysmal aortoarteritis
causing intrauterine fetal death is presented.
Introduction
Takayasu’s
aortoarteritis is a chronic inflammatory disease of unknown origin. It usually
affects the aorta and its primary branches.
It is most common in young reproductive women. It is seen more often in
eastern Asia than in western countries.[1]
It can be aneurysmal or non-aneurysmal. The aneurysms are often multiple, more than
twice as often fusiform than saccular.[2] The clinical
features are due to ischemia of limb(s) or organ(s) due to stenosis of the involved arteries. Though
the disease does not worsen during pregnancy, complications like intrauterine
growth restriction (IUGR), fetal death, hypertension, cardiac failure and
rupture of the aneurysm have been reported.[3,4,5,6,7,8,9]
Risk
of aortic dissection is increased due to the presence of chronic
hypertension, preeclampsia and pregnancy.
Case
Report
A 27 year old female married since 10 years, gravida 3 with previous one normal delivery and one intrauterine foetal death with 27.3 weeks gestation presented to the emergency department with the chief complaint of lack of perception of fetal movements for one day. There was no other complaint. She presented to us with a ultrasonography (USG) showing absent fetal cardiac activity and a gestational age of 27.3 weeks. The patient was a known case of aortic aneurysm with a USG showing 5.2x3x3.2 cm proximal aortic aneurysm distal to the superior mesenteric artery, infrarenal aneurysm of size 3.3x3.4x6.7 cm, bilaterally scarred kidneys and bilaterally normal carotids. 2D echocardiography showed mild concentric hypertrophy, ejection fraction of 65% and type 1 left ventricular dysfunction. Computerized tomography (CT) aortogram done prior to the pregnancy showed 5.3x3x2.4 cm aneurysm above superior mesenteric artery, 6.8x 3.3x2.8 cm in the infrarenal aorta and multiple small fusiform dilatations in common iliac and internal iliac arteries. The patient was under regular follow-up with a private cardiologist and was receiving alpha methyldopa and tablet labetalol. She had no antenatal care but was following up with the cardiovascular and thoracic surgery department of our hospital. Her past menstrual cycles were regular and with moderate flow. On examination her general condition was fair. She was afebrile. Her left upper limb blood pressure was 170/110 mm Hg, right upper limb blood pressure was 160/110, and pulse rate 76 per min. There was no pallor, icterus or pedal edema. Respiratory system showed no abnormality. Abdominal examination showed uterine enlargement to 24 weeks' size, and absence of fetal heart sounds. uterus relaxed .On per vaginal examination os was closed , unffecaced. Her hemoglobin was 10.2 gm/dl, platelet count 237000/cmm, white blood cell count 10800/cmm, prothrombin time 13.4 sec, INR 0.99, plasma fibrinogen 300 mg/dl, serum creatinine was 1.3 mg/dl, albumin / globulin ratio 0.7, uric acid 10.7 mg/dl. The intesivist felt the risk of rupture of the aneurysms during induced abortion with prostaglandin and oxytocin was high, and hence a hysterotomy was advised to terminate the pregnancy. A hysterotomy was performed. A macerated fetus weighing 895 g was removed. There were no visible anomalies in the fetus, no knots in the umbilical cord, and no retroplacental clot. The patient withstood the procedure well and made an uneventful recovery.
Figure 1. CT aortogram showing aneurysms.
Discussion
Presence
of at least of three of the
following six criteria of the American
College of Rheumatology (1990) is
required for making a diagnosis
of Takayasu’s arteritis: age less than 40 years, claudication of an extremity,
decreased brachial artery pulse, greater than 10 mm Hg difference in the
systolic pressure between the left and the right arm, a bruit over the
subclavian arteries or the aorta, and angiographic evidence
of narrowing or
occlusion of the aorta or its
primary or proximal branches.[10] Our patient had three of these criteria. The risk of dissection is
mainly during the third trimester, especially between 32 and 38 weeks of
gestation, due to the expansion of aneurysm more during labor and delivery.[11]
Mandal et al reported IUGR in 51.7% cases,[5] Guilherme et al in 36%
cases,[12] and Suri et al in only 16.7% cases.[9] Our
patient had chronic hypertension. However the fetus died in utero in the second
trimester, in absence of any dissection of the aorta. It was due to poor blood
flow in the uterine vessels and resultant poor perfusion of the placental bed.
She had another fetal loss of similar nature in the past. Since the risk of
dissection of the aorta was considered to be high during a second trimester
abortion induced with misoprostol due to uncontrollable hypertension, a hysterotomy
had to be performed. The patient was counseled not to plan a pregnancy until
the aneurysms had been treated. She opted not to have any more babies, even
after correction of the aneurysms.
Conclusion
Aneurysmal
aortoarteritis can be associated with obstetric complications like IUGR and
fetal death for the fetus, and dissection of the aorta for the mother. The
woman hypertension should be controlled with drugs and her aneurysms surgically
before planning a pregnancy.
References
- Galesic K, Morovic-Vergles J, Zivko M, Racic I, Vergles D, Borkovic Z, Cikes N. Renovascular hypertension due to Takayasu arteritis- A case report. Reumatizam. 2005;52(1):28-32.
- Kumar S, Subramanyan R, Mandalam KR, Rao VR, Gupta AK, Joseph S, et al. Aneurysmal form of aortoarteritis (Takayasu's disease): analysis of thirty cases. Clin Radiol. 1990 Nov;42(5):342-7.
- Hauenstein E, Frank H, Bauer JS, Schneider KT, Fischer T. Takayasu’s arteritis in pregnancy: review of literature and discussion. J Perinat Med 2009; 38 (1): 55-62.
- Lakhi NA, Jones J. Takayasu’s arteritis in pregnancy complicated by peripartum aortic dissection. Arch Gynecol Obstet 2009; 282 (1): 103-6.
- Mandal D, Mandal S, Dattaray C, et al. Takayasu arteritis in pregnancy: an analysis from eastern India. Arch Gynecol Obstet 2011; 285 (3): 567-71.
- Manika A, Ananya D. Pregnancy in Takayasu’s arteritis with bilateral renal artery and abdominal aorta stents. Aust N Z J Obstet Gynaecol 2010; 50 (2): 203-4.
- Shafi NA, Malik A, Silverman DI. Management of Takayasu arteritis during pregnancy. J Clin Hypertens (Greenwich) 2009; 11 (7): 383-5.
- Sharma BK, Jain S, Vasishta K. Outcome of pregnancy in Takayasu arteritis. Int J Cardiol 2000; 75 (Suppl 10): S159-62.
- Suri V, Aggarwal N, Keepanasseril A, Chopra S, Vijayvergiya R, Jain S. Pregnancy and Takayasu arteritis: a single centre experience from North India. J Obstet Gynaecol Res 2010; 36 (3): 519-24.
- Arend W.P., Michel B.A., Bloch D.A., Hunder G.G Calabrese L.H., Edworthy S.M. and Fauci A.S. The American College of Rheumatology 1990 criteria for the classification of Takayasu's arteritis. Arthritis and Rheumatism. 199;33 1129-1134.
- Fignon A, Marret H, Alle C, Jacquet A, Avigdor S, Descamps P, Body G, Lansac J. Association of Takayasu’s arteritis, pregnancy and Still’s disease. J Gynecol Obstet Biol Reprod (Paris). 1995;24(7):747-50.
- de Jesús GR, d’Oliveira ICC, dos Santos FC, Rodrigues G, Klumb EM, de Jesús NR, Levy RA. Pregnancy may aggravate arterial Hypertension in women with takayasu arteritis. IMAJ 2013 Vol14. Available from: http://www.ima.org.il/FilesUpload/IMAJ/0/46/23069.pdf
Citation
Dalvi P, Parulekar SV, Mirchandani AM. Aneurysmal
Aortoarteritis And Fetal Death. JPGO 2015. Volume 2 No. 4. Available from: http://www.jpgo.org/2015/05/aneurysmal-aortoarteritis-and-fetal.html