1
|
Toshimitsu M, Iriyama T, Sato J, Abe O, Ichinose M, Sayama S, Seyama T, Sone K, Kumasawa K, Osuga Y. A Case of Ruptured Exophytic Uterine Artery Pseudoaneurysm without Specific Risk Factors That Manifested Seven Days after Vaginal Delivery. Case Rep Obstet Gynecol 2023; 2023:1637463. [PMID: 38046834 PMCID: PMC10693466 DOI: 10.1155/2023/1637463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 12/05/2023] Open
Abstract
A uterine artery pseudoaneurysm (UAP) is a life-threatening complication during pregnancy and postpartum. Early diagnosis of exophytic UAP rupture is difficult due to the absence of vaginal bleeding. This study reports the case of a 31-year-old postpartum woman who presented with abdominal pain and fever seven days after vaginal delivery, without symptoms of maternal shock. Ultrasonography revealed a ruptured exophytic UAP with hemoperitoneum, which was confirmed using computed tomography. Interventional radiology confirmed that the site of the pseudoaneurysm was at the level of the uterine artery bifurcation, and embolization was performed immediately after diagnosis using a coil and n-butyl-2-cyanoacrylate. The patient's symptoms were relieved, and she was discharged 12 days after the embolization. At eight months postpartum, the UAP was not visible on transvaginal ultrasonography. Exophytic UAP can occur even in the absence of specific risk factors such as cesarean section or endometriosis, and the UAP may not necessarily rupture immediately after delivery. Obstetricians must remain aware of the possibility of exophytic UAP rupture manifesting as abdominal pain with postpartum fever, rather than as unstable vital signs. This is the first report of an exophytic UAP that occurred at the level of the uterine artery bifurcation. Identification of the sites where exophytic UAP can occur can aid in the early diagnosis of the condition.
Collapse
Affiliation(s)
- Masatake Toshimitsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Takayuki Iriyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Jiro Sato
- Department of Radiology, Tokyo Metropolitan Police Hospital, 4-22-1, Nakano, Nakano-ku, Tokyo 164-8541, Japan
| | - Osamu Abe
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Mari Ichinose
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Seisuke Sayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Takahiro Seyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kenbun Sone
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| |
Collapse
|
2
|
Coroyannakis C, Tome M, Watt-Coote I, Cauldwell M. Pregnancy following personalised aortic root support in Marfan syndrome. Obstet Med 2023; 16:200-202. [PMID: 37719992 PMCID: PMC10504882 DOI: 10.1177/1753495x221078447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 01/03/2022] [Accepted: 01/18/2022] [Indexed: 09/19/2023] Open
Abstract
Marfan syndrome (MFS) is linked with adverse pregnancy events, one of the most significant being aortic dissection. We present a case of a woman with MFS with prior aortic root dilatation who opted for a Personalised External Aortic Root Support (PEARS). To date, she is only the fifth woman to have had this valve-sparing procedure prior to pregnancy. We outline her care in a tertiary centre with multidisciplinary expertise, from preconception through to the postpartum period.
Collapse
Affiliation(s)
- Christina Coroyannakis
- Christina Coroyannakis, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - Maite Tome
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | | | | |
Collapse
|
3
|
Wander G, van der Zande JA, Patel RR, Johnson MR, Roos-Hesselink J. Pregnancy in women with congenital heart disease: a focus on management and preventing the risk of complications. Expert Rev Cardiovasc Ther 2023; 21:587-599. [PMID: 37470417 DOI: 10.1080/14779072.2023.2237886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Congenital heart disease (CHD) is the most common cardiac disorder in pregnancy in the western world (around 80%). Due to improvements in surgical interventions more women with CHD are surviving to adulthood and choosing to become pregnant. AREAS COVERED Preconception counseling, antenatal management of CHDs and strategies to prevent maternal and fetal complications.Preconception counseling should start early, before the transition to adult care and be offered to both men and women. It should include the choice of contraception, lifestyle modifications, pre-pregnancy optimization of cardiac state, the chance of the child inheriting a similar cardiac lesion, the risks to the mother, and long-term prognosis. Pregnancy induces marked physiological changes in the cardiovascular system that may precipitate cardiac complications. Risk stratification is based on the underlying cardiac disease and data from studies including CARPREG, ZAHARA, and ROPAC. EXPERT OPINION Women with left to right shunts, regurgitant lesions, and most corrected CHDs are at lower risk and can be managed in secondary care. Complex CHD, including systemic right ventricle need expert counseling in a tertiary center. Those with severe stenotic lesions, pulmonary artery hypertension, and Eisenmenger's syndrome should avoid pregnancy, be given effective contraception and managed in a tertiary center if pregnancy does happen.
Collapse
Affiliation(s)
- Gurleen Wander
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Johanna A van der Zande
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roshni R Patel
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Mark R Johnson
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Jolien Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
4
|
Sayama S, Iriyama T, Takeda N, Yamauchi H, Toshimitsu M, Seyama T, Sone K, Kumasawa K, Nagamatsu T, Fujii T, Osuga Y. Proposed Management Policy for Pregnant Women with Loeys-Dietz Syndrome Following Prophylactic Aortic Root Replacement Based on Experience from a Tertiary Care Center. Int Heart J 2022; 63:176-179. [DOI: 10.1536/ihj.21-341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Seisuke Sayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Takayuki Iriyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Norifumi Takeda
- Department of Cardiovascular Medicine, Faculty of Medicine, The University of Tokyo
| | - Haruo Yamauchi
- Department of Cardiac Surgery, Faculty of Medicine, The University of Tokyo
| | - Masatake Toshimitsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Takahiro Seyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Kenbun Sone
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Takeshi Nagamatsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo
| |
Collapse
|
5
|
Russo ML, Yetman AT. Further Evidence for the Safety Considerations in Pregnancy of Women With Marfan Syndrome. J Am Coll Cardiol 2021; 78:880-882. [PMID: 34446159 DOI: 10.1016/j.jacc.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/14/2021] [Accepted: 07/14/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Melissa L Russo
- Women and Infants Hospital, Brown University School of Medicine, Providence, Rhode Island, USA.
| | - Anji T Yetman
- Children's Hospital and Medical Center, University of Nebraska Medical Center Omaha, Omaha, Nebraska, USA
| |
Collapse
|
6
|
Groth KA, Nielsen BB, Sheyanth IN, Gravholt CH, Andersen NH, Stochholm K. Maternal health and pregnancy outcome in diagnosed and undiagnosed Marfan syndrome: A registry-based study. Am J Med Genet A 2021; 185:1414-1420. [PMID: 33590700 DOI: 10.1002/ajmg.a.62122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/15/2021] [Accepted: 01/30/2021] [Indexed: 11/09/2022]
Abstract
In Marfan syndrome (MFS), pregnancy is considered as high risk due to the deficiency of fibrillin in the connective tissue and increased risk of aortic dissection. The objective was to demonstrate the consequences on maternal health, in women with diagnosed and undiagnosed MFS at the time of pregnancy and childbirth. By using national health care registries, we identified all pregnancy related outcomes, from women with MFS (n = 183) and an age-matched background population (n = 18,300). We found 91 pregnancies during follow-up. Significantly fewer women with MFS gave birth, compared to the background population. No women with known MFS had a pregnancy related aortic dissection but complications related to the cervix were increased (HR:19.8 [95% CI:2.2-177.5]). Fifty women with MFS were undiagnosed at the time of their first pregnancy and/or childbirth. Among these, there were more birth canal related complications HR:27.2 (95% CI: 2.3-315.0), preeclampsia (HR:2.25 [95% CI: 1.11-4.60]), fetal deaths (HR:12.3 [95% CI: 1.51-99.8]), and all delivery-related dissections came from this subgroup. In conclusion, undiagnosed women with MFS experienced more pregnancy and childbirth related complications including fetal death, birth canal issues, preeclampsia, and aortic disease, which emphasizes the need for an early MFS diagnosis and special care during pregnancy and childbirth.
Collapse
Affiliation(s)
- Kristian A Groth
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Birgitte B Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Inger N Sheyanth
- Department of Clinical Genetics, Aalborg University Hospital, Aalborg, Denmark
| | - Claus H Gravholt
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Kirstine Stochholm
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
7
|
Rimmer L, Mellor S, Harky A, Gouda M, Bashir M. Pernicious pregnancy: Type B aortic dissection in pregnant women. J Card Surg 2021; 36:1232-1240. [PMID: 33533078 DOI: 10.1111/jocs.15354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/22/2020] [Accepted: 10/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Type B aortic dissection (TBAD) occurs seldomly, particularly in pregnancy, but has disastrous consequences for both mother and fetus. The focus of immediate surgical repair of type A aortic dissection due to higher mortality of patients is less clear in its counterpart, TBAD, in which management is controversial and debated. This article collates knowledge so far on this rare event during pregnancy. METHODS A comprehensive literature search was performed in PubMed, Scopus, Google Scholar, Embase, and Medline. Key search terms included "type B aortic dissection," "pregnancy," and corresponding synonyms. Non-English papers were excluded. RESULTS Risk factors for TBAD include aortic wall stress due to hypertension, previous cardiac surgery, structural abnormalities (bicuspid aortic valve, aortic coarctation), and connective tissue disorders. In pregnancy, pre-eclampsia is a cause of increased aortic wall stress. Management of this condition is often conservative, but this is dependent on a number of factors, including gestation, cardiovascular stability of the patient, and symptomology. In most cases, a cesarean section before intervention is carried out unless certain indications are present. CONCLUSIONS Due to a scarce number of cases across the decades, it is difficult to determine which management is optimal. The gold-standard management of TBAD has traditionally been the medical treatment for uncomplicated cases and open surgery for those needing urgent intervention, but with the advent of techniques, such as thoracic endovascular aortic repair, the management of these group of patients continues to develop.
Collapse
Affiliation(s)
- Lara Rimmer
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Sophie Mellor
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Amer Harky
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Mohamed Gouda
- Vascular & Endovascular Surgery, Mataria Teaching Hospital, Cairo, Egypt
| | - Mohamad Bashir
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
| |
Collapse
|
8
|
Shitara R, Iriyama T, Sayama S, Takeda N, Nagamatsu T, Osuga Y, Fujii T. Postpartum Stanford type B aortic dissection in a woman with Loeys-Dietz syndrome who underwent a prophylactic aortic root replacement before conception: A case report. Taiwan J Obstet Gynecol 2021; 60:145-147. [PMID: 33494990 DOI: 10.1016/j.tjog.2020.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Loeys-Dietz syndrome (LDS) is associated with a higher risk of aortic dissections (ADs) during pregnancy and postpartum. However, there is limited evidence about the perinatal management of LDS patients who have undergone prophylactic aortic root replacements (ARRs) before conception. CASE REPORT We present the case of a 28-year-old nulliparous pregnant woman with LDS with a pathogenic variant within exon 5 of TGFBR2 (c.1379G > T, p.[Arg460Leu]), who underwent an ARR at 20 years of age. Cardiac echocardiography did not show any significant changes in the aorta during pregnancy, and her blood pressure remained normal. She had a cesarean section at 37 weeks of gestation. She developed an acute Stanford type B AD extending from the aortic arch to the infrarenal aorta 8 days postpartum and underwent a total arch replacement. CONCLUSION This case report suggests that patients with LDS after prophylactic ARRs still possess a risk for Stanford type B ADs.
Collapse
Affiliation(s)
- Rieko Shitara
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan; Departments of Obstetrics & Gynecology, Japan Community Health Care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Takayuki Iriyama
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan.
| | - Seisuke Sayama
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Norifumi Takeda
- Department of Cardiovascular Medicine, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Takeshi Nagamatsu
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Tomoyuki Fujii
- Departments of Obstetrics & Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| |
Collapse
|
9
|
Campens L, Baris L, Scott NS, Broberg CS, Bondue A, Jondeau G, Grewal J, Johnson MR, Hall R, De Backer J, Roos-Hesselink JW. Pregnancy outcome in thoracic aortic disease data from the Registry Of Pregnancy And Cardiac disease. Heart 2021; 107:1704-1709. [PMID: 33468574 PMCID: PMC8522458 DOI: 10.1136/heartjnl-2020-318183] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 12/29/2022] Open
Abstract
Background Cardiovascular disease is the leading cause of death during pregnancy with thoracic aortic dissection being one of the main causes. Thoracic aortic disease is commonly related to hereditary disorders and congenital heart malformations such as bicuspid aortic valve (BAV). Pregnancy is considered a high risk period in women with underlying aortopathy. Methods The ESC EORP Registry Of Pregnancy And Cardiac disease (ROPAC) is a prospective global registry that enrolled 5739 women with pre-existing cardiac disease. With this analysis, we aim to study the maternal and fetal outcome of pregnancy in women with thoracic aortic disease. Results Thoracic aortic disease was reported in 189 women (3.3%). Half of them were patients with Marfan syndrome (MFS), 26% had a BAV, 8% Turner syndrome, 2% vascular Ehlers-Danlos syndrome and 11% had no underlying genetic defect or associated congenital heart defect. Aortic dilatation was reported in 58% of patients and 6% had a history of aortic dissection. Four patients, of whom three were patients with MFS, had an acute aortic dissection (three type A and one type B aortic dissection) without maternal or fetal mortality. No complications occurred in women with a history of aortic dissection. There was no significant difference in median fetal birth weight if treated with a beta-blocker or not (2960 g (2358–3390 g) vs 3270 g (2750–3570 g), p value 0.25). Conclusion This ancillary analysis provides the largest prospective data review on pregnancy risk for patients with thoracic aortic disease. Overall pregnancy outcomes in women with thoracic aortic disease followed according to current guidelines are good.
Collapse
Affiliation(s)
- Laurence Campens
- Department of Cardiology, Ghent University Hospital, Gent, Belgium
| | - Lucia Baris
- Cardiology Department, Erasmus Medical Center, Rotterdam, Netherlands
| | - Nandita S Scott
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Craig S Broberg
- Adult Congenital Heart Disease Program. Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Antione Bondue
- Department of Cardiology, CUB Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Brussels, Belgium
| | - Guillaume Jondeau
- Department of Cardiology, CRMR Syndrome de Marfan et Apparentés, Bichat-Claude Bernard Hospital, Université de Paris, INSERM U1148, Paris, France
| | - Jasmine Grewal
- Division of Cardiology, University of British Columbia, Pacific Adult Congenital Heart Disease Clinic, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Mark R Johnson
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Roger Hall
- Department of Cardiology, University of East Anglia, Faculty of Medicine, Norwich Research Park, Norwich, Norfolk, UK
| | - Julie De Backer
- Department of Cardiology, Ghent University Hospital, Gent, Belgium.,Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | | | | |
Collapse
|
10
|
Habashi JP, MacFarlane EG, Bagirzadeh R, Bowen C, Huso N, Chen Y, Bedja D, Creamer TJ, Rykiel G, Manning M, Huso D, Dietz HC. Oxytocin antagonism prevents pregnancy-associated aortic dissection in a mouse model of Marfan syndrome. Sci Transl Med 2020; 11:11/490/eaat4822. [PMID: 31043570 DOI: 10.1126/scitranslmed.aat4822] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 09/14/2018] [Accepted: 03/25/2019] [Indexed: 01/18/2023]
Abstract
Women with Marfan syndrome (MFS) are at high risk for pregnancy-associated aortic dissection. Pathogenic models that singularly invoke hemodynamic stress are difficult to reconcile with predominant postnatal occurrence of aortic tear, often occurring weeks to months after delivery. In consideration of events that peak at term, are sustained after delivery, and might synergize with previously defined signaling pathways implicated in aneurysm progression, we examined the hormone oxytocin, which initiates uterine contraction and milk letdown for the duration of lactation through phosphorylation of extracellular signal-regulated kinase (ERK). In a mouse model of MFS that shows highly penetrant postnatal aortic dissection, risk was strongly attenuated by preventing lactation or use of an oxytocin receptor antagonist. Survival correlated inversely with the extent of ERK activation in the aortic wall, and strong protection was observed upon attenuation of ERK phosphorylation using an inhibitor of ERK kinase (MEK) or the U.S. Food and Drug Administration-approved medication hydralazine, offering potential therapeutic strategies for pregnancy-associated vascular catastrophe in the setting of MFS.
Collapse
Affiliation(s)
| | | | - Rustam Bagirzadeh
- Center for Medical Genetics, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Caitlin Bowen
- Center for Medical Genetics, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Nicholas Huso
- Center for Medical Genetics, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Yichun Chen
- Center for Medical Genetics, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Djahida Bedja
- Division of Comparative Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Tyler J Creamer
- Department of Surgery, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Graham Rykiel
- Center for Medical Genetics, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Maurice Manning
- Department of Cancer Biology, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - David Huso
- Division of Comparative Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Harry C Dietz
- Center for Medical Genetics, Johns Hopkins University, Baltimore, MD 21287, USA. .,Howard Hughes Medical Institute, Chevy Chase, MD 20815, USA
| |
Collapse
|
11
|
Cardiac interventions and cardiac surgery and pregnancy. Int J Cardiol 2019; 276:43-47. [DOI: 10.1016/j.ijcard.2018.09.100] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/25/2018] [Accepted: 09/25/2018] [Indexed: 01/12/2023]
|
12
|
Minsart AF, Mongeon FP, Laberge AM, Morin F, Dore A, Leduc L. Obstetric and cardiac outcomes in women with Marfan syndrome and an aortic root diameter ≤ 45mm. Eur J Obstet Gynecol Reprod Biol 2018; 230:68-72. [DOI: 10.1016/j.ejogrb.2018.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/10/2018] [Accepted: 09/10/2018] [Indexed: 01/16/2023]
|
13
|
Williams D, Lindley KJ, Russo M, Habashi J, Dietz HC, Braverman AC. Pregnancy after Aortic Root Replacement in Marfan's Syndrome: A Case Series and Review of the Literature. AJP Rep 2018; 8:e234-e240. [PMID: 30473905 PMCID: PMC6193806 DOI: 10.1055/s-0038-1675347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/30/2018] [Indexed: 11/03/2022] Open
Abstract
Objectives We sought to characterize pregnancy-related aortic complications in women with Marfan's syndrome who had prior aortic root replacement. Study Design This is a retrospective case series study and literature review of women with Marfan's syndrome with pregnancy after aortic root replacement. We surveyed women with Marfan's syndrome who had successful pregnancy after aortic root replacement using the Marfan Foundation Website and from two large tertiary care Marfan's clinics. Clinical data, counseling information, and details of pregnancy-related aortic complications were compiled. A literature review was performed assessing aortic outcomes in women with Marfan's syndrome with pregnancy after aortic surgery. Results Fourteen women with 20 pregnancies were identified. Two women had three pregnancies following root replacement for aortic dissection. There were no aortic dissections during the 20 pregnancies. In contrast, aortic dissection was frequently reported in the literature. Conclusions Women with Marfan's syndrome who become pregnant following aortic root replacement remain at risk for distal aortic dissection related to pregnancy. The exact risk is difficult to quantify but is not zero and women should be counseled accordingly.
Collapse
Affiliation(s)
- Dominique Williams
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Melissa Russo
- Department of Obstetrics and Gynecology, Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Jennifer Habashi
- Johns Hopkins University School of Medicine, Howard Hughes Medical Institute, Baltimore, Maryland
| | - Harry C Dietz
- Johns Hopkins University School of Medicine, Howard Hughes Medical Institute, Baltimore, Maryland
| | - Alan C Braverman
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
14
|
Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, Lang IM, Morais J, Pieper PG, Presbitero P, Price S, Rosano GMC, Seeland U, Simoncini T, Swan L, Warnes CA. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39:3165-3241. [PMID: 30165544 DOI: 10.1093/eurheartj/ehy340] [Citation(s) in RCA: 1071] [Impact Index Per Article: 178.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
15
|
Takeda N, Hara H, Fujiwara T, Kanaya T, Maemura S, Komuro I. TGF-β Signaling-Related Genes and Thoracic Aortic Aneurysms and Dissections. Int J Mol Sci 2018; 19:ijms19072125. [PMID: 30037098 PMCID: PMC6073540 DOI: 10.3390/ijms19072125] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 12/29/2022] Open
Abstract
Transforming growth factor-β (TGF)-β signaling plays a crucial role in the development and maintenance of various organs, including the vasculature. Accordingly, the mutations in TGF-β signaling pathway-related genes cause heritable disorders of the connective tissue, such as Marfan syndrome (MFS), Loeys-Dietz syndrome (LDS), and Shprintzen-Goldberg syndrome (SGS), and these syndromes may affect skeletal, ocular, pulmonary, and cardiovascular systems. Aortic root aneurysms are common problems that can result in aortic dissection or rupture, which is the leading cause of sudden death in the natural history of MFS and LDS, and recent improvements in surgical treatment have improved life expectancy. However, there is currently no genotype-specific medical treatment. Accumulating evidence suggest that not only structural weakness of connective tissue but also increased TGF-β signaling contributes to the complicated pathogenesis of aortic aneurysm formation, but a comprehensive understanding of governing molecular mechanisms remains lacking. Inhibition of angiotensin II receptor signaling and endothelial dysfunction have gained attention as a possible MFS treatment strategy, but interactions with TGF-β signaling remain elusive. Heterozygous loss-of-function mutations in TGF-β receptors 1 and 2 (TGFBR1 and TGFBR2) cause LDS, but TGF-β signaling is activated in the aorta (referred to as the TGF-β paradox) by mechanisms yet to be elucidated. In this review, we present and discuss the current understanding of molecular mechanisms responsible for aortopathies of MFS and related disorders.
Collapse
Affiliation(s)
- Norifumi Takeda
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Hironori Hara
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Takayuki Fujiwara
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Tsubasa Kanaya
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Sonoko Maemura
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| |
Collapse
|
16
|
Keepanasseril A, Thendral N, Dorairajan G, Subbaih M, Pillai AA, Sai Chandran BV. Management of aortic aneurysm presenting during pregnancy: A case report. Obstet Med 2018; 13:37-40. [PMID: 32284731 DOI: 10.1177/1753495x18782627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/18/2018] [Indexed: 11/15/2022] Open
Abstract
Aortic aneurysm in pregnancy is associated with higher risk of complications due to the stress induced by the physiologic changes in pregnancy. Many of the reports are concentrated on those with catastrophic outcomes or who underwent surgical repair during pregnancy/puerperium. We report a case of aortic aneurysm, who presented during the second trimester and had a successful pregnancy outcome, and discuss the various issues concerning the management during pregnancy.
Collapse
Affiliation(s)
- Anish Keepanasseril
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - N Thendral
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Gowri Dorairajan
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Murali Subbaih
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Ajith Ananthakrishna Pillai
- Department of Cardiology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - B V Sai Chandran
- Department of Cardio-Thoracic & Vascular Surgery, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| |
Collapse
|
17
|
Abstract
Pregnancy in women with Marfan syndrome (MFS) presents challenges to the clinician and the patient due to the increased incidence of maternal complications and involvement of the fetus, and deserves special consideration. The leading cause of morbidity and mortality in MFS is aortic dissection. This article presents an extensive review of available clinical information and provides recommendations for the management of patients with MFS during pregnancy.
Collapse
Affiliation(s)
- Sorel Goland
- Heart Institute, Kaplan Medical Center, Rehovot, affiliated to Hebrew University, Jerusalem, Israel
| | - Uri Elkayam
- Department of Medicine, Division of Cardiovascular Disease, and Department of Obstetrics and Gynaecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
18
|
Abstract
OPINION STATEMENT Advances in cardiac surgical interventions in infancy and childhood have led to an increased number of women with congenital heart disease of childbearing age. For these women, individualized preconception counseling and pregnancy planning should be a vital component of their medical management, and presentation for obstetric care may even be an opportunity to re-establish cardiovascular care for patients who have been lost to follow-up. These patients have unique cardiovascular anatomy and physiology, which is dependent upon the surgical intervention they may have undergone during childhood or adolescence. These factors are associated with a variety of long-term complications, and the normal hemodynamic changes of pregnancy may unmask cardiac dysfunction and pose significant risk. Among three published risk assessment algorithms, the World Health Organization classification is the most sensitive in predicting maternal cardiovascular events in this population. Women with simple congenital heart defects generally tolerate pregnancy well and can be cared for in the community with careful monitoring. Conversely, women with complex congenital defects, with or without surgical repair and/or residual defects, should be managed in tertiary care centers under a multidisciplinary team of physicians experienced in adult congenital heart disease and high-risk obstetrics, who collaboratively participate in pregnancy planning, management, and care through childbirth and postpartum. Women who are cyanotic with oxygen saturation less than 85%, have significant pulmonary arterial hypertension of any cause, or have systemic ventricular dysfunction should be counseled to avoid pregnancy due to a very high risk of maternal and fetal mortality.
Collapse
Affiliation(s)
- Evin Yucel
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Doreen DeFaria Yeh
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA. .,Adult Congenital Heart Disease Program, Massachusetts General Hospital, Division of Cardiology, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
19
|
Sayama S, Takeda N, Iriyama T, Inuzuka R, Maemura S, Fujita D, Yamauchi H, Nawata K, Bougaki M, Hyodo H, Shitara R, Nakayama T, Komatsu A, Nagamatsu T, Osuga Y, Fujii T. Authors' reply re: Peripartum type B aortic dissection in patients with Marfan syndrome who underwent aortic root replacement: a case series study. BJOG 2017; 125:502-503. [DOI: 10.1111/1471-0528.14778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Seisuke Sayama
- Department of Obstetrics and Gynecology; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Norifumi Takeda
- Department of Cardiovascular Medicine; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Takayuki Iriyama
- Department of Obstetrics and Gynecology; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Ryo Inuzuka
- Department of Pediatrics; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Sonoko Maemura
- Department of Cardiovascular Medicine; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Daishi Fujita
- Department of Cardiovascular Medicine; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Haruo Yamauchi
- Department of Cardiovascular Surgery; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Kan Nawata
- Department of Cardiovascular Surgery; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Masahiko Bougaki
- Department of Anesthesiology and Pain Relief Center; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Hironobu Hyodo
- Department of Obstetrics and Gynecology; Tokyo Metropolitan Bokutoh Hospital; Sumida-ku Tokyo Japan
| | - Rieko Shitara
- Department of Obstetrics and Gynecology; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Toshio Nakayama
- Department of Obstetrics and Gynecology; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Atushi Komatsu
- Department of Obstetrics and Gynecology; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Takeshi Nagamatsu
- Department of Obstetrics and Gynecology; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology; Faculty of Medicine; University of Tokyo; Bunkyo-ku Tokyo Japan
| |
Collapse
|
20
|
Cauldwell M, Steer PJ. Re: Peripartum type B aortic dissection in patients with Marfan syndrome who underwent aortic root replacement: a case series study. BJOG 2017; 125:502. [DOI: 10.1111/1471-0528.14777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew Cauldwell
- Academic Department of Obstetrics and Gynaecology; Chelsea and Westminster Hospital; London UK
| | - Philip J Steer
- Academic Department of Obstetrics and Gynaecology; Chelsea and Westminster Hospital; London UK
| |
Collapse
|