Aortic insufficiency in pregnancy


 * Associate Editor-in-Chief: Varun Kumar, M.B.B.S., Lakshmi Gopalakrishnan, M.B.B.S.

Overview
Isolated aortic insufficiency in pregnant patients can be managed with combination of diuretics and vasodilators. ACE inhibitors are contraindicated in pregnancy. Patients with signs and symptoms of left ventricular failure should be monitored throughout labor and delivery with strict attention to volume status and blood pressure.

Risk Stratification


 * High risk: Aortic insufficiency associated with NYHA class III to IV symptoms, Marfan syndrome or left ventricular ejection fraction of less than 40%. Such patients ideally should undergo definitive surgical therapy before pregnancy. If patient is already pregnant, termination of pregnancy is recommended.


 * Low risk: Aortic insufficiency associated with NYHA class I to II symptoms. Such women generally tolerate pregnancy without complications and the natural fall in systolic blood pressure during pregnancy may be beneficial in reducing the regurgitant volume.

Aortic root dilatation in pregnant patients with Marfan syndrome are at increased risk of developing aortic dissection or rupture which usually occur in third trimister or near time of delivery. Patients are at high risk if aortic root diameter is greater than 40mm with approximately 10% probability of developing aortic dissection. Women with marfan syndrome should be counseled against pregnancy and should undergo screening transthoracic echocardiogram to assess the aortic root dimensions. However, replacement of aortic root and ascending aorta may be considered if the aortic diameter exceeds 40 mm in women with marfan syndrome who are contemplating pregnancy. Beta blockers can be used prophylactically throughout pregnancy with labetalol or metoprolol being the preferred drugs. As per AHA/ACC 2006 guidelines, serial transthoracic echocardiogram and regular monitoring of blood pressure throughout the pregnancy with providing adequate analgesia during labor are recommended. Shortening of second stage of labor using various obstetric techniques may be beneficial. In patients with an aortic root diameter greater than 40 mm, severe aortic regurgitation, heart failure or aortic dissection, cesarean delivery with general anesthesia is preferred as it allows optimal hemodynamic control.