Aortic regurgitation in pregnancy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Mohammed A. Sbeih, M.D.[2]; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Isolated aortic regurgitation in pregnant subjects can be managed with combination of diuretics and vasodilators.[1] 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

Pregnant patients are deemed to be high risk if aortic regurgitation is associated with NYHA class III to IV symptoms, Marfan syndrome, or a left ventricular ejection fraction of less than 40%. Such patients ideally should undergo definitive surgical therapy before pregnancy. If the patient is already pregnant, termination of pregnancy is recommended.[2]

Low Risk

Pregnant patients are deemed to be low risk if aortic regurgitation is 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.[2]

Marfan's Syndrome

Patients with Marfan's syndrome who have aortic root dilatation during pregnancy are at an increased risk of developing aortic dissection or rupture which usually occurs in the third trimester or near the time of delivery. Pregnant patients are at high risk if the aortic root diameter is greater than 40 mm in which case there is approximately a 10% probability of developing aortic dissection.[3][2] Women with Marfan's syndrome should be counseled against pregnancy and should undergo screening transthoracic echocardiography 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.[4] Beta blockers can be used prophylactically throughout pregnancy with labetalol or metoprolol being the preferred drugs.[2]

Delivery

As per AHA/ACC 2006 guidelines, serial transthoracic echocardiography and regular monitoring of blood pressure throughout the pregnancy with provision of adequate analgesia during labor are recommended. Shortening of the 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.[4][5]

References

  1. Sheikh F, Rangwala S, DeSimone C, Smith HS, O'Leary AM (1995). "Management of the parturient with severe aortic incompetence". Journal of Cardiothoracic and Vascular Anesthesia. 9 (5): 575–7. PMID 8547563. Retrieved 2011-03-25. 
  2. 2.0 2.1 2.2 2.3 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. PMID 18820172. doi:10.1161/CIRCULATIONAHA.108.190748. Retrieved 2011-03-25. 
  3. "Expert consensus document on management of cardiovascular diseases during pregnancy". European Heart Journal. 24 (8): 761–81. 2003. PMID 12800857. Retrieved 2011-03-25. 
  4. 4.0 4.1 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–369. PMID 20233780. doi:10.1161/CIR.0b013e3181d4739e. Retrieved 2011-03-25. 
  5. Elkayam U, Ostrzega E, Shotan A, Mehra A (1995). "Cardiovascular problems in pregnant women with the Marfan syndrome". Annals of Internal Medicine. 123 (2): 117–22. PMID 7778824. Retrieved 2011-03-27. 


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