Copyright © 2004, The European Society of Cardiology
Serial pressure gradients across a thoracic coarctation of the aorta during pregnancy
Department of Cardiology, University Hospital Aintree, Liverpool, UK
Received 29 June 2004; .
* Corresponding author. Tel.: +44-151-525-5980. E-mail: kelly.dominic@talk21.com
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Case of maternal aortic coarctation distal to the left subclavian artery followed throughout a successful pregnancy with serial echocardiography. We demonstrate changes in pressure gradients across the defect which may have management implications in similar pregnancies.
Keywords: Coarctation; Pregnancy; Echocardiography; Continuous wave
Coarctation of the thoracic aorta represents a significant percentage (6–8%) of patients with congenital heart disease.1,2 Most of these would be expected to reach maternal age,3 and although recent studies have shown overall favourable outcomes during pregnancy4,5 it remains an anxious period. Physiological changes in maternal stroke volume and heart rate contribute to a cardiac output 45% above the non-pregnant level by 24 weeks, this is associated with an increased venous return and reduction in peripheral vascular resistance. Blood pressure falls during the first 20 weeks followed by a progressive increase until term.6 Little has been documented regarding any haemodynamic changes across such a coarctation during the pregnancy period. This information may contribute to the management of such patients. We report the case of a 33 year female during her first pregnancy followed with serial echocardiography.
Our patient has a previous history of aortic coarctation distal to the left subclavian artery, diagnosed during her teenage years and treated with balloon angioplasty at the age of 19. She re-presented following a history of palpitations at the age of 29 and was found to be persistently hypertensive. Repeat echocardiograhy showed a peak gradient in the descending aorta of 28 mmHg signifying persistent coarctation. She was treated medically with antihypertensives.
At the age of 33 she was referred to our unit during her first pregnancy. Echocardiography at presentation demonstrated an enlarged left ventricle which contracted well, the aortic valve was bicuspid with a maximum peak gradient of 16 mmHg, mean 10 mmHg consistent with mild outflow tract obstruction. There was a mild eccentric regurgitant jet. Increased flow velocity was seen in the descending aorta of 3 m/sec consistent with a significant coarctation. Trans-oesophageal echo confirmed these findings. MRI was arranged to better visualise the coarctation (Fig. 1). No additional dilatation or aneurysm formation was observed.
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Serial echocardiography was performed through the 3 trimesters to observe any significant changes across the coarctation.
Pressure gradients were calculated using the Bernoulli equation from continuous wave Doppler flow velocities of the descending aorta to obtain peak velocity and pulsed wave Doppler proximal to the coarctation (Fig. 2). Results are shown below (Fig. 3).
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Tight blood pressure control was maintained using oral labetolol initially at a dose of 200 mg bd. At 20 weeks duration upper limb BP readings were low with systolic readings between 80 and 120. This was associated with a gradient of 27 mmHg across the defect. Labetolol dose was reduced to 100 mg bd, with subsequent improvement in BP and a fall in gradient at 22 weeks to 21 mmHg.
Obstetric progress was uneventful with appropriate foetal development both clinically and via ultrasonography. The pregnancy proceeded to term with an uncomplicated vaginal delivery with antibiotic cover. Both mother and child remain well.
Our case outlines as previously shown that pregnancy with maternal coarctation may proceed without complication. As far as we are aware, no cases have previously been presented of successful pregnancy following coarctation intervention by angioplasty. Our demonstration of significant pressure changes over the pregnancy period indicates the importance of close monitoring to minimise both maternal and foetal complications. Tight BP control is likely to minimise the haemodynamic stress effects on the aortic wall and hence the associated potential complications. However satisfactory upper body blood pressure control may lead to hypotension beyond the coarctation and hence foetal complications such as growth retardation and premature delivery. Knowledge of gradient changes through the trimesters across such a coarctation and the associated BP changes are likely to aid with management. In addition serial measurement of right arm versus left leg blood pressure would provide an easy, non-invasive measure of pressure gradient, this information was not available in this case. Further research may be aimed at determining optimum blood pressure through the differing stages of pregnancy to minimise risks in similar situations.
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[Abstract/Free Full Text] - Beauchesne L.M., Connolly H.M., Ammash N.M., Warnes C.A. Coarctation of the aorta: outcome of pregnancy. J Am Coll Cardiol (2001) 38(6):1728–1733.
[Abstract/Free Full Text] - Janku K., Unzeitig V., Mikulik R., Uchytil B., Janku P., Volkova N. Management and methods of delivery in women with aortic coarctation – results of 64 pregnancies in 41 women. Ceska Gynekol (2000) 65(4):236–239.[Medline]
- Hunter S., Robson S.C. Adaptation of the maternal heart in pregnancy. Br Heart J (1992) 68(6):540–543.
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