Managing aortic aneurysms and dissections during pregnancy

Abstract

Cardiovascular diseases during pregnancy account for significant morbidity and mortality, with aortic aneurysms, complicated by aortic dissection or rupture, being high on the list of underlying causes in this category. Correct knowledge of the diagnosis, risks and treatment is mandatory to improve the outcome and save lives. In this article, the authors aim to provide an overview of the underlying causes and risk factors for aortic aneurysms and dissections during pregnancy, while presenting the ways of preventing and treating these conditions. Although an important focus lies on the proximal part of the aorta due to it bearing the greatest risk for complications and being more frequently implicated in aortic disease in younger subjects, many aspects on the etiology and underlying diseases also apply to the other parts of the vessel.

Keywords:

• beta-blockers
• bicuspid aortic valve
• coarctation
• Marfan syndrome
• pregnancy
• thoracic aneurysm
• thoracic dissection
• Turner syndrome
• valve-sparing surgery

Financial & competing interests disclosure

J De Backer holds a grant as Senior Clinical Investigator from the Fund for Scientific Research (FWO), Flanders (Belgium). L Muiño Mosquera is supported by a doctoral fellowship from the Special Research Fund (BOF) of the University of Ghent (Belgium). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Pregnancy may increase the risk of aortic dissection in women with aortic aneurysms.

• Women with underlying medical conditions such as connective tissue disorders, bicuspid aortic valve, Turner syndrome and aortic coarctation have a higher predisposition to dissection during pregnancy.

• Counseling before pregnancy for cardiovascular and obstetric risks is essential.

• Prior to pregnancy, genetic counseling addressing the transmission risk is equally important.

• Appropriate follow-up before and during pregnancy is the cornerstone of prevention of aortic dissection in pregnant women with aneurysms. This follow-up should occur every 4–8 weeks and up to 6 months after pregnancy.

• Medical treatment with beta-blockers during pregnancy should be encouraged in patients with Marfan syndrome (MFS) and in all other conditions if hypertension is present. However, special considerations regarding fetal impact should be taken into account.

• Medical treatment with Losartan and angiotensin-converting enzyme inhibitor is contraindicated during pregnancy.

• Surgical replacement before pregnancy is recommended if the aortic root is above 45 mm in patients with MFS and 50 mm in patients with bicuspid aortic valve. However, caution needs to be taken regarding the safety of pregnancy in these groups of patients.

• An aortic diameter of 40 mm or lower in patients with MFS is considered safe when considering pregnancy.

• Surgical treatment during pregnancy carries an important risk for the mother and fetus and should only be performed in case of life-threatening circumstances. Cesarean section is recommended after 28th week of pregnancy before aortic surgical treatment.