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Aortic Coarctation and Labor and Delivery—A Careful Balance.
Abstract Number: SAT-81
Abstract Type: Case Report/Case Series
Case: 17 y.o. G1P0 with PMH of coarctation of aorta, bicuspid aortic valve (BAV) and chronic HTN presented for IOL at 39w6d. She underwent coarctation resection with end-to-end anastomosis as a neonate, and required redilation and stent placement for residual stenosis proximal to left subclavian at age 4 and 8. Recent echo showed a juxtaductal aortic peak gradient of 60mmHg and a mean gradient of 25mmHg at the stent. BPs in OB clinic were 140-150s/60s-90s, though location of measurement was not recorded.
BP was monitored during labor using right radial arterial line and left upper extremity NIPB cuff. Assisted second stage was planned to minimize hemodynamic effects of Valsalva. Primary cesarean was performed following failed operative vaginal delivery. On arrival to OR, right-sided ABPs were 186/78 (mean 114) and left sided NIBP was 103/72 (mean 82). The MAP showed 25-30mmHg discordance throughout the case, matching the mean gradient across her stent by echo. Epidural was incrementally dosed with lidocaine 2% with 1:200K epi and delivery and postpartum course were uneventful.
Discussion: Aortic coarctation represents 6-8% of congenital heart disease and is frequently associated with other anomalies, such as BAV. Typically repaired in infancy, most patients survive to childbearing years. Restenosis can occur and is usually treated with balloon angioplasty and stent placement (1). HTN develops from decreased arterial compliance and increased LV afterload (2). Hormone induced vascular remodeling, increased plasma volume and increased cardiac output during pregnancy increases gradients and places parturients at risk for aortic dissection (3).
Twenty-two to 30% of patients with aortic coarctation develop hypertensive disorders of pregnancy, compared to 8% of general population (1,3). As residual stenosis was proximal to the left subclavian, arterial line was placed on the right to monitor for severe proximal hypertension, which increases risk of dissection. Left sided pressures were used to monitor pressure distal to the stent, where hypotension may compromise uterine blood flow (3,4).
Coarctation patients have an underlying aortopathy that predisposes them to dissection and merits formal cardiac assessment (5). Location of each recorded blood pressure is pertinent, as hemodynamic goals should be set based on location of measurement (4). For those with significant aortic pressure gradients undergoing labor, dual arterial blood pressure monitoring pre and post coarctation is recommended. This allows for the careful balance between decreasing risk for aortic dissection while preventing uterine hypoperfusion (4).
1. European Heart Journal (2005) 26, 2173–2178
2. Curr Treat Options Cardiovasc Med. 2016 Jun;18(6):40
3. J Am Coll Cardiol. 2001;38:1728–33
4. J Clin Anesth. 2006 Jun;18(4):300-3
5. Ann Thorac Surg. 2013 Jun;95(6):1961-7