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Spontaneous vaginal delivery in a parturient with thoracic aortic aneurysm
Abstract Number: RF5BH-373
Abstract Type: Case Report Case Series
Aortic aneurysm is a rare risk of pregnancy complicated by aortic dissection and may lead to maternal and or fetal morbidity and mortality. Herein we present the management of a multiparous parturient with pregnancy complicated by descending thoracic aortic aneurysm (TAA).
A 37 yo G3P2 at 37 3/7 weeks EGA with history of 2 prior vaginal deliveries presented for scheduled induction of labor. Past medical history was significant for tobacco abuse and descending thoracic aortic aneurysm with associated type B dissection s/p endovascular repair 1 year prior to her current presentation. CT angiography confirmed 5.7 X 4.2 cm TAA with stent graft and without evidence of endoleak. A radial arterial line was placed for close hemodynamic monitoring and she underwent uneventful dural puncture epidural (DPE) placement. She remained comfortable throughout her labor and a forceps-assisted vaginal delivery (Apgars 9/9) was performed to minimize maternal effort. Her postpartum course was uneventful and she was discharged home on postpartum day 3.
The incidence of an acute aortic dissection in women of childbearing age is approximately 2.6- 3.5 cases per 100,000. Risk factors include tobacco abuse, hypertensive disorders, advanced maternal age, inherited connective tissue disorders, bicuspid aortic valve, coarctation, and aortitis. Although the physiological changes of pregnancy do not directly cause dissections, these changes in addition to an inherited defect or previously compromised arterial wall increase the risk of dissection. Unfortunately, most aneurysms and or dissections are inadvertently discovered in the third trimester of pregnancy due to the maximal hemodynamic stress during pregnancy (increased HR, SV, CO, left ventricular mass, and end diastolic dimensions), which results in increased maternal and fetal mortality. This case is unique due to the paucity in the literature regarding pregnancy management and outcomes in women with previous endovascular repair. There was significant concern for a dissection during labor or the postpartum period and therefore, after input from cardiology, maternal fetal medicine, & obstetric anesthesia, she was allowed to labor with close hemodynamic monitoring and excellent labor analgesia.
References: Thalamus 2011, Notle 1995, Immer 2003