Cardiovascular Journal of Africa: Vol 26 No 1 (January/February 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 1, January/February 2015 e14 AFRICA
Case Report
Takayasu arteritis in pregnancy
Priya Soma-Pillay, Adekunle Adeyemo, Farhana Ebrahim Suleman
Abstract
Takayasu arteritis is a chronic, granulomatous arteritis affect-
ing large and medium-sized arteries. During pregnancy,
maternal and foetal complications are largely as a conse-
quence of maternal arterial hypertension. We present a case
of a 35-year-old para one gravida two patient with Takayasu
arteritis (group III disease) complicated by chronic hyper-
tension and a severely dilated ascending aorta. Good blood
pressure control during pregnancy is an important measure
in reducing obstetric morbidity.
Keywords: Takayasu arteritis, pregnancy, hypertension, pre-
eclampsia
Submitted 18/9/14, accepted 10/1/15
Published online 5/2/15
Cardiovasc J Afr 2015; 26: e14–e16
DOI: 10.5830/CVJA-2015-003
Takayasu arteritis is a chronic granulomatous arteritis affecting
large and medium-sized arteries. The disease is characterised
by inflammation of the blood vessels, resulting in destruction
and distortion of the layered components of their walls. During
the early stages of the disease, there are mononuclear cell
infiltrations in the adventitia and granulomas with Langerhans
cells in the media. This is followed by disruption of the elastin
layer and subsequent massive medial and intimal fibrosis. These
lesions result in segmental stenosis, occlusion, dilatation and
aneurysmal formation in the affected vessels.1
Stenotic lesions predominate and have been reported in 90%
of cases, while aneurysms are only reported in approximately
25%.2 This is a disease of young adults with a peak onset in the
second and third decades of life. A case series reported from
South Africa of Takayasu arteritis in childhood demonstrated
a 2:1 female-to-male ratio.3 Patients with Takayasu arteritis may
present with a variety of clinical manifestations, but arterial
hypertension is the most common feature of the disease.4
Case report
A 35-year-old para one gravida two patient, with a previous
uncomplicated full-term delivery at the age of 16 years, was
referred to the cardiac-obstetric unit at eight weeks’ gestation.
She had been diagnosed with Takayasu arteritis six years earlier,
and tuberculosis two years previously, for which she was treated.
She was hypertensive and her blood pressure was controlled with
nifedipine, carvedilol and hydrochlorothiazide. The Takayasu
disease was being treated with prednisone and azathioprine.
Further history revealed that her ascending aorta was dilated,
and on evaluation by cardiothoracic surgeons, the lesion was
considered to be inoperable. The patient was not using any
contraception and this was a planned and wanted pregnancy.
She had no other medical or surgical history of note.
On examination, the patient was apyrexial with a blood
pressure of 120/70 mmHg in both arms and a pulse of 88 beats
per minute. Cardiac examination revealed normal first and
second heart sounds. No third or fourth heart sounds were
heard and there was a one-quarter aortic regurgitation murmur.
Respiratory and abdominal examinations were normal.
Ultrasound examination confirmed an intra-uterine
pregnancy of eight weeks’ gestation. The electrocardiogram
was normal. On echocardiography, the patient had good left
ventricular systolic function with no regional wall-motion
abnormality. There was a tricuspid aortic valve with trivial
aortic regurgitation. The ascending aorta was markedly dilated,
measuring 5.7 cm. No dissection flap was seen.
The descending aorta and its branches had been evaluated by
CT angiography two months prior to pregnancy. The ascending,
arch and descending thoracic aorta were dilated (Fig. 1A, B) with
marked mural thickening of the thoracic (2.3 cm) aorta (Fig. 2A,
B). A laminated thrombus was found on the descending aorta.
The renal arteries were patent. No abnormality was detected on
fundoscopy.
Laboratory findings showed an elevated erythrocyte
sedimentation rate of 56 mm/h and a C-reactive protein level of
9 mg/dl. The full blood count, renal function, electrolytes and
urinalysis were normal.
The patient was managed by a multidisciplinary team of
cardiologists, obstetricians and rheumatologists. After the initial
investigations were performed, the patient was counselled about
the aortic lesions. She was informed about the possibility of
further dilatation or rupture of the aorta during pregnancy.
The patient was offered a termination of pregnancy for medical
reasons, which she declined.
The pregnancy was managed further by the multidisciplinary
team and the patient was treated with prednisone (10 mg
daily) and azathioprine (150 mg alternating with 200 mg daily)
for Takayasu disease, methyl-dopa for hypertension, aspirin
Cardiac-Obstetric Unit, Steve Biko Academic Hospital,
University of Pretoria, Pretoria, South Africa
Priya Soma-Pillay, FCOG, Cert
(Maternal and Foetal Med) SA
Adekunle Adeyemo, MB BS, MCFP (SA), FCP (SA), Cert Cardiol (SA)
Department of Radiology, Steve Biko Academic Hospital,
University of Pretoria, South Africa
Farhana Ebrahim Suleman, FCRad (D), MMed Rad (D)