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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 1, January/February 2015
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AFRICA
Low-dose aspirin for pre-eclampsia prevention should be started
before 16 weeks.
Lakhi and Jones reported a case of Takayasu arteritis
complicated by aortic dissection in the peripartum period.
8
In this report, the patient’s blood pressure remained elevated
(160/91 mmHg) when she became symptomatic on the third
postpartum day. In the 2003–2005 Confidential Enquiries into
Maternal Deaths in the United Kingdom, aortic dissection
was one of the leading causes of maternal death.
9
The deaths
occurred mostly from failure to treat systolic hypertension.
Foetal complications such as growth restriction, miscarriage and
foetal death have been reported in 60–90% of cases.
10
Foetal growth
restriction is most likely the result of impaired placental blood flow
caused by uncontrolled blood pressure and the involvement of the
abdominal aorta and renal arteries. Another mechanism could
be occlusion of the renal arteries, leading to an increase in renin
production, with consequent increase in blood pressure.
11
The mode of delivery is determined by the maternal
haemodynamic status and by obstetric indications. Unfortunately
there are very little data to guide clinicians as to the optimal mode
of delivery. Labour and vaginal delivery with or without epidural
anaesthesia is safe provided blood pressure is controlled.
8
Patients with Takayasu disease experience a severe elevation of
systolic blood pressure during uterine contractions, compared
to control patients, so regular monitoring of blood pressure is
important during labour.
12
The second stage of labour should be
shortened by the use of low forceps or vacuum delivery.
Leal
et al
. recommend vaginal delivery for patients in groups
I and IIa, as long as epidural analgesia is used for pain relief
and the second stage of labour shortened by vacuum or forceps.
5
Caesarean section is recommended for patients in group IIb and III
because the increased blood volume and blood pressure observed
during uterine contractions may lead to cardiac decompensation
.5
Regional anaesthesia has been reported successfully for caesarean
delivery.
13
This method also allows monitoring of brain perfusion
through the patient’s level of consciousness. Our patient had an
elective caesarean section because, although the blood pressure
was controlled, her aorta was severely dilated. This put her at a
significant risk of dissection or rupture of the aorta.
Patients should be nursed in a high-care unit postoperatively
to allow for early detection of hypoperfusion of organs
and hypertensive complications. After delivery, maternal
peripheral resistance and left ventricular workload increases.
This physiological change may lead to the development of
pulmonary oedema, heart failure, renal dysfunction or cerebral
haemorrhage.
14
Use of immunosuppressive treatment may also
increase the risk of puerperal infection.
Conclusion
Patients with Takayasu disease in pregnancy are at risk of
several obstetric complications. These patients should be jointly
managed during pregnancy by obstetricians, rheumatologists
and cardiologists. Systemic hypertension must be aggressively
treated to reduce the risk of complications.
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