Journal of Obstetrics and Gynaecology

ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20

Two successful sequential pregnancies in the same woman following aortic valvotomy with coarctation repair and subsequent Ross procedure for bicuspid aortic valve and aortic coarctation N. Demir, M. T. Canda & G. Saylam To cite this article: N. Demir, M. T. Canda & G. Saylam (2015) Two successful sequential pregnancies in the same woman following aortic valvotomy with coarctation repair and subsequent Ross procedure for bicuspid aortic valve and aortic coarctation, Journal of Obstetrics and Gynaecology, 35:1, 91-92, DOI: 10.3109/01443615.2014.935727 To link to this article: http://dx.doi.org/10.3109/01443615.2014.935727

Published online: 14 Jul 2014.

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Date: 05 November 2015, At: 12:50

Obstetrics Case Reports 91

Two successful sequential pregnancies in the same woman following aortic valvotomy with coarctation repair and subsequent Ross procedure for bicuspid aortic valve and aortic coarctation N. Demir1, M. T. Canda1 & G. Saylam2 1Department of Obstetrics and Gynecology Kent Hospital and

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2Department of Pediatric Cardiology, Dokuz Eylul University Medical Faculty, Izmir, Turkey

anticoagulation was used. In the 1st-trimester of pregnancy, the echocardiography revealed a mild dilatation of the aorta (34 mm) and ascending aorta (38 mm) with mild aortic and pulmonary insufficiency. She tolerated the pregnancy period well, and at 39 weeks’ gestation, she had a repeat caesarean section under epidural anaesthesia after a course of antibiotic prophylaxis for subacute bacterial endocarditis. She delivered a baby boy of 2,760 g with 47 cm in length with a head circumference of 35 cm with Apgar scores of 9/10. Both the mother and the newborn were discharged on the second postoperative day. At 2 months after this caesarean delivery, the echocardiography revealed a mild dilatation of the aorta (36 mm) and ascending aorta (39 mm) with mild aortic and pulmonary insufficiency. After 1-year of follow-up after the second delivery, the mother and children were doing well.

DOI: 10.3109/01443615.2014.935727

Discussion

Correspondence: M. T. Canda, Department of Obstetrics and Gynecology, Kent Hospital, 35580, Cigli, Izmir, Turkey. E-mail: [email protected]

Congenital BAV is the most common congenital heart defect with a prevalence of 4.6 cases per 1,000 live births and a higher occurrence in males (Larson and Edwards 1984). BAV and associated cardiovascular anomalies includes aortic coarctation, aortic aneurysm and hypoplastic left heart structures (Losenno et al. 2012). For women of childbearing age with BAV, it is unclear which type of valve replacement (homograft, mechanical, bioprosthetic or autologous) optimises pregnancy outcomes. The Ross procedure uses the patient’s pulmonary valve to replace a problematic aortic or mitral valve, followed by replacement of the pulmonary valve with a bioprosthetic valve, which is supposed to last longer (Ross 1967). Freedom from reoperation was about 99% at 13 years (El-Hamamsy et al. 2010). In women of childbearing age, mechanical and bioprosthetic valves were found to be associated with many pregnancy complications, such as spontaneous abortions, warfarin associated fetal damage, valve dysfunction, endocarditis, haemorrhage and thromboembolic events (Lee et al. 1994; Vitale et al. 1999). There is limited data on pregnancy outcomes after the Ross procedure; however pregnancy outcomes are more favourable after the Ross procedure than with mechanical and bioprosthetic valves (Dore and Somerville 1997; Ali et al. 2009; Martin et al. 2003). Dore and Somerville (1997) found that among eight women who had previously undergone the Ross procedure, 14 had full-term pregnancies, all of which were uneventful except for one neonatal death. Additionally, no maternal deaths, thromboembolic events, haemorrhagic complications or structural valve deterioration were reported. Another pregnancy outcome study among women with aortic valve prostheses reported that human tissue valves should be considered as the optimal option for aortic valve replacement (AVR) choice in young women (Heuvelman et al. 2013). Additionally, this study reported preterm delivery and SGA infants as the most common obstetrical complications. In the present case study, similar to Heuvelman et al. (2013), no maternal cardiac complications occurred in either pregnancy, and the only obstetric complications, which were preterm delivery secondary to PPROM and a SGA infant, occurred only in the first pregnancy. Women who have had AVR and expect to become pregnant require appropriate clinical evaluation and suitable haemodynamics for good pregnancy outcomes. Thus, given their congenital cardiac histories, these patients should be encouraged to discuss their intentions for pregnancy, and if it all possible, plan their pregnancies with the input and support of their physicians. Additionally, the most beneficial mean interval time length between AVR and pregnancy is unclear in the current literature. In the present study, the first pregnancy occurred 10 years after AVR with the Ross procedure, which may seem a long time. However, the interval between the surgical repair of congenital cardiac valve disease and pregnancy described in the literature ranges from 1 year to 21 years, with a mean time interval of 5.6 years (Dore and Somerville 1997). We report here on two successful sequential pregnancies and deliveries after a Ross procedure for BAV and coarctation of the aorta in the same woman. Our experience with this case and currently

Case report This is a report of a woman born with congenital bicuspid aortic valve (BAV) stenosis and aortic coarctation at the 10th cm of the aorta. After her initial diagnosis at 3 years of age, she underwent aortic valvotomy and coarctation repair at 4 years of age and did well except for mild post-pericardiotomy syndrome. She subsequently experienced some episodes of chest discomfort and shortness of breath but otherwise did well. At 13 years of age, echocardiographic assessment of the valve stenosis showed mild residual aortic valve stenosis with a peak velocity of 3.7 m/s with a mean pressure estimate of 24 mmHg and moderate aortic regurgitation with mild concentric left ventricular hypertrophy. Her medications included captopril 12.5 mg p.o. daily and digoxin 0.125 mg p.o. daily. The possibility of left ventricular outflow tract (LVOT) obstruction in the future and the timing of a second surgical intervention once she was fully grown, anticoagulation and implications for pregnancy were discussed with the patient. At 18 years of age, she was referred for a Ross procedure. Her preoperative echocardiography showed a BAV with thickened leaflet tips and an annulus of 21 mm, moderate aortic stenosis with a peak velocity of 4 m/s and a mean pressure gradient of 43 mmHg associated with moderate aortic insufficiency. Her electrocardiogram (ECG) showed left ventricular hypertrophy. Due to significant LVOT obstruction secondary to a bicuspid aortic valve, she underwent a Ross procedure. Her aortic valve was replaced with her pulmonary valve, and a Hancock valve replaced the pulmonary valve. After the Ross procedure, she reported no complaints. She was started on aspirin 100 mg p.o. daily and enalapril 10 mg p.o. daily and has been followed for the degree of aortic root expansion, aortic regurgitation and monitoring of the Hancock valve. At 28 years of age, 10 years after the Ross procedure, she conceived and received routine prenatal care and close follow-up by her cardiologist with ECG and echocardiography. Her enalapril was stopped as soon as pregnancy was confirmed. During pregnancy, mild dilatation of the aortic root (29 mm) and the ascending aorta (33 mm) were detected with mild aortic and pulmonary insufficiency. No sign of stenosis was detected in either the autologous or Hancock valves. No anticoagulation was used during the prenatal or postpartum periods. At 36 weeks’ gestation, due to the premature rupture of membranes and because the patient did not want an instrumental delivery for the second stage of labour and to avoid any negative effects from the Valsalva pushing technique, a caesarean section was performed under epidural anaesthesia after an antibiotic prophylaxis for subacute bacterial endocarditis. A small-for-gestational-age (SGA) baby girl of 2,150 g with 43.5 cm in length and with a head circumference of 32 cm was born with Apgar scores of 7/9. Except for an episode of hypoglycaemia no other problems developed during the newborn period. The mother and the infant were discharged on the second postoperative day. At 30 years of age, 2 years after the first delivery and 12 years after the Ross procedure, the patient became pregnant again. This gestational period was uneventful. Enalapril was stopped and no

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published literature suggest that for young women of childbearing age who require AVR, the Ross procedure should be recognised as a safe operation with low operative mortality and favourable long-term results, which are unaffected by pregnancy and with only minimal adverse effects on maternal and fetal outcome. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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References Ali U, Copel J, Friedman A. 2009. A successful pregnancy outcome following the Ross procedure: a case report. American Journal of Perinatology 26:287–289. Dore A, Somerville J. 1997. Pregnancy in patients with pulmonary autograft valve replacement. European Heart Journal 18:1659–1662. El-Hamamsy I, Eryigit Z, Stevens LM et al. 2010. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet 376:524–531. Heuvelman HJ, Arabkhani B, Cornette JM et al. 2013. Pregnancy outcomes in women with aortic valve substitutes. American Journal of Cardiology 111:382–387. Larson EW, Edwards WD. 1984. Risk factors for aortic dissection: a necropsy study of 161 cases. American Journal of Cardiology 53:849–855. Lee CN, Wu CC, Lin PY et al. 1994. Pregnancy following cardiac prosthetic valve replacement. Obstetrics and Gynecology 83:353–356. Losenno KL, Goodman RL, Chu MW. 2012. Bicuspid aortic valve disease and ascending aortic aneurysms: gaps in knowledge. Cardiology Research and Practice 2012:145202. Martin TC, Idahosa V, Ogunbiyi A et al. 2003. Successful pregnancy and delivery after pulmonary autograft operation (Ross procedure) for rheumatic aortic valve insufficiency. West Indian Medical Journal 52:62–64. Ross DN. 1967. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet 2:956–958. Vitale N, De Feo M, De Santo LS et al. 1999. Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves. Journal of the American College of Cardiology 33:1637–1641.

Pulmonary embolism presenting as a seizure in the immediate postpartum period Y. H. Ching1, E. N. Alvey1, H. R. Omar2, C. M. Lynch3, D. Mangar1,4 & E. M. Camporesi1,4 1Department of Research, Florida Gulf-to-Bay Anesthesiology

Associates, 3Department of Obstetrics and Gynecology and 4Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, 2Department of Internal Medicine, Mercy Medical Center, Clinton, IA, USA DOI: 10.3109/01443615.2014.936842 Correspondence: Y.-H. Ching, 1 Tampa General Circle, Suite C-208, Tampa, FL 33606, USA. E-mail: [email protected]

Introduction Seizures in the postpartum period are not always due to eclampsia, and the various potential aetiologies have a considerable amount of overlap leading to difficulty in diagnosis. Massive pulmonary embolism (PE) as a cause of seizure in the postpartum period has not been previously reported. Herein, we describe a case of massive PE presenting with seizures in the immediate postpartum period, diagnosed utilising bedside transthoracic echocardiography (TTE) and successfully treated by surgical embolectomy.

Case report A 33-year-old, G3P2002, African-American woman presented for scheduled induction of labour at 39 weeks’ gestation, with a pregnancy complicated by malnutrition and anaemia. Her history was significant for gastric bypass surgery, from which the patient achieved a normal

body mass index prior to pregnancy. She did not have a current or remote history of tobacco use, pre-eclampsia, eclampsia, epilepsy or a family history of seizure disorder. Approximately 2 h after a spontaneous vaginal delivery, the patient experienced a postpartum haemorrhage, which was controlled by misoprostol and oxytocin. An hour later, she suddenly became unresponsive with development of myoclonic seizure activity. The patient was started on diazepam and fluid resuscitation, but she continued to deteriorate and went into pulseless electrical activity (PEA), for which cardiopulmonary resuscitation (CPR) measures were initiated. She was stabilised and prepared for transfer to the intensive care unit (ICU), but she again arrested with PEA approximately 5 min later, followed by CPR with return of spontaneous circulation (ROSC). During transport to the ICU, the patient arrested for a third time with PEA, and CPR was resumed until ROSC was achieved. Bedside TTE was performed revealing dilation of the right atrium (RA) and right ventricle (RV); severe tricuspid regurgitation (TR) and pulmonary hypertension; right ventricular dysfunction and an echodense lesion in the pulmonary artery, suggestive of acute saddle PE (Figure 1). As she had undergone a recent vaginal delivery and had experienced chest compressions, thrombolytic therapy was contraindicated. As such, she was brought to the operating room and underwent successful surgical pulmonary embolectomy with extraction of a large saddle embolus and placement of an IVC filter. A Bakri balloon for control of active uterine bleeding was also performed. The patient was started on levetiracetam to control post-hypoxic myoclonus activity (Lance-Adams syndrome) and head magnetic resonance imaging did not demonstrate any abnormalities. Anticoagulation therapy with warfarin was initiated on postoperative day (POD) 8 and was continued upon discharge. The remainder of the patient’s hospital course was uneventful, and she was discharged home on POD 22. The patient returned for her postpartum examination and was well except for some memory deficits.

Discussion Venous thromboembolism (VTE), a disease state inclusive of deep vein thrombosis (DVT) and PE, remains a leading cause of maternal morbidity and mortality in developed countries (Berg et al. 2010; Chang et al. 2003; Heit et al. 2005). Pregnant and postpartum women are at a four- to five-fold increased risk of developing VTE compared with non-pregnant women, with the highest incidence in the first week after delivery (Conti et al. 2013; Heit et al. 2005; James 2009; Baue 1986; Virkus et al. 2011). As such, prompt recognition and treatment of acute PE in this setting is paramount. However, the clinical presentation of acute PE can mimic the changes of normal pregnancy and various pathophysiological states, leading to potential delays in diagnosis and treatment. Acute PE can also present in unusual ways, such as seizures, which occur in less than 1% of cases (Meyer 2009). Although the pathophysiology of seizures in PE is not well-defined, Marine and Goldhaber (1997) theorised that seizures may arise from transient cerebral ischaemia, hypoxia and metabolic and respiratory acidosis resulting from the right ventricular and respiratory failure caused by the pulmonary embolus. The presented case emphasises several interesting aspects of acute PE in pregnancy and the postpartum period. In reviewing the literature, we did not find any previously reported cases of acute PE presenting as seizures in this population. However, the literature supports maintaining a high index of suspicion for PE in any patient presenting with seizures and abnormal vital signs that are not explained by the seizure activity alone (Volz and Jasani 2014). As our patient was haemodynamically unstable and did not have a history of seizures, PE was felt to be high in the differential. Our case also demonstrates the potential role of echocardiography in the diagnosis of PE in pregnancy. Current standards for imaging the pulmonary arteries presents risks for radiation and contrast agent exposure to mother and fetus. Echocardiography mitigates these risks while also providing the ability for expeditious evaluation. Additionally, while thrombolysis is currently recommended for the initial treatment of massive PE, recent evidence suggests that early surgical embolectomy may impart a greater survival benefit (Basciani et al. 2011). In summary, clinicians treating pregnant and parturient women