Systemic hypertension is more common in pregnant women presenting with aortic coarctation or Takayasu’s arteritis. Uncontrolled hypertension leads to increased neonatal and maternal adverse events.1,2
A 36-year-old G2P1 woman presented at 9 weeks’ gestation with headaches. She was normotensive and had no visual changes, chest pain, dyspnoea or other neurological symptoms. Her previous in-vitro fertilisation pregnancy was complicated by pre-eclampsia at 27 weeks gestation based on intra-uterine growth restriction and hypertension, delivering via Caesarean-section at 36 weeks. Other past history was significant for infrarenal aortic stenosis diagnosed on CT angiogram to investigate persistent hypertension post-partum. Her only regular medication was aspirin 100mg daily. Family history was significant for paternal ischaemic heart disease and maternal hypertension, both in their 50’s.
Review of the CT angiogram in 2013 showed 75% stenosis of the infrarenal aorta with hypertrophied internal mammary and epigastric arteries. The remaining aortic branches were largely spared. Laboratory investigations revealed low-grade proteinuria (urine protein:creatinine ratio 40mg/mmol), and normal renal and liver function. Her CRP was normal (3.8mg/L) and ESR mildly elevated (16mm/hr). ANA, ANCA, anti-double stranded DNA antibodies, and antiphospholipid antibodies were negative. Complement 3 and 4 were normal.
This pregnancy has been complicated by alloimmunisation with anti-D antibodies (titre stable at 1:1024), anti-C antibodies (titre 1:16) and gestational diabetes requiring insulin. She remains normotensive and continues on aspirin and calcium as pre-eclampsia prophylaxis. Her 28-week ultrasound showed an estimated foetal weight at 94th percentile with normal middle cerebral artery peak systolic velocity and normal placental vascular resistance. Currently she is 31 weeks’ gestation and future delivery by Caesarean-section was decided based on patient preference and her complex anatomy.
In summary, this significant chronic aortopathy with little evidence of active inflammation suggests a diagnosis of abdominal aortic coarctation or ‘burnt out’ Takayasu’s arteritis. There is satisfactory foetal growth and uterine blood flow through collateral supply from the internal mammary and epigastric arteries.