Successful Prophylactic Embolization of a Renal Artery Aneurysm During Pregnancy.

Renal artery aneurysms (RAA) have an increased risk of rupture during pregnancy with high mortality rates for the mother and fetus. There are many reports on the treatment of ruptured RAA during pregnancy and the Society for Vascular Surgery recommends to prophylactically treat unruptured RAA of any size in women of reproductive age to limit risk of rupture during pregnancy. However, to the best of our knowledge, there is no reported case of prophylactic treatment of unruptured RAA during pregnancy. Here we report the case of a 39-year-old G2P1 who had prophylactic endovascular coiling of an unruptured left RAA during her second trimester of pregnancy. Our case report is the first to demonstrate that unruptured RAA can be safely intervened endovascularly to prevent rupture without disrupting the pregnancy.

Laparoscopic Resection of a Splenic Artery Aneurysm with Vascular Reconstruction During Pregnancy.

Splenic artery aneurysms (SAA) are more frequent in women and have a high rupture risk during pregnancy, with catastrophic outcomes. It is advisable to treat these aneurysms in pregnant and fertile women, whatever their diameter, given their increased risk for rupture. There are several therapeutic approaches: endovascular surgery using coil embolization or stent graft coverage; laparoscopic or open surgical resection with arterial reconstruction and ligation followed by splenectomy when necessary. This paper aims to report the successful treatment of SAA in second-trimester pregnant women using a laparoscopic approach with aneurysm resection and arterial reconstruction. This is a unique report of a minimally invasive approach with arterial reconstruction in a pregnant woman, thus reducing the risk of spleen infarction and potentially avoiding splenectomy.

Warfarin-associated intracranial haemorrhage in pregnant woman with double mechanical valve replacement: a case presentation.

BACKGROUND: Management of warfarin-associated major haemorrhage in prosthetic valve diseases is difficult as there is a fine line between haemorrhage and thrombosis. An individual's propensity towards thrombosis, such as pregnancy, makes this situation even more complicated. Cases like these are very rare in the literature. CASE PRESENTATION: A 26 weeks pregnant, gravida two, para one, 35-year-old patient with prosthetic aortic and mitral valves presented to an external emergency clinic with clouding of consciousness. Her international normalised ratio(INR) was 8.9 at presentation. Brain MRI revealed a left subdural haematoma with no significant mass effect. Warfarin treatment was discontinued. On the second day of follow-up, she was referred to our centre for further evaluation of her clinical deterioration. She was haemodynamically stable on admission to the intensive care unit and followed up with a stable condition until the fourth day when she developed right eye drop and subsequent loss of consciousness. Her haematoma was surgically evacuated, and her condition improved. Eventually, she and a healthy newborn were discharged. CONCLUSION: Intracranial haemorrhage during pregnancy is a relatively rare complication that requires a multidisciplinary management plan. Although the thrombogenic risk is high, it is vital to complete a reversal of warfarin anticoagulation in pregnant women with major bleeding.

Aortocaval Compression Syndrome: Time to Revisit Certain Dogmas.

More than 70 years ago, the phenomenon of "postural shock" in the supine position was described in healthy women in late pregnancy. Since then, avoidance of the supine position has become a key component of clinical practice. Indeed, performing pelvic tilt in mothers at term to avoid aortocaval compression is a universally adopted measure, particularly during cesarean delivery. The studies on which this practice is based are largely nonrandomized, utilized a mix of anesthetic techniques, and were conducted decades ago in the setting of avoidance of vasopressors. Recent evidence is beginning to refine our understanding of the physiologic consequences of aortocaval compression in the context of contemporary clinical practice. For example, magnetic resonance imaging of women at term in the supine and tilted positions has challenged the dogma that 15° of left tilt is sufficient to relieve inferior vena cava compression. A clinical investigation of healthy term women undergoing elective cesarean delivery with spinal anesthesia found no difference in neonatal acid-base status between women randomized to be either tilted to the left by 15° or to be in the supine position, if maternal systolic blood pressure is maintained at baseline with a crystalloid coload and prophylactic phenylephrine infusion. This review presents a fresh look at the decades of evidence surrounding this topic and proposes a reevaluation and appraisal of current guidelines regarding entrenched practices.

Management of a Thoracic Aortic Aneurysm during Pregnancy Leading to the Diagnosis of Takayasu Arteritis.

Takayasu arteritis is a chronic inflammatory arteritis affecting large vessels, predominantly the aorta and its main branches. We report the case of a patient presenting with the rapid growth of a thoracic aortic aneurysm during pregnancy leading to the diagnosis of Takayasu disease and treated by a rapid delivery by cesarean section followed by an open aortic repair. One year after the operation the patient and her baby are alive and well.

Pulmonary CT angiography in the diagnosis of pulmonary embolism in pregnancy--a case report.

This paper describe the case of pulmonary thromboembolism (PTE) in pregnancy diagnosed by angio CT The clinical diagnosis of PTE in normal population is difficult. In pregnancy is even more complicated, because physiologic changes of pregnancy can mimic signs and symptoms of PTE. Our patient presented dyspnoea, breathing effort and cyanosis of the mouth at admission. In the check-up there was a distinct murmur just under the heart and tachycardia 115 bpm. The Doppler examination of the venous vessels of the lower extremities was normal. Echocardiography revealed features of right ventricular failure. Due to increased level of D-dimers and echocardiographic features of right-ventricular overload, the suspicion of pneumonic embolism was made. Therefore, in order to verify the initial diagnosis the decision of pulmonary CT angiography was made with the radiological protection of the fetus. This study revealed pulmonary embolism in the form of numerous defects in the contrast fillings of the pulmonary arteries. CT pulmonary angiography is the first imaging test of choice in general population who is suspected to have PTE. However there is no consensus what should be preferred during pregnancy. In this paper the diagnostic concepts and an evidence-based guidelines were discussed in case of PTE in pregnancy as well as its side effects including teratogenicity and oncogenicity. In each case, the risks and benefits must be compared before a decision is taken. In case of thrombosis symptoms in the lower extremities, ultrasound should be taken as the next step, otherwise chest X-ray must be performed. In patients with normal chest X-ray the next step should be scintigraphy but if chest X-ray is abnormal, angio CT is preferred.

Isolated ruptured inter-atrial septal cystic echinococcosis during pregnancy.

Herein, we present a case of asymptomatic isolated cardiac cystic echinococcosis localized entirely to the inter-atrial septum in a pregnant woman. The patient underwent successful surgery. Cardiac cystic echinococcosis is rarely seen in pregnancy. A high index of suspicion is necessary for the diagnosis of a cardiac cyst hydatid. The treatment of cardiac cyst hydatid is surgical and should not be delayed during pregnancy. Early surgery might prevent septic embolization and cardiac life-threatening complications and save the lives of both mother and baby as in the present case.

A case of spontaneous intra-amniotic hemorrhage in an asymptomatic patient at near term pregnancy.

A spontaneous intra-amniotic hemorrhage is a very rare condition, which has been previously described in symptomatic patients. We report a case of an asymptomatic spontaneous intra-amniotic hemorrhage at 38 weeks of gestation, resulting in a favorable maternal and neonatal outcome following sonographic antenatal detection of an intra-amniotic blood clot. This pathology should be acknowledged, since a good clinical outcome depends on early diagnosis.

Peripartum cardiomyopathy: a rare cause of acute heart failure.

A woman in her early 30s presented herself with acute dyspnoea and elevated D-dimers 5 weeks after delivery of her second child. Echocardiographic findings showed signs of acute left ventricular failure, and an MRI confirmed a non-ischaemic dilated left heart failure compatible with peripartum cardiomyopathy. The antihormonal therapy with bromocriptine during 6 weeks and an intensive heart failure therapy led to an amelioration of the heart function within 3 years, but full recovery was not yet observed.

Cervical varices complicated by thrombosis in pregnancy.

We present a case of a 36-year-old pregnant woman with varicose veins of the uterine cervix diagnosed during the second trimester. The cervical tissue was completely replaced with dilated venous plexus. Therapeutic decisions were further complicated by the presence of blood clots within the dilated vessels. Pregnancy proceeded uneventfully, no bleeding occurred and the patient underwent a planned Cesarean delivery. This is the first reported case in the medical literature where the rare phenomenon of cervical varices was accompanied by thrombosis.

Uterine arteriovenous malformations induced after diagnostic curettage: a systematic review.

PURPOSE: To perform an extensive systematic review to examine all the available literature reporting iatrogenic acquired arteriovenous malformation (AVM) induced after diagnostic curettage and to describe a further case of a 34-year-old woman presenting with acute vaginal bleeding due to AVM induced after uterine curettage for termination of pregnancy. METHODS: We searched the electronic databases: MEDLINE (1950-2011), Embase (1980-2011), Cochrane Library (2004-2011), Cinahl (1981-2011), Popline (2004-2011). RESULTS: Initial search extracted 333 relevant articles. Final assessment resulted to the inclusion of 91 studies, 85 case reports and 6 observational studies. Studies are dated between 1954 and 2011. A metanalysis of the 85 case reports reporting 100 patients was performed. The mean age of the women diagnosed with AVM was 30 ± 9.1 years, range (16-72) years, 96 women were premenopausal (96%) and 4 were postmenopausal (4%). Ultrasound imaging was applied in 86 patients (86%), and ultrasound combined with angiography was performed in 51 patients (51%). Uterine artery embolization (UAE) was the most common treatment option performed in 59 patients (59%). Total abdominal hysterectomy was performed in 29 patients (29%). Spontaneous resolution of AVM occurred in six patients (6%). In 17 patients (17%), recurrence occurred after treatment with UAE. Twenty-four articles reported pregnancies in 27 patients (27%). CONCLUSION: Ultrasound imaging with appropriate knowledge of color Doppler features minimizes the use of inappropriate interventional procedures such as diagnostic curettage. UAE is effective in treatment, and rarely leads to complications.

Successful repair of a ruptured Stanford type B aortic dissection during pregnancy.

We present our experience with an acute Stanford type B aortic dissection in a 25-year-old, 26-week gravid patient without a known connective tissue disorder and discuss a literature-based treatment strategy. After failed conservative treatment manifest by aneurysm rupture, emergency cesarean section delivery and immediate repair of her thoracic aorta was performed. Seven months later, she is fully caring for her healthy baby. During pregnancy, thoracic aortic dissection occurs from physiologic and hemodynamic changes. Emergency cesarean delivery, followed by immediate aortic repair, is the treatment choice if malperfusion syndrome, rupture, uncontrolled hypertension, or unremitting pain occurs.

A case report of a normal aorta misdiagnosed as type A dissection by modern multidetector computed tomography.

Computed tomography (CT) is generally considered the investigation of choice to exclude acute aortic syndrome. We report an important potentially disastrous misdiagnosis using a modern 32 slice multidetector CT system.

Surgery for Acute Type A Aortic Dissection in A Pregnant Woman At 28 Weeks' Gestation.

A 27-year-old woman with sudden back pain was transported to our hospital. Abdominal ultrasonography revealed pregnancy of 28 weeks' gestation. Computed tomography demonstrated a type A aortic dissection. Because of progressive fetal deterioration, an emergency cesarean section was forced to perform. The next day, simple hysterectomy followed by an aortic procedure was completed. Valve-sparing aortic replacement and total arch replacement were employed as central operations. The mother and baby are well 9 months postoperatively. Although the strategy for acute type A aortic dissection during pregnancy is controversial, collaborations among neonatologists, obstetricians, and cardiovascular surgeons can ensure mother and infant survival.

[Spontaneous false aneurysm of the extracranial internal carotid artery - during pregnancy]. / Faux anévrisme spontané de l'artère carotide interne extracrânienne - pendant la grossesse.

Extracranial carotid false aneurysms are rare but serious because of the high risk of rupture and thromboembolic ischemic strokes. Although hemodynamic and hormonal physiological changes in pregnant women may favor arterial rupture and the development of false aneurysms, only one case of extracranial carotid false aneurysm related to pregnancy has been reported in the literature. Surgical repair is still the treatment of choice of these lesions. We report a case of spontaneous false aneurysm of the extracranial internal carotid artery occurring at the end of pregnancy. The surgical procedure consisted in resection of the false aneurysm with interposition of a prosthetic graft. The follow-up was uneventful.

Radiofrequency catheter ablation of atrioventricular nodal reciprocating tachycardia using intracardiac echocardiography in pregnancy.

We describe a case report of a 32-year-old woman during the 10th week of pregnancy with symptomatic and recurrent atrioventricular nodal reciprocating tachycardia successfully treated by conventional radiofrequency ablation, under intracardiac echocardiography surveillance.

Retrograde type a dissection in a 24th gestational week pregnant patient - the importance of interdisciplinary interaction to a successful outcome.

BACKGROUND: Type A Dissection in pregnancy is a devastating medical condition with 2 lives at stake and unclear strategy at early gestational stages. We describe a successful outcome, clearly dependent on the coordination of all involved disciplines. CASE PRESENTATION: This case history describes a 28 year old female with a 24th week pregnancy gravida 2 para 0 with a DeBakey Type I aortic dissection, diagnosed via ultrasound. Surgery was perfomed on the day of diagnosis. After conferral with the mother, caesarean section was performed and a 690 g fetus could be delivered and was immediately transferred to the neonatal unit. Subsequent aortic repair was performed after hysterectomy, with replacement of the ascending aorta and hemiarch treatment. Intraoperatively no entry in the ascending aorta or transverse arch could be demonstrated, so that a retrograde Type A with entry distal to the left subclavian had to be postulated. We decided to perform subsequent computer tomography, demonstrating multiple entry sites in the descending aorta distal to the left subclavian artery. Successful endovascular treatment could be performed with a Medtronic Valiant Stent via a transfemoral approach. The further hospital stay was uneventful and the patient could be discharged on the 18th postoperative day. The baby demonstrated fighter qualities and could be discharged home after a 3 month hospital stay to be reunited with his mother. CONCLUSION: Prompt diagnosis, precise coordination between all involved subspecialties and ultimately, as in this case, definitive treatment in consensus with operative and interventional departments have led to a successful outcome and encourages us in our daily struggle in this often demanding surgery.

Spontaneous coronary artery dissection in puerperium.

Spontaneous coronary artery dissection in puerperium is uncommon and most often occurs in the third trimester of pregnancy and in the early postpartum period. Two weeks after delivery, a 41-year-old woman presented with typical retrosternal chest pain and inverted T-waves in leads II, V5 and V6, and Q-waves in aVR. Her peak troponin I level was 16.39 µgcL(-1) Coronary angiography showed left main spiral dissection extending to the mid left anterior descending artery and involving the first diagonal branch. Urgent coronary artery bypass grafting was performed successfully. The mechanism and approach are discussed.

Extracorporeal Membrane Oxygenation for Treatment of Acute Inverted Takotsubo-Like Cardiomyopathy From Hemorrhagic Pheochromocytoma in Late Pregnancy.

We describe the first case of a pregnant woman presenting with an acute inverted takotsubo-like cardiomyopathy caused by a postpartum diagnosed hemorrhagic pheochromocytoma, successfully treated with percutaneous venoarterial extracorporeal membrane oxygenation (va-ECMO). During admission, an emergency cesarean delivery had to be performed. The fetus needed resuscitation for 5 minutes. The mother was successfully resuscitated and treated with percutaneous va-ECMO for 7 days. Despite advances in diagnostic techniques during the past decade, in many cases, pheochromocytoma in pregnancy is still missed. This results in a maternal and fetal mortality rate of up to 30% in both.