Aortic insufficiency in pregnancy


 * Associate Editor-in-Chief: Mohammed A. Sbeih, M.D.[mailto:msbeih@perfuse.org]; Lakshmi Gopalakrishnan, M.B.B.S.

Overview
Isolated aortic insufficiency in pregnant patients can be managed with combination of diuretics and vasodilators. ACE inhibitors are contraindicated in pregnancy. Patients with signs and symptoms of left ventricular failure should be monitored throughout labor and delivery with strict attention to volume status and blood pressure.

==Risk Stratification ==

High risk
Pregnant patients are deemed to be high risk if aortic insufficiency is associated with NYHA class III to IV symptoms, Marfan syndrome or a left ventricular ejection fraction of less than 40%. Such patients ideally should undergo definitive surgical therapy before pregnancy. If the patient is already pregnant, termination of pregnancy is recommended.

Low risk
Pregnant patients are deemed to be low risk of aortic insufficiency associated with NYHA class I to II symptoms. Such women generally tolerate pregnancy without complications and the natural fall in systolic blood pressure during pregnancy may be beneficial in reducing the regurgitant volume.

Marfan's Syndrome
Patients with Marfan's syndrome who have aortic root dilatation during pregnancy are at an increased risk of developing aortic dissection or rupture which usually occur in the third trimister or near the time of delivery. Pregnant patients are at high risk if the aortic root diameter is greater than 40 mm in which case there is approximately a 10% probability of developing aortic dissection. Women with marfan syndrome should be counseled against pregnancy and should undergo screening transthoracic echocardiography to assess the aortic root dimensions. However, replacement of aortic root and ascending aorta may be considered if the aortic diameter exceeds 40 mm in women with marfan syndrome who are contemplating pregnancy. Beta blockers can be used prophylactically throughout pregnancy with labetalol or metoprolol being the preferred drugs.

Delivery
As per AHA/ACC 2006 guidelines, serial transthoracic echocardiography and regular monitoring of blood pressure throughout the pregnancy with provision of adequate analgesia during labor are recommended. Shortening of second stage of labor using various obstetric techniques may be beneficial. In patients with an aortic root diameter greater than 40 mm, severe aortic regurgitation, heart failure or aortic dissection, cesarean delivery with general anesthesia is preferred as it allows optimal hemodynamic control.