Venous thromboembolism (VTE), and specifically its manifestation – pulmonary embolism (PE) – is the most common direct cause of maternal mortality in the world and ranks 3-4th among the causes of maternal mortality in Ukraine. The multidisciplinary team (pregnancy heart team) established at two academic institutions in 2013, presents its experience of treating VTE in pregnant women and parturients, as well as analysis of common pitfalls of medical care for pregnant women with VTE. The group of pregnant women (parturients) with VTE consisted of 8 patients, 6 of whom were pregnant, 2 were parturients. In 2 pregnant women and 2 parturients with high-risk PE, 4 surgical procedures were performed (three open-heart surgeries – thromboectomy from pulmonary artery, one endovascular inferior vena cava filter implantation), including a pregnant woman (24–25 week) with a massive high-risk PE who underwent an urgent surgery – pulmonary artery thrombectomy and a tricuspid valve repair (with fetus in utero) with prolongation of pregnancy to 39 weeks and the birth of a healthy baby. One perinatal twin loss was observed in patient after extracorporeal fertilization and acute VTE. The main causes of the VTE are the underestimation of risk factors in preconceptional counseling, and the lack of pre-gravid preparation of women, as well as the prevention of the development of venous thrombosis in ante-, intra- and postnatal periods. The diagnosis of VTE and PE in time, and competent medical support provided for such women during pregnancy is a key to minimizing cardiovascular risks and reducing maternal mortality rates. The National Pregnancy Heart Team presents algorithms for primary and secondary prevention and treatment of VTE.
Objective. To share the experience of endovascular interventions in pregnant women and women in labor, gained by national team “obstetric cardiology”. Materials and methods. The algorithm of medical support was presented, including the cases of cardiosurgical interventions performance , for pregnant women with critically severe pathology of the heart, which was based on actual recommendations and own experience. Into the clinic of Amosov National Institute of Cardiovascular Surgery during 6.5 yrs (12.2013 - 05.2020) 145 women-patients were admitted to hospital, in 79 of them cardiosurgical intervention was done. Endovascular cardiosurgical operations were performed in 36 patients, and the hybrid - in 2. Urgent and emergency endovascular interventions were performed in 17 women-patients with various terms of pregnancy (15 - 35 weeks) and in 2 women in labor. Conditionally-elective cardiosurgical interventions were performed in 17 women-patients on various terms of pregnancy (as a rule, in II trimester) and in 2 women in labor. In 34 patients the interventions were performed with fetus in utero. Early and late maternal mortality was absent. One «programmed» loss of the fetus have occurred on 12-th week of pregnancy with the inborn heart failure. Modern views on impact of ionized radiation and contrast substances on fetus were presented, and the methods of lowering of their potential harm. Conclusion. There was trusted, that while applying strict indications for performance of endovascular interventions during pregnancy, these methods of diagnosis and treatment are more secure in comparison with «open» operative interventions and may be performed under supervision of experienced multidisciplinary team, taking into account the pregnancy term and the fetus defense.
Pregnancy is a period of high risk for all patients with aortic pathology. Heritable thoracic aortic diseases (HTAD) refer to aortopathies with a high risk of formation and dissection of thoracic aortic aneurysm (TAA). HTAD are caused by a mutation of a certain gene. This paper reviews current perceptions of manifestations of rare hereditary diseases of the thoracic aorta during pregnancy and general recommendations for the medical care of these patients. To date, 16 genes (or loci of unidentified genes) are known to be associated with the development of thoracic aortic aneurysm, and since many families with a history of TAA (about 70%) have no pathogenic changes in any of these 16 genes, additional genes associated with HTAD have not yet been identified. In this paper, HTAD are considered which occur (or are identified) quite rare but provide a significant risk for patients, which is significantly increased during pregnancy (multisystemic smooth muscle dysfunction syndrome, Meester Lois syndrome, LOX and PRKG1 genes mutations, vascular Ehlers-Danlos syndrome, mutations in TGFB2, TGFBR1, TGFBR2, SMAD3 loci, Loeys-Dietz syndrome). The article analyzes the frequency of occurrence of the most threatening complication of HTAD – acute aortic dissection – in various syndromes, defines general recommendations for the examination of patients with HTAD, recommendations for conservative treatment of these patients. Recommendations for the patients (especially fertility women) concerning the preventive cardiac surgery are also summarized in the paper. These principles of pregravidary preparation and multidisciplinary medical support during pregnancy are the most effective prophylactic measures for major cardiac events and maternal death. Pregnancy heart team that has been working in Ukraine since 2013 does all its best to organize medical support for every pregnant woman with suspected HTAD. In this context, it is very important to collaborate with general practitioners and genetics to “catch” such patients before they become pregnant or in very early terms. Individualized plan of pregravidary preparation and medical care during pregnancy and delivery should be developed by a multidisciplinary team.
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