Download Vascular Surgery and Pregnancy

S Sadie Ahanchi, MD
Sentara Vascular
Specialists
Assistant Professor
Eastern Virginia
Medical School
Vascular Surgery
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and Pregnancy
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Challenges of the vascular patient
• Multiple medical problems
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diabetes
hypertension
carotid disease
cardiac disease
sepsis/infection
coagulopathy
smoking
COPD
• The geriatric patient
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Outline
• Non obstetric surgery and pregnancy
• Angiography and pregnancy
• Vascular pathology during pregnancy
– Arterial
• Eclampsia and Aortic Dissection
• Splenic aneurysms
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– Venous
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• Venous insufficiency and varicose veins Date
• Deep venous thrombosis (DVT) and Pulmonary Embolism (PE)
Non obstetric surgery and Pregnancy
• Each case warrants a
team approach for
optimal safety of the
woman and the fetus
– anesthesia
– obstetric care providers
– surgeons
– pediatricians
– nurses
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Non obstetric surgery and Pregnancy
• A pregnant woman
should never be denied
indicated surgery,
regardless of trimester
• Elective surgery should
be postponed until after
delivery
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Non obstetric surgery and Pregnancy
• If possible, nonurgent
surgery should be
performed in the
second trimester when
preterm contractions
and spontaneous
abortion are least likely
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Non obstetric surgery and Pregnancy
• Fetal heart rate
monitoring may assist in
maternal positioning
and cardiorespiratory
management, and
influences the decision
to deliver the fetus
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Non obstetric surgery and Pregnancy
• Intraoperative electronic fetal monitoring:
– viable fetus
– physically possible to perform intraoperative
electronic fetal monitoring
– OB/GYN available to intervene during the surgical
procedure for fetal indications
– mother has given informed consent
to emergency
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cesarean delivery
Title or
– planned surgery will allow the safe interruption
alteration of the procedure to provide access
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perform emergency delivery
Angiography and Pregnancy
• Prior to 2 weeks gestation an
exposure of 100 mGy (10 rads)
may lead to death of the
embryo
• The dose necessary to kill 100%
of embryos or fetuses before
18 weeks’ gestation is about
5000 mGy
• IQ damage
– 8-15 weeks >100 mGy
– 16-25 weeks >700 mGy
• >26 weeks >1000 mGy risks for
stillbirth and neonatal death
increases
Maximum Estimated Fetal Dose in
Milligray (mGy) During Diagnostic
Imaging Studies
Study
Dose
Chest
<.01
Abdomen
7.00
CT Head
2.00
CT Chest
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CT Abdomen/Pelvis
10.00
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CT Angiography
20-40
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EVAR
1000
Vascular Pathology during Pregnancy
• Arterial
– Pre-eclampsia, Eclampsia and Aortic Dissection
– Pre-Eclampsia
• Multi-system disorder of pregnancy traditionally
characterized by hypertension and significant proteinuria
– Aortic Dissection
•
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Occurs when a tear in the inner wall of the Title
aorta causes
blood to flow between the layers of the wall of the aorta,
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forcing the layers apart
• Associated with HTN
Maternal Cardiovascular changes in
Pregnancy
• Decrease in systemic vascular
resistance until 24 weeks and then
a gradual increase
• Increase in blood volume by 45 %
(1200-1600cc) by 32 weeks
gestation
• Increase in ventricular wall muscle
mass and end- diastolic volume
• “Softening” of the collagen in the
entire vascular system associated
with hypertrophy of smooth
muscle components . This results
in increased compliance of the
vascular system
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Maternal Cardiovascular changes in
Pregnancy
• Increase in cardiac output by 50 % due to an
increase in both stroke volume and heart rate
(heart rate goes up by 20 bpm)
• Posture has a significant impact on cardiac
output. Turning from left lateral
to supine
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position will drop output by 25-20 Title
%.
Date
Pregnancy and Aortic Dissection
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Title
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Pregnancy and Aortic Dissection
25-year-old 26 week pregnant woman
admitted with chest pain and dyspnea
found to have an acute Stanford type B
aortic dissection with a maximum
aortic size of 4 cm
Admitted to ICU
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BP & HR control using labetalol
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Maternal fetal medicine consultation
providing daily neonatal stress tests
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A 48-hour course of antenatal steroids
Pregnancy and Aortic Dissection
CTA on day 4
demonstrated acute
expansion of the proximal
thoracic aorta to a
diameter of 5.1 cm
Tachycardia with
worsening pain the next
morning concerning for
rupture
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Pregnancy and Aortic Dissection
Operation
Emergency cesarean delivery of a viable infant,
followed by abdominal closure and then
repositioning
A left posterolateral thoracotomy, thoracic aortic
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placement and perivisceral aortic
open fenestration
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Case #1
The patient was
discharged on
postoperative day 15, and
7 months after the repair,
mother and infant
continue to do well
CTA demonstrates stable
repair of her aortic
dissection
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Vascular Pathology during Pregnancy
• Arterial
– Splenic Artery Aneurysm
• While visceral aneurysms are
rare, this is the most common
visceral aneurysm
• Aneurysms less than 2 cm are
at fairly low risk for rupture
• There is a tendency for rupture
in pregnancy, especially during
the third trimester so all
women of childbearing age
should have these repaired
– Rupture with pregnancy has a
maternal mortality rate of 70%
and a fetal mortality rate of 75%
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Vascular Pathology during Pregnancy
• Arterial
– Splenic Artery
Aneurysm
• Coil embolization with
or without
splenectomy, and
endovascular exclusion
with covered stent
grafts have been
reported
• Splenectomy for distal
aneurysms often
provides definitive
cure
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Vascular Pathology during Pregnancy
• Venous
– Maternal venous changes
during pregnancy
• increased venous compliance
• decreased venous flow
velocity and stasis
• increased venous capacitance
(relaxing effect of progesterone)
• increased venous pressures
(effect of enlarging uterus)
• VENOUS REFLUX - VARICOSE VV
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Venous Reflux
• Signs and Symptoms
– Varicose veins
• Tenderness
• Cosmetic
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Venous Reflux
• Signs and Symptoms
– Chronic venous
insufficiency
• Venous ulcers
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Surgical Treatment
• Endovascular procedures for venous
reflux
– After birth and when done breast feeding
– Endovenous Ablation
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Local anesthesia
Quick 15-30 minutes
Minimal recovery time
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Low complication rate
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Highly effective
Low surgical trauma
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Maximal precision with ultrasound guidance
Pregnancy and Varicose Veins
35 year old 30 week female
with varicose veins
Compression stockings until Presenter name
after she had the baby and she
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was done breast feeding
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US study showing reflux
Pregnancy and Varicose Veins
Ultrasound guided
venous access
Laser fiber placement
Tumescent anesthesia
Vein ablated by gradual
withdrawal of energized
catheter tip
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Pregnancy and Varicose Veins
• Open procedures for
venous reflux
– Microavulsion for
large varicose veins
– Sclerotherapy for
spider veins
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Pregnancy and Varicose Veins
6 months later
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Vascular Pathology during Pregnancy
• Venous
– DVT/PE
– DVT is a blood clot that
forms in a deep vein in
the body
– A part can break free and
become lodged in the
blood vessels of the lung,
causing PE
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Deep Venous Thrombosis
• DVT prevention
– Avoid modifiable risk
factors
– STAY MOBILE
– TED HOSE
– PROPHYLACTIC
ANTICOAGULATION IF
MAJOR SURGERY
PLANNED
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Deep Venous Thrombosis
• Signs and Symptoms
– Swelling or Pitting edema
– Pain or tenderness
– Warmth
– Red or discolored skin
– Visible surface veins
– Leg fatigue
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Deep Venous Thrombosis
• Diagnosis
– Can use a combo of Ddimer and Ultrasound
– Ultrasound findings
• non compressible vein
• thrombus
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Vascular Pathology during Pregnancy
• DVT treatment
– No Coumadin (Warfarin) during 1st trimester
– Heparin bridge to lovenox
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In summary
• The pregnant patient in the vascular practice
is rare
• Common pathologies include arterial (aortic
dissection and splenic aneurysms) and venous
(venous insufficiency and DVT/PE)
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• A multidisciplinary approach with close
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communication with an obstetrician
is
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imperative