Question: What are the current recommendations on mode of delivery in a patient with un corrected Coarctation of Aorta?
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Cases of vaginal delivery by women with uncorrected aortic coarctation have been reported (1,2). A cohort including 7 women with uncorrected coarctation of the aorta (3) found a greater risk of rupture of the aneurysm of the aorta and aneurysm of the cerebral arteries in the 2nd and 3rd trimester, during the labor and in the early puerperium, and the authors recommended caeasean section.
(Evidence level III)
The RCOG Study Group on Heart disease and pregnancy (4) published the following consensus views regarding intrapartum care:
- Management of intrapartum care should be supervised by a team experienced in the care of women with heart disease (obstetrician, anaesthetist and midwife), with a cardiologist readily available.
- A clear plan for management of labour and the puerperium in women with heart disease should be established in advance, be well documented and be distributed widely (including to the woman herself) so that all personnel likely to be involved in the woman’s intrapartum and postpartum care are fully informed.
- The main objective of management should be to minimise any additional load on the cardiovascular system from delivery and the puerperium.This is usually best achieved by aiming for spontaneous onset of labour, providing effective pain relief with low-dose regional analgesia and, if necessary, assisting vaginal delivery with instruments such as the ventouse or forceps, limiting or even avoiding active maternal bearing down (‘pushing’).
- Vaginal delivery is the preferred mode of delivery over caesarean section for most women with heart disease – whether congenital or acquired – unless obstetric or specific cardiac considerations determine otherwise.
- Induction of labour may be appropriate, to optimise the timing of delivery in relation to anticoagulation and the availability of specific medical staff or because of deteriorating maternal cardiac function. However, it should be recognised that induction of labour before 41 weeks of gestation, especially in nulliparous women with an unfavourable cervix, increases the likelihood of caesarean section.
(Evidence level IV)
- Zwiers WJ. Blodgett TM. Vallejo MC. Finegold H. Successful vaginal delivery for a parturient with complete aortic coarctation. Journal of Clinical Anesthesia. 18(4):300-3, 2006 Jun. Abstract
- Singh BM. Kriplani A. Bhatla N. Vaginal delivery in a woman with uncorrected coarctation of aorta. Journal of Obstetrics & Gynaecology Research. 30(1):24-6, 2004 Feb. Abstract
- Janku K. Unzeitig V. Mikulik R. Uchytil B. Janku P. Volkova N. [Management and methods of delivery in women with aortic coarctation--results of 64 pregnancies in 41 women]. [Czech] Original Title. Dispenzarizace a zpusob vedeni porodu u zen s koarktaci aorty--vysledky 64 tehotenstvi u 41 zen. Ceska Gynekologie. 65(4):236-9, 2000 Jul. Abstract
- Heart disease and pregnancy. Philip J Steer, Michael A Gatzoulis and Philip Baker ed.s London: RCOG Press, 2006 Consensus views
Search date: May 2010
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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