Major complications with aortic coarctation include congestive heart failure after long-standing severe hypertension, bacterial endocarditis of the bicuspid aortic valve, and aortic rupture. Because hypertension may worsen in pregnancy, antihypertensive therapy using 3-blocking drugs is usually required. Aortic rupture is more likely late in pregnancy or early puerperium.
Cerebral hemorrhage from circle of Wiis aneurysms may also occur.
Of outcomes from 188 pregnancies, a third of women had hypertension that was related to significant coarctation gradients, and one woman died from dissection at 36 weeks' gestation (Beauchesne, 2001). Of nearly 700 deliveries in women with coarctation from the Nationwide Inpatient Sample, hypertensive complications of pregnancy were increased threeto fourfold (rieger, 2011). Importantly, almost 5 percent of women with coarctation had an adverse cardiovascular outcome-maternal death, heart failure, arrhythmia, cerebrovascular or other embolic event-compared with only 0.3 percent of controls. Of women with coarctation, 41 percent underwent cesarean delivery compared with 26 percent of controls.
Congestive heart failure demands vigorous eforts to improve cardiac function and may warrant pregnancy interruption. Some authors recommend that resection of the coarctation be undertaken during pregnancy to protect against the possibility of a dissecting aneurysm and aortic rupture. This poses significant perfusion risk, especially for the fetus, because all the arterial collaterals must be clamped for variable periods.
Pregnant women with coronary artery disease commonly have the classic risk factors of diabetes, smoking, hypertension, hyperlipidemia, and obesity Games, 2006). Although relatively rare, the risk of acute myocardial infarction is approximately threefold higher in pregnant women compared with nonpregnant women of similar age (Elkayam, 2014b). From more than 50 million hospitalizations in the United States between 1998 and 2009, rates of acute myocardial infarction approximated 2 per 100,000 delivery hospitalizations and 4 per 100,000 postpartum hospitalizations (Callaghan, 2012). Ladner and colleagues (2005) reported a similar rate of 2.7 per 100,000 deliveries.
The mortality rate with myocardial infarction in pregnancy is higher compared with age-matched nonpregnant women. In a Nationwide Inpatient Sample study totaling 859 pregnancies complicated by acute infarction, the death rate was 5.1 percent Games, 2006). Women who sustain an infarction <2 weeks before delivery are at especially high risk of death due to the greater myocardial demand of labor and delivery (Esplin, 1999).