Dear Editor
A 24-year-old parturient presented to us who underwent an operation for ventricular septal defect and bicuspid aortic valve. Her obstetric and general clinical examination results were within normal limits. Chest examination revealed a healed scar and a swelling (5 cm × 5 cm; Fig. 1). This swelling progressed after the cardiac operation. No murmur was heard over the swelling. Echocardiography showed a normally functioning prosthetic aortic valve without any pericardial effusion. Ultrasound examination revealed aneurismal dilation of the ascending aorta (5.7 cm in diameter and 8.7 cm in length, with mural thrombus) extending up to the arch of aorta, with no suggestion of dissection.
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The patient was admitted immediately. A multidisciplinary team was formed. A decision was taken to monitor the aneurysm closely and allow the pregnancy to continue, which progressed uneventfully.
She was scheduled for an elective cesarean section at 37 weeks. She refused regional anesthesia, and hence we opted for general anesthesia. The patient received infective endocarditis and acid aspiration prophylaxis. The operation was conducted in the cardiothoracic theatre with cardiothoracic surgeons on standby. She was placed in a left lateral tilt position. Standard monitoring was performed. Two large-bore (16 gauge) intravenous accesses were established and the right radial artery were cannulated. Anesthesia was induced with intravenous thiopentone and rocuronium using the modified rapid sequence induction technique, and her trachea was intubated. Intravenous esmolol was used to suppress pressor response to intubation. Anesthesia was maintained with oxygen, nitrous oxide, and sevoflurane. A transesophageal echocardiography probe was placed to monitor the size of the aneurysm. A live and crying baby was delivered after 3 minutes. Forceps were used to deliver the baby to avoid excessive pressure on the abdomen and thorax. Oxytocin was administered as per protocol. Analgesia was provided with intravenous fentanyl and morphine. Intraoperatively, the patient maintained the hemodynamics. The surgical line was infiltrated with a local anesthetic, and she received diclofenac and paracetamol suppositories. At the end of surgery, her trachea was extubated under intravenous esmolol to suppress the response to extubation. She was transferred to the intensive care unit. Her postoperative pain was managed with morphine (patient-controlled analgesia), oral paracetamol, and diclofenac. Her postoperative echocardiography and ultrasound examination as well as her postoperative stay were unremarkable.
An aortic aneurysm may rarely complicate pregnancy.1Hemodynamic and hormonal changes of advance pregnancy may increase aneurysmal dilation.1, 2, 3, 4, 5 Systemic hypertension has been found to be the main predisposing factor; however, there are other risk factors as well, of which bicuspid aortic valve is an important one.1, 4, 6 Our patient was an operated case of bicuspid aortic valve, which might have contributed to changes related to pregnancy as well.
Management of such a patient requires a multidisciplinary approach.1, 3, 7 We admitted the patient at 28 weeks on presentation to monitor her closely, as dissection has been reported to occur most commonly in the 3rd trimester.2, 7We opted for elective cesarean section just to prevent the hemodynamic stress of normal labor and vaginal delivery on the aneurysm.1, 7
In the literature, we have not come across any such unusual presentation of an operated case of aortic valve replacement presenting asymptomatically, with a visible ascending aortic aneurismal swelling on the anterior chest wall, who presented for cesarean section. This prompted us to report this case.