Background Takayasu arteritis (TA) is a rare, chronic inflammatory disease of the aorta and its branches, typically presenting before the age of 40 years in women of reproductive age. Pregnancy poses a management challenge as physiological rises in blood volume and cardiac output, and vascular steals may exacerbate TA.
Objectives We report our experience from a tertiary TA centre and make recommendations for management.
Methods Retrospective review of 92 patients seen between 2000-2011, identified 13 live births in 8 women post-diagnosis of TA. All patients fulfilled ACR diagnostic criteria for TA.
Results The median age at delivery was 31 years (range 20-39) and time since diagnosis was 3.5 years (range 0.2-10). Three patients had vascular involvement above and below the diaphragm and one patient had isolated lower limb vasculitis. Six patients had pre-pregnancy echocardiography, which excluded pulmonary hypertension and demonstrated aortic regurgitation in two patients. Two patients unknowingly conceived on methotrexate, including one on infliximab, which were stopped during pregnancy. Two conceived on azathioprine, which was continued. Seven patients received antenatal corticosteroids, three were short courses for disease flares (worsening symptoms and rising CRP). Four patients received aspirin, two anti-hypertensives and one heparin for an antenatal lower limb deep-vein thrombosis. Labour was spontaneous in 50% and two patients suffered pre-term labour. There were three vaginal deliveries and five caesarean sections. Two had caesareans because of undue medical anxiety regarding TA, and had uncomplicated vaginal deliveries in subsequent pregnancies. The median gestation was 38 weeks (range 34-41) and median birthweight 2746g (range 1814-3332g). One high-risk patient, who previously had an aortoiliac graft and bilateral renal artery revascularisation, had three pre-term deliveries and obstetric cholestasis during two pregnancies. All three babies had growth restriction, one an intestinal malformation and another hepatic encephalopathy. Post-partum haemorrhages were observed in two patients. Post-partum disease activity was quiescent in four patients, mild in two and active in one. The latter high-risk patient, who received methotrexate and infliximab pre-pregnancy and prednisolone alone during pregnancy/breast feeding, suffered a severe post-partum systemic disease flare requiring re-introduction of methotrexate and anti-TNF.
Conclusions Our study shows successful outcome is possible in quiescent TA and pregnancy should not be discouraged. Preconception counselling and echocardiography are recommended, as pregnancy in patients with active disease or pulmonary hypertension should be avoided. Individual strategies for treatment, disease activity and blood pressure monitoring are required. Disease activity assessment is complicated and based on symptoms, CRP, clinical exam, arterial US and MRA if required. Caesarean section is not routinely indicated.
Disclosure of Interest None Declared
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