A young woman from the United Arab Emirates undergoes the birth of her baby and aorta repair one month apart.
Giving birth is challenging enough, but when a mother has a narrowed aorta affecting blood flow to herself and her unborn child, the challenge is greater still.
It was just such a narrowed vessel that brought Fatimah Hefaiti, a 22-year-old from a rural village in the United Arab Emirates, halfway around the world to Cleveland Clinic.
The Problem
According to Benito Alvarez, MD, a Cleveland Clinic ob/gyn who specializes in high-risk pregnancies, “(Ms. Hefaiti‘s) symptoms were evident well before she came to us.”
In the first two months of pregnancy, doctors in her hometown of Masafi noticed that her blood pressure was higher, and pulse stronger, in her upper body than lower. This is the telltale sign of a narrowing (or coarctation). The blood going through the narrowed aortic branch speeds up; blood going through the branch to her lower body does not. An echocardiogram done at a major medical center in Abu Dhabi confirmed the narrowing aorta and its location.
Over the next two months, doctors tried to ease her hypertension with a combination of rest and medications, but to no avail. A referral to Cleveland Clinic was arranged.
Assessing the Risk
“Some narrowings have a mild impact on blood pressure, but this one was severe,” says Richard Krasuski, MD, a Cleveland Clinic adult congenital heart disease specialist.
Severity is determined by the relative increase in blood speed as it goes through the narrowing. An increase of three meters per second is considered severe; Ms. Hefaiti’s was going four meters faster. To compound the risk, a woman’s blood volume increases 50 percent during pregnancy, putting further strain on all blood vessels.
A Balanced Approach
The dichotomy between upper and lower blood pressure made it tricky to manage Ms. Hefaiti’s problem medically – drugs given to reduce hypertension above the narrowing could jeopardize the level of blood flow below it, where the fetus attaches to the placenta.
“It’s a careful balancing act requiring lots of monitoring of mother and fetus,” says Dr. Krasuski. Over the next four months, doctors worked within a careful safety profile for both patients, avoiding ace inhibitors, which could adversely affect the baby’s growth and development or diuretics which could threaten the placental flow. Instead, they used a combination alpha and beta blocker.
In addition to monitoring the mother for decompensation (such as abnormally low cardiac output and pulmonary congestion), a fetal ultrasound was done every three to four weeks, and a maternal echocardiogram every two months. In anticipation of early delivery, Dr. Alvarez prepped the baby with steroids at 24 weeks to accelerate fetal lung development.
Delivery Day
The plan was to keep monitoring Ms. Hefaiti, let her get as close to term as safety profiles would allow, then call in the cardiologists, thoracic surgeons, anesthesiologists, and neonatologists to help with delivery. The call went out in the 34th week. General anesthesia was used, rather than an epidural, to better control maternal blood pressure. But even this didn’t prevent the sudden drop in blood pressure that occurred when the initial incision was made in the uterus. Quickly stabilized, Ms. Hefaiti soon gave birth to a baby girl – Metha Hefaiti.
Repairing the Heart
Repair of the coarctation was done a month after delivery. This delay avoided risk of damaging the aorta during cardiac catheterization, as the aorta becomes weakened from the hormones of pregnancy.
Ms. Hefaiti has returned to the UAE, to the large house she shares with her husband, his parents, and two aunts and uncles. She is enjoying life with her young daughter and she has even been cleared for having more children in the future.
