Dr JULIEN NITHIANANDAN1, Dr CHAU WANG NG1,2
1Department of Renal Medicine, Bendigo Health, , Australia, 2School of Rural Health, Monash University, , Australia
Biography:
Julien is a nephrology advanced trainee who has worked in Victoria and the Northern Territory. His interests include chronic disease management, lupus nephritis, and the health of Aboriginal and Torres Strait Islander peoples.
Background:
Coarctation of the aorta (CoA) is a secondary cause of hypertension. Pregnant women with unrepaired CoA confer ‘extremely high risk of maternal mortality or severe morbidity’ (modified WHO classification IV). CoA diagnosed peripartum is rare in the literature. We present a case of an adolescent female with a history of hypertension, who developed late-onset pre-eclampsia in pregnancy, with CoA diagnosed postpartum.
Case Report:
A primigravida female, with a two-year history of hypertension, was managed with methyldopa and labetalol during pregnancy. She presented at 37+3 weeks gestation with elevated blood pressure of 165/85mmHg, associated with photopsia and hyperreflexia. Investigations showed creatinine 70umol/L, no proteinuria, normal full blood count, liver function, and cardiotocography. She required intravenous labetalol and hydralazine administration. Labour was induced with subsequent vaginal delivery.
On day four postpartum, she had elevated blood pressure of 200/100mmHg with neurological manifestations and proteinuria. Postpartum pre-eclampsia superimposed on chronic hypertension was diagnosed. She developed pulmonary oedema with hypoxia requiring HDU admission for non-invasive ventilation. Transthoracic echocardiogram was normal, but continuous abdominal aortic flow was suspicious for CoA. CT aortic angiography confirmed a focal high-grade stenosis of the proximal descending aorta. Not breastfeeding by choice, her hypertension was controlled on ramipril 10mg daily and spironolactone 50mg daily.
She subsequently underwent CoA repair at ten months postpartum, with a 20mm interposition graft to the proximal descending aorta. Postoperatively, she maintained target blood pressure control with perindopril 2.5mg daily.
Conclusion:
Clinicians should be cognisant of CoA, an often-overlooked secondary cause of hypertension. Our patient’s CoA was unmasked following postpartum pre-eclampsia, further highlighting the high risks associated with pregnancy in individuals with unrepaired CoA.