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Hepatic ischemia associated with coarctation of the aorta in pregnancy: key issues in differential diagnosis
George J M Webster1, Jelica Kurtovic, Sandra A Lowe
1Gastrointestinal and Liver Unit, The Prince of Wales Hospital, and Royal Hospital for Women, Sydney, Australia.
Insights
Pregnancy can worsen aortic coarctation, leading to hepatic ischemia in adults. This case highlights the importance of considering circulatory demands during pregnancy when evaluating liver disease.
Area of Science:
- Cardiology
- Hepatology
- Obstetrics
Background:
- Coarctation of the aorta (CoA) is a congenital narrowing of the aorta.
- Hepatic ischemia in adults with CoA is rare.
- Pregnancy exacerbates the pressure gradient across native CoA.
Observation:
- A pregnant woman with known CoA developed severe hepatic ischemia.
- The pressure gradient across her CoA increased from 18 mm Hg pre-pregnancy to 40 mm Hg in the third trimester.
- Dehydration contributed to critical hepatic hypoperfusion.
Findings:
- This case establishes an association between CoA and hepatic ischemia in a pregnant adult.
- Pregnancy and dehydration were identified as precipitating factors.
- Increased hemodynamic stress from pregnancy can induce liver injury.
Implications:
- Clinicians must consider non-traditional causes of liver disease in pregnant patients.
- Assessment of pregnant patients with liver disease should include evaluation for conditions like CoA.
- Understanding pregnancy's impact on cardiovascular physiology is crucial for managing liver complications.
Background:
Hepatic ischemia associated with coarctation of the aorta has not previously been reported in an adult; pregnancy increases the pressure gradient across a coarctation.
Case:
A young woman with known coarctation of the aorta developed severe hepatic ischemia in pregnancy. A pregnancy-induced increase in the mean pressure gradient across the coarctation, from 18 mm Hg before pregnancy to 40 mm Hg in the third trimester, predisposed to critical hepatic hypoperfusion in the setting of dehydration.
Conclusion:
This case documents an association between coarctation of the aorta and hepatic ischemia, precipitated by pregnancy and dehydration in combination. It emphasizes the need in the assessment of patients with liver disease in pregnancy to consider not only "traditional" pregnancy-related conditions such as acute fatty liver and the hemolysis, elevated liver enzymes, low platelets syndrome, in which delivery may be necessary as a clinical emergency, but also those in which the circulatory and metabolic demands of pregnancy may precipitate liver injury.
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