Management of Takayasu Arteritis During Pregnancy

25-year-old woman who was at 24 weeks’gestation presented to our institution with a2-day history of worsening epigastric and midtho-racic back pain. The patient denied chest pain,shortness of breath, palpitations, nausea, andvomiting. Her medical history was signiﬁcant fora history of 2 spontaneous abortions, hyperten-sion, and anemia. Her only medications wereprenatal vitamins and iron supplements. Onphysical examination, blood pressure (BP) of120⁄70 mm Hg was noted in the right arm and152⁄90 mm Hg in the left arm. Neck examina-tion revealed 1+ bilateral carotid pulsations withloud carotid and subclavicular bruits. There wasno jugular venous distension or thyromegaly.Normal ﬁrst and second heart sounds were nor-mal intensity with II⁄VI diastolic murmur at theleft upper sternal border. Abdominal examinationrevealed positive bowel sounds, tender epigastri-um with no fundal tenderness, rebound, orguarding. Lower extremities revealed 2+ pittingedema. Right upper extremity (radial and bra-chial) pulses were absent with 1+ left brachialand radial pulses. Initial laboratory valuesincluded mild anemia with hemoglobin of11 g⁄dL. White blood cell and platelet counts,chemistries, liver function tests, urine toxicology,and pancreatic enzymes were within normallimits. Urinalysis revealing a 4+ proteinuria.Erythrocyte sedimentation rate was 41 mm⁄hrand C-reactive protein was 4.4, respectively. Elec-trocardiography results showed normal sinusrhythm at 84 beats per minute with no ST⁄T-wave changes. Chest x-ray showed a mildly ectat-ic thoracic aorta. Fetal heart tracing at baselinewas 140 to 150 seconds with minimal heart ratevariability.The patient was admitted to the obstetrics wardfor preeclampsia and fetal monitoring. Consideringthe vascular and cardiac examination ﬁndings, thecardiology service was consulted. Transthoracicechocardiography was performed and revealed nor-mal left and right systolic function with mild tomoderate aortic insufﬁci ency. No valvular or con-genital abnormalities were identiﬁed. A computedtomography (CT) scan of the chest without con-trast revealed circumferen tial wall thickening of thedescending aorta with no dissection. Limited mag-netic resonance imaging (MRI) of the abdomenwithout gadolinium showed irregular wall thicken-ing of the aorta and signiﬁcant stenoses of theproximal celiac and superior mesenteric arteries.Based on American Society of Rheumatology classi-ﬁcation criteria, the patient was diagnosed withTakayasu arteritis and started on intravenous ste-roids. She later underwent duplex ultrasonographyof the neck, which showed absence of ﬂow in theinnominate, common carotid, and right vertebralartery. Flow was maintained in the internal carotidartery through retrograde ﬂow in the external caro-tid artery. The right subclavian artery was occludedwith minimal ﬂow in the right axillary arterythrough collaterals, which was later conﬁrmed byselective angiography after pregnancy.The following morning, the patient complainedof recurrent epigastric abdominal pain and had ele-vatedBP196⁄108 mm Hg measured from the leftarm BP cuff. The patient was started on labetololvia oral and intravenous routes as well as methyl-dopa. These measures only temporarily decreased