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ABSTRACT
Case Report
INTRODUCTION
Leriche syndrome is a thrombotic oblitera-
tion of the bifurcation of the aorta, a rare con-
dition that usually affects older men due to
atherosclerosis.
1
The most frequent symptom
is intermittent claudication, although other
manifestations can occur. The diagnosis is based
on progressive vascular insufficiency, and con-
firmed by angiographic studies. The ideal treat-
ment is surgical revascularization using an
aortoiliac prosthesis.
2
Women of childbearing age rarely need a
vascular prosthesis (as a result of Leriche syn-
drome or other conditions). Our literature
search for studies on Leriche syndrome/vas-
cular prosthesis and pregnancy/labor/delivery
yielded no results. Having recently faced a case
of Leriche syndrome and pregnancy, we de-
cided to share our experience and considera-
tions on the topic, in the hope that they could
be useful to others.
CASE REPORT
A 38-year-old asymptomatic white female
was booked in for prenatal care in our Hospi-
tal in the 10
th
week of her fourth pregnancy.
Her past history was significant, with Leriche
syndrome diagnosed at 36 years of age (Fig-
ure 1) and surgery (at the Instituto Dante
Pazzanese) 6 months later for the insertion of
an aortoiliac prosthesis (14 x 7 mm Dacron)
with reimplantation of the inferior mesenteric
artery. She had been smoking 10 cigarettes a
day since her twenties, but quit following her
diagnosis. She showed no evidence of athero-
sclerosis in other vessels and no previous his-
tory of heart disease, hyperviscosity or throm-
botic episodes, and all her coagulation tests
were normal. No other definitive cause for
Leriche syndrome was identified. Her previ-
ous three pregnancies (all prior to the vascu-
lar surgery) were uneventful, resulting in term
vaginal deliveries of healthy infants.
Along with her routine prenatal care (8
visits), she was also periodically being evalu-
ated by the vascular surgeons of the Instituto
Dante Pazzanese. Throughout pregnancy, she
had normal peripheral pulses, blood pressure
and fetal growth, and no obstetric or clinical
complications. All her obstetric Doppler tests
(uterine and fetal umbilical and middle cer-
ebral arteries) were normal. She was only re-
ceiving iron tablets until the 35
th
week, at
which point she was admitted to the high-
risk obstetric ward.
Following recommendations from the
vascular team, she was started on subcutane-
ous heparin (15,000 units daily) and main-
tained on this medication until labor ensued,
spontaneously, three weeks later. After 8 hours
of regular contractions she delivered a 2,900-
gram healthy boy vaginally, without episi-
otomy. The infant’s Apgar scores were 9 and
10. No anesthesia was given during labor and
the patient remained predominantly on her
side until the final moments of delivery, when
she was placed on her back (lithotomy). She
had a normal postpartum course, resumed the
use of heparin and was discharged with the
infant on the 3
rd
day.
DISCUSSION
The occurrence of Leriche syndrome in
• Nelson Sass
• Antonio Henrique Moura Poli
• Maria Regina Torloni
• Paula Gabriela Monteagudo
Gibim
• Januário de Andrade
• Nilo Mitsuro Izukwa
Pregnancy and delivery
in a patient with aortic
prosthesis for Leriche syndrome
Hospital Maternidade Escola Dr. Mário de Moraes Altenfelder
(Maternidade Escola de Vila Nova Cachoeirinha) and Instituto Dante
Pazzanese de Cardiologia, São Paulo, Brazil
CONTEXT: Leriche syndrome is a thrombotic oblit-
eration of the bifurcation of the aorta, a rare
condition that usually affects older men as a
result of atherosclerosis. Women of childbear-
ing age rarely need a vascular prosthesis (as a
result of Leriche syndrome or other conditions)
and there is no literature on an association
between Leriche syndrome/vascular prosthesis
and pregnancy/labor/delivery.
CASE REPORT: A case of pregnancy and delivery
in a 38-year-old patient with Leriche syndrome
and an aortoiliac prosthesis is presented. The
patient had no complications during pregnancy,
and was admitted to the maternity hospital when
close to term, to begin heparin therapy. Labor
ensued spontaneously and a normal vaginal
delivery occurred, resulting in a healthy infant.
The authors present their considerations regard-
ing the delivery route and the rationale for de-
ciding in favor of vaginal childbirth.
KEY WORDS: Leriche syndrome. Vascular prosthe-
sis. Pregnancy. Labor. Delivery. Lateral recum-
bent position.
Sao Paulo Med J/Rev Paul Med 2003; 121(1):34-36.
São Paulo Medical Journal - Revista Paulista de Medicina
35
young women is indeed rare, and smoking was
the only predisposing factor identified in this
patient. Heparin is not routinely recom-
mended after vascular prosthetic surgery at the
Instituto Dante Pazzanese, and this patient
received the usual therapy, i.e. a short course
of anti-platelet aggregating medication. How-
ever, pregnancy elevates the levels of most co-
agulation factors and predisposes to vascular
congestion of the lower limbs, due to the com-
pression of the pelvic veins by the gravid
uterus. The risk of thrombosis is highest in
the postpartum period, due to the vascular
lacerations sustained during delivery. This ris-
ing risk of thrombosis prompted the vascular
team to introduce heparin in the third trimes-
ter, in order to avoid this serious complica-
tion in this patient with a vascular prosthesis.
In deciding the route for delivery we had
no previous experience (personal or published)
on which to rely, and therefore had to deal
with some doubts.
1. Could the fetal skull mechanically
compress the prosthesis during
vaginal delivery?
We were concerned that the synthetic ma-
terial of the prosthesis would be less resistant
to external compression than a normal vessel
wall, possibly collapsing and shutting off vas-
cular flow during labor and vaginal birth. The
affected area depicted in Figure 1 is situated
above the bifurcation of the aorta, which oc-
curs at the level of the fourth lumbar vertebra
3
(Figure 2A). As can be seen on Figure 2B, the
promontorium, the area of greatest contact with
the fetal head during engagement, is located
several centimeters below, clearly eliminating
the possibility of mechanical compression of
the aortic portion of the vascular prosthesis by
the fetal skull. Likewise, the iliac vessels would
suffer no compression during the descent of
the fetal head, due to their oblique and out-
ward course. These anatomical considerations
reassured us that a vaginal delivery would not
compress the prosthesis.
2. Would uterine contractions
contribute to vascular occlusion?
During labor, along with muscular con-
traction of the uterus, the round ligaments are
also shortened due to the existence of con-
tractile fibers in their sheath. Emerging from
the cornual and fundic portions of the uterus,
the ligaments run laterally and anteriorly to-
ward the labium major. Because of this ana-
tomical trajectory, the contraction of the
round ligaments during labor tends to pull
the uterus away from the vertebrae.
4
This
movement could potentially reduce the pres-
Figure 1. Patient’s preoperative arteriography. White arrow points to the affected aortic area.
Figure 2. The aortic bifurcation and its anatomical relationship to
the vertebrae and the bony pelvis (A: bifurcation at L4. B:
promontorium).
sure of the gravid uterus on the aorta and in-
ferior vena cava and facilitate blood flow
through the area of the vascular implant.
Therefore, uterine contractions might in fact
improve vascular flow through the prosthesis.
3. Could the patient’s position during
labor and vaginal delivery reduce blood
flow through the prosthesis?
During prolonged dorsal decubitus, the
full term gravid uterus could compress and
reduce the diameter of the vascular prosthe-
sis. We therefore encouraged the patient to
maintain a lateral recumbent position during
most of her labor, switching her to the dorsal
lithotomy position only for the last moments
of the expulsive period.
4. Would a cesarean section be safer?
Compared to vaginal delivery, a cesarean
always entails greater risks of hemorrhage, in-
fection and thrombosis, all potentially dan-
gerous complications in a patient with an ar-
tificial vascular graft. These considerations
helped us to decide in favor of a vaginal deliv-
ery, which ultimately occurred uneventfully.
On the basis of our experience and reflec-
tions, we believe that vaginal delivery in pa-
tients with vascular prosthesis of the aortic bi-
furcation is an adequate option for childbirth.
Sao Paulo Med J/Rev Paul Med 2003; 121(1):34-36.
São Paulo Medical Journal - Revista Paulista de Medicina
36
CONTEXTO: A síndrome de Leriche, oclusão
arterial crônica da bifurcação da aorta, é uma
condição rara que acomete geralmente ho-
mens idosos em decorrência de arteriosclero-
se. Mulheres em idade reprodutiva raramen-
te necessitam de enxertos vasculares, associa-
dos ou não a síndrome de Leriche e não en-
contramos na literatura nenhuma publicação
sobre síndrome de Leriche/prótese vascular e
gestação/trabalho de parto/parto.
RELATO DO CASO: A gestação e parto de
uma paciente de 38 anos com síndrome de
RESUMO
Nelson Sass, MD, PhD. Hospital Maternidade Escola Dr.
Mário de Moraes Altenfelder (Maternidade Escola de Vila
Nova Cachoeirinha), São Paulo, Brazil.
Antonio Henrique Moura Poli, MD. Hospital
Maternidade Escola Dr. Mário de Moraes Altenfelder
(Maternidade Escola de Vila Nova Cachoeirinha), São
Paulo, Brazil.
Maria Regina Torloni, MD, PhD. Hospital Maternidade
Escola Dr. Mário de Moraes Altenfelder (Maternidade
Escola de Vila Nova Cachoeirinha), São Paulo, Brazil.
Paula Gabriela Monteagudo. Gibim, MD. Hospital
Maternidade Escola Dr. Mário de Moraes Altenfelder
(Maternidade Escola de Vila Nova Cachoeirinha), São
Paulo, Brazil.
Januário de Andrade, MD, PhD. Instituto Dante
Pazzanese de Cardiologia, São Paulo, Brazil.
Nilo Mitsuro Izukwa, MD. Instituto Dante Pazzanese de
Cardiologia, São Paulo, Brazil.
Sources of funding: None
Conflict of interest: None
Date of first submission: February 7, 2002
Last received: August 26, 2002
Accepted: September 9, 2002
Address for correspondence
Nelson Sass
Maternidade Escola de Vila Nova Cachoeirinha
Avenida Deputado Emílio Carlos, 3100
São Paulo/SP- Brasil - CEP 02720-200
Tel. (+55 11) 3859-4122
E-mail: nelsonsa.alp@zaz.com.br
COPYRIGHT©2002, Associação Paulista de Medicina
Publishing information
Leriche com prótese aorto-bilíaca são des-
critos. A paciente evoluiu bem durante a
gestação sendo internada próximo ao ter-
mo para iniciar tratamento com heparina.
O trabalho de parto iniciou-se espontane-
amente, resultando em parto normal com
recém-nascido saudável. Os autores apre-
sentam suas considerações sobre a via de
parto e os motivos que levaram à escolha
da via vaginal.
PALAVRAS-CHAVE: Síndrome. Leriche.
Prótese. Vascular. Gravidez. Trabalho. Parto.
1. Martorell F. Enfermedades de la Aorta. In: Martorell F, ed.
Angiologia: Enfermedades Vasculares. 9
th
ed. Barcelona: Salvat
Editores SA; 1967.p.498-509.
2. Krupski WC, Effeney DJ. Artérias. In: Way LW, ed. Cirurgia:
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2
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4. Delascio D, Guariento A. Contração Uterina. In: Briquet R,
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ed. São Paulo: Sarvier; 1994.p.304.
Sao Paulo Med J/Rev Paul Med 2003; 121(1):34-36.
