Successful delivery in pregnancy complicated by multiple Takayasu arteritis: a case report and clinical experience
Case Report

Successful delivery in pregnancy complicated by multiple Takayasu arteritis: a case report and clinical experience

Changsheng Peng1,2, Jie Chen1,2, Qiang Yao1,2

1Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China; 2Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China

Contributions: (I) Conception and design: C Peng, Q Yao; (II) Administrative support: Q Yao; (III) Provision of study materials or patients: C Peng, J Chen; (IV) Collection and assembly of data: C Peng, J Chen; (V) Data analysis and interpretation: C Peng, J Chen; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Qiang Yao, PhD. Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China. Email: qiangyaom@163.com.

Background: Takayasu arteritis (TA) is a rare immune system disorder that predominantly affects young women, potentially involving large arteries throughout the body and leading to organ dysfunction. For TA patients, pregnancy eligibility and optimal timing require comprehensive assessment of disease severity. Management during pregnancy extends beyond timely pharmacologic control to necessitate immediate multidisciplinary response capabilities for unpredictable complications. We describe the successful delivery in a pregnant patient with active TA. The uniqueness of this case lies in the presence of severe complications (to the extent that pregnancy was contraindicated) alongside the patient’s strong desire to continue the pregnancy, ultimately resulting in successful delivery through multidisciplinary collaboration.

Case Description: A 26-year-old primigravida (G1P0) was diagnosed with TA at West China Hospital in 2018 due to dizziness and headache (treated with oral medication including oral prednisone and calcitriol; poor compliance with specific regimen unknown). In 2023, her condition worsened, complicated by spontaneous syncope, leading to treatment at Peking Hospital and Peking Union Medical College Hospital. She underwent bilateral carotid artery replacement surgery and received prednisone and clopidogrel. During this pregnancy, ultrasound and computed tomography scans at Peking Union Medical College Hospital at 7 and 11 weeks’ gestation revealed vascular stenosis and cardiac dysfunction secondary to TA. Given the high-risk pregnancy, multidisciplinary consultations at multiple institutions (including Peking Union Medical College Hospital and Beijing Obstetrics & Gynecology Hospital) recommended termination. The patient and her family, however, opted to continue the pregnancy. In September 2024, she presented to West China Second University Hospital. Through coordinated multidisciplinary team management—including medical therapy (tacrolimus 2 mg orally every morning and 1 mg every evening, combined with prednisone 10 mg orally daily), disease monitoring, fetal growth assessments, and priority admission pathways—she successfully delivered a healthy infant via cesarean section at 34 weeks’ gestation. At the 42-day postpartum follow-up, her condition remained stable.

Conclusions: Pregnancy complicated by uncontrolled TA poses significant risks to maternal and fetal health, necessitating thorough risk stratification and individualized management strategies. Beyond pharmacologic control during gestation, establishing a readily available multidisciplinary team with emergency management capabilities is imperative.

Keywords: Takayasu arteritis (TA); high-risk pregnancy; case report; multidisciplinary management

Received: 25 April 2025; Accepted: 17 September 2025; Published online: 26 September 2025.

doi: 10.21037/gpm-25-14

Highlight box

Key findings

• Pregnancy complicated by Takayasu arteritis (TA) may critically threaten maternal-fetal health, making comprehensive risk stratification and early individualized management imperative.

What is known and what is new?

• TA is a rare systemic immune-mediated disorder that can affect multiple organs with potentially severe consequences.

• Pregnancy in patients with advanced TA poses significant challenges, requiring multidisciplinary consensus to determine pregnancy risks and optimal timing.

What is the implication, and what should change now?

• This study underscores the intricate management challenges and imperative of multidisciplinary collaboration in pregnancies complicated by severe chronic conditions, providing valuable experience for clinical practice.

Introduction

Background

Takayasu arteritis (TA) is a chronic progressive non-specific inflammatory disease affecting the aorta and its branches. Lesions predominantly involve the aortic arch and its branches, followed by the descending aorta, abdominal aorta, and renal arteries, causing vascular stenosis or occlusion that compromises blood supply to organs, potentially leading to ischemia, infarction, and eventual organ failure (1). The most common initial symptoms include dizziness, headache, or syncope, with hypertension, systemic manifestations (fever, fatigue, arthralgia), and visual disturbances also frequently observed. Major complications are hypertension, aneurysm formation, and aortic regurgitation. Cardiac involvement represents the primary cause of mortality and poor prognosis (2,3). TA demonstrates higher prevalence in East Asia (estimated incidence: 2.6 per million), predominantly affecting young women with 90% of cases occurring before age 30 years. Onset after age 40 years is uncommon (4). The pathogenesis remains incompletely understood but involves immune mechanisms. While no specific laboratory markers exist, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels reflect disease activity and guide treatment monitoring (5-7).

Approximately 20% of cases are self-limiting, but most patients experience relapsing-remitting or progressive courses requiring long-term immunosuppression (8). Complete cure is rarely documented. Long-term prognosis correlates with complications and disease progression: studies indicate 15-year survival rates of 66.3% with complications vs. 96.4% without, and 58.3% with progressive disease vs. 92.7% without (9). During pregnancy, physiological changes may exacerbate chronic conditions. TA patients face significantly elevated risks including hypertension, placental complications, and preterm delivery (10).

Rationale and knowledge gap

This case report describes a successful delivery of a patient with pregnancy complicated by TA during an active disease phase. Despite limited generalizability due to the isolated case nature, disease-specific constraints (pregnancy is contraindicated in this condition), and inter-hospital discrepancies in medical resources, our findings provide valuable insights for managing complex pregnancies with severe chronic comorbidities. Unlike previous case reports focusing primarily on pharmacotherapy for disease stabilization (11-13), we emphasize multidisciplinary co-management and intensive surveillance to address unpredictable complications in such exceptional patients. This approach offers a management paradigm while underscoring the imperative for multitiered healthcare facilities to arrange proactive transfer of high-risk obstetric patients to tertiary centers for timely comprehensive evaluation.

Objective

This approach offers a management paradigm while underscoring the imperative for multitiered healthcare facilities to arrange proactive transfer of high-risk obstetric patients to tertiary centers for timely comprehensive evaluation. We present this article in accordance with the CARE reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-14/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent has been obtained from the legally authorized representative of this patient for the publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

A 26-year-old patient was admitted on September 14, 2024, at 15+1 weeks of gestation due to “pregnancy complicated by TA”. In 2018, she presented with recurrent dizziness to the Rheumatology Department at West China Hospital and was diagnosed with TA, with peak blood pressure reaching over 200/(120–140) mmHg. Treatment included oral prednisone and calcitriol (doses unclear). She had no other medical conditions. Subsequent visits to West China Hospital and Peking Union Medical College Hospital revealed systemic large-vessel involvement on multiple ultrasounds, indicating uncontrolled disease. Severe dizziness from carotid artery stenosis led to open-chest bilateral carotid artery artificial graft replacement at Beijing Hospital in 2023. Postoperatively, she took aspirin 100 mg once daily, Plavix (clopidogrel) 75 mg once daily, and prednisone 5 mg once daily, with normalized blood pressure monitoring. Aspirin and Plavix were discontinued on June 26, 2024, and tacrolimus 2 mg morning and 1mg evening was added. During pregnancy, headaches, dizziness, and fatigue recurred at 7 and 11 weeks, prompting visits to Peking Union Medical College Hospital. Head-neck computed tomography angiography (CTA) showed multiple arterial wall thickening and stenosis; aortic CTA revealed similar findings in the aorta; echocardiography indicated moderate aortic regurgitation, reduced left ventricular systolic function, and diastolic dysfunction. She experienced chest tightness, unstable blood pressure [monitored via the right lower limb, fluctuating between (150–185)/(90–120) mmHg], and inadequate control. Termination of pregnancy was advised but refused. Prednisone was increased to 10 mg daily from 11 weeks onward.

Due to social and family factors, the patient insisted on continuing the pregnancy and presented to West China Second University Hospital without significant symptoms. At 15+1 weeks, a multidisciplinary consultation involving ultrasound, radiology, pharmacy, hematology, rheumatology, medical genetics, and obstetrics assessed cardiac risk as grade IV. High maternal and fetal risks were emphasized, but after deliberation, the patient and family chose to continue. Intensive monitoring included biweekly obstetric visits, regular cardiac and pulmonary function tests, blood immune markers, blood pressure surveillance, and fetal growth assessments to preempt preeclampsia. Her condition stabilized during later pregnancy, with stable cardiac and pulmonary functions, normal CRP, and no discomfort. To facilitate care, she resided near the hospital with professional follow-up for rapid admission if needed. Per Guidelines for the Management of Cardiovascular Disease in Pregnancy, grade IV risk warranted immediate termination, but after comprehensive evaluation, cesarean delivery was performed at 34 weeks, yielding a healthy infant (2,420 g, Apgar 9-10-10 score). Postoperatively, medication was adjusted to tacrolimus 2 mg morning and 1 mg evening, plus prednisone 5 mg daily. At 42-day follow-up, she was stable with no symptoms, postpartum blood pressure remained at (140–150)/(80–100) mmHg (clinically optimal for this patient). The patient was asymptomatic and subsequently transferred to the Rheumatology-Immunology Department of West China Hospital for ongoing management. A graphical timeline of the case evolution is presented in Table 1.

Table 1

Timeline cue

Time Event description Treatment
2018-05 Diagnosed with TA Prednisone + calcitriol (doses unclear)
2023-03 Dizziness worsened, and imaging studies indicated systemic large artery involvement Underwent thoracotomy for bilateral carotid artery artificial blood vessel replacement. Daily administration of aspirin 100 mg, clopidogrel 75 mg, and prednisone 5 mg
2024-06-26 Diagnosed with pregnancy Discontinuation of aspirin and clopidogrel, with oral tacrolimus 2 mg in the morning and 1 mg in the evening
2024-07-19 Headaches, dizziness, and fatigue recurred Oral tacrolimus 2 mg in the morning and 1 mg in the evening, and prednisone 5 mg
2024-08-25 Symptoms worsened and chest tightness appeared, CTA revealed multiple arterial wall thickening and stenosis, and echocardiography indicated impaired cardiac function The physician recommended termination of pregnancy, but the patient refused
2024-09-14 The patient presented to West China Second University Hospital for medical care Multidisciplinary team involvement for comprehensive assessment and management of the patient. Oral tacrolimus 2 mg in the morning and 1 mg in the evening, and prednisone 10 mg
2025-01-24 Cesarean section delivery of a healthy neonate Oral tacrolimus 2 mg in the morning and 1 mg in the evening, and prednisone 5 mg
2025-03-07 Routine follow-up at 42 days postpartum, the patient’s condition is stable continued treatment in the Department of Rheumatology and Immunology

CTA, computed tomography angiography; TA, Takayasu arteritis.

Discussion

TA is a rare systemic inflammatory vasculopathy primarily diagnosed using the 1990 American College of Rheumatology criteria (14). Key diagnostic criteria (≥3 required) include: (I) age ≤40 years at symptom/sign onset; (II) limb ischemia manifestations; (III) decreased brachial artery pulse; (IV) systolic blood pressure difference >10 mmHg between limbs; (V) vascular bruits; and (VI) radiographically confirmed vascular stenosis. This patient met four criteria: age <40 years, limb numbness, asymmetric blood pressure, and angiographic abnormalities. TA has been definitively diagnosed. TA during pregnancy may cause gestational hypertension (35%), preeclampsia (9%), fetal growth restriction (14%), HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (2%), preterm birth, intrauterine fetal demise, and cerebrovascular events. Cardiovascular events cause 5–19% of maternal deaths (15,16). Chronic hypertension or renal vascular involvement impairs placental perfusion, increasing risks of miscarriage, preterm delivery, fetal growth restriction, and stillbirth; bilateral renal involvement correlates with worse fetal outcomes (17). It is noteworthy that this case is more severe compared to previously reported cases. Due to severe vascular lesions, carotid artery replacement surgery was performed, but the condition continued to progress postoperatively. According to pregnancy-related risk classification, it is a contraindication for pregnancy. However, due to religious or family factors, the patient has a very strong desire to continue the pregnancy.

Pregnancy’s impact on TA progression remains debated, though most studies suggest no effect (18,19). However, TA severity and disease activity significantly impact maternal-fetal outcomes (17,20). Pregnancy may be considered for patients with mild, stable disease under multidisciplinary management, with strict blood pressure control. Contraindications include severe complications (pulmonary/renal/carotid stenosis). This patient had widespread arterial lesions, prior arterial replacement, uncontrolled hypertension, active inflammation, and cardiac involvement (pregnancy risk class IV), deeming pregnancy inadvisable (21).

Management and treatment during pregnancy can refer to the most recent relevant guidelines from the 2021 American College of Rheumatology/Vasculitis Foundation on TA management (22), but there is a lack of specific descriptions for pregnancy management. Generally, medication during pregnancy requires special caution; corticosteroids, mycophenolate mofetil, infliximab, tocilizumab, and similar drugs may be used after careful assessment of the condition, but their safety is uncertain. Due to multiple factors (in some parts of China, particularly in remote and impoverished areas, the notion that a woman is incomplete without bearing children may still persist), the patient and family insisted on continuing the pregnancy. Our approach involves establishing a multidisciplinary management team, designating the patient as “code red” (high-risk pregnancy), and implementing a personalized management plan with the following elements: (I) assigning dedicated personnel for regular follow-up and recording of disease changes; (II) increasing the frequency of prenatal visits: monthly visits during the second trimester, biweekly visits from 28 to 32 weeks of pregnancy, and weekly visits after 32 weeks of pregnancy; (III) collaboration with neonatology, blood bank, vascular surgery, and intensive care unit (ICU) departments to reserve green channels for immediate care; (IV) organizing multidisciplinary discussions near delivery time, with the team jointly formulating a delivery plan based on the patient’s current condition; and (V) strengthening medical administration, where enhanced patient communication and oversight of medical records by medical and legal departments are crucial for such complex and high-risk cases. Ultimately, the patient successfully delivered a healthy infant via cesarean section, completing this pregnancy.

Limitations and future directions

This research has several notable limitations: (I) limited case complexity scope. While our institution manages numerous TA-complicated pregnancies, this represents the first ultra-complex presentation requiring empirically guided management. (II) Delayed intervention timeline. Presentation at 15 gestational weeks precluded first-trimester screening and early therapeutic initiation. (III) Incomplete longitudinal follow-up. Recommended 6-week postpartum rheumatology evaluation at West China Hospital was not pursued due to socioeconomic constraints.

In future clinical practice, greater focus should be placed on optimizing pre-pregnancy counseling, prenatal monitoring, and perinatal management strategies to improve maternal and neonatal outcomes. This includes: (I) further clarifying the association between standardized assessment strategies for disease activity in TA during pregnancy and maternal-infant outcomes, while exploring safe dose adjustment strategies for immunosuppressants during pregnancy; (II) standardizing and normalizing multidisciplinary collaboration models for pregnant patients with severe comorbidities; and (III) emphasizing patient education and risk stratification for high-risk pregnancies, and developing targeted risk prediction models for TA.

Conclusions

TA is a rare and complex vascular disease. Pregnancy risk assessment and timing require multidisciplinary consensus-based decisions. Beyond pharmacotherapy, early multidisciplinary management involving obstetricians, pediatricians, radiologists, hematologists, anesthesiologists, cardiologists, and rheumatologists is essential for optimizing perinatal outcomes.

Acknowledgments

The authors thank the patient who kindly allowed her disease data for this research.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-14/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-14/prf

Funding: This research was supported by the Natural Science Foundation of Sichuan Province (No. 2023NSFSC0738).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-14/coif). The authors reported this research was supported by the Natural Science Foundation of Sichuan Province (No. 2023NSFSC0738). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent has been obtained from the legally authorized representative of this patient for the publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/gpm-25-14
Cite this article as: Peng C, Chen J, Yao Q. Successful delivery in pregnancy complicated by multiple Takayasu arteritis: a case report and clinical experience. Gynecol Pelvic Med 2025;8:26.

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