**8. Management of BAV in pregnancy**

Patients with known BAV should be counseled regarding the risks of heritable disease, risk of aneurysm dissection or rupture during pregnancy, and complications of valve related disease. Valve related management is achieved keeping in mind the risk of anticoagulation during and after pregnancy. Pregnant patients with BAV and aneurysm disease are at a higher risk of spontaneous aortic dissection or rupture [63]. Pregnancy associated hemodynamic changes are associated with this increased risk along with the inherent intima media weakness attributed to BAV patients. The highest risk is during the 3rd trimester or postpartum [63]. Aortic aneurysm >40 mm and increase in aortic size during pregnancy have been demonstrated to be common factors in patients who had Type A dissections pre- or post-partum [64]. Contemporary management of BAV and ascending aortic disease has reduced the significant maternal and fetal risk associated with these entities. Contemporary guidelines suggest surveillance of any aortic dilatation in pregnant patients with echocardiography every month during pregnancy if the diameter is >40 mm and every 12 weeks if there is dilation of the aorta but the diameter does not exceed 40 mm [65]. Current guidelines recommend avoidance of pregnancy if the known aortic diameter is >50 mm in BAV patients [65, 66]. Blood pressure control is the mainstay for general management in pregnant females with any thoracic aortic dilation. Surgery during pregnancy is generally avoided due to the high maternal and fetal risk involved; however, it would be indicated in severe valve dysfunction if transcatheter approaches are not an option.
