DOUBLE JEOPARDY: AORTIC DISSECTION IN PREGNANCY

Angela Taylor, M.D.*;Britt Warner, PA;Douglas Tangel, M.D. and Charles J VanHook, M.D., Longmont United Hospital, Longmont, CO

Meeting: Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.

Abstract number: 749

Categories: Adult, Clinical Vignette Abstracts

Case Presentation: A 39 year old G7, P5 female at week 36 of gestation presented with a two day history of back pain and shortness of breath. There was no significant past medical history. The patient appeared acutely anxious, with blood pressure of 152/80 mm Hg and heart rate of 112/minute.  The right femoral pulse was absent. CAT angiogram of the chest demonstrated an extensive Type A aortic dissection (Figure 1).  A continuous esmolol infusion was initiated and the patient was transported to the operating suite.  She initially underwent primary low transverse Caesarean section with delivery of a viable male infant.  The patient was then repositioned and midline sternotomy was performed, which revealed pericardial tamponade, a classic false and true lumen of the ascending aortic arch, and destruction the aortic sinuses with unseating of the anatomically normal aortic valve. The aortic valve was replaced with a mechanical valve, and transverse hemi-arch and descending thoracic aortic grafts were placed. The patient and her infant son were discharged together in good condition ten days postoperatively.

Discussion: The incidence of Type A aortic dissection in pregnancy is 0.4 cases per 100,000 person years.  During pregnancy, changes in the levels of estrogen and progesterone are thought to affect the structural integrity of the aortic wall. Other risk factors for dissection include hypertension, bicuspid aortic valve,  Marfan syndrome and other collagen-vascular diseases, cocaine use, smoking, and a positive family history, none of which were present in this patient.   The classic presentation is one of chest or back pain with accompanying signs of malperfusion.  The mortality is 25% at 24 hours, and increases to 80% for those untreated at 14 days. The treatment of Type A aortic dissection is immediate stabilization with titratable agents that reduce both blood pressure and aortic wall sheer stress, such as esmolol or labetelol, coupled with surgical repair. In late pregnancy, with a viable fetus, C-section usually precedes thoracotomy because of the relative brevity of that procedure and because of the potential for compromise of the uterine circulation during aortic repair.

Conclusions: Prompt recognition of a Type A dissection in pregnancy, with early hemodynamic stabilization and coordination of the obstetric and cardiovascular surgical services, is essential to optimal outcome.  Although rare, dissection should be included in the differential diagnosis of any pregnant patient, regardless of additional risk factors, who presents with chest or back pain and evidence of malperfusion.

To cite this abstract:

Taylor, A; Warner, B; Tangel, D; VanHook, CJ . DOUBLE JEOPARDY: AORTIC DISSECTION IN PREGNANCY. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 749. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/double-jeopardy-aortic-dissection-in-pregnancy/. Accessed September 19, 2019.

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