Acute postpartum aortic dissection

Abstract

A previously healthy 22-year-old woman presented with sudden circulatory collapse in the department of obstetrics 5 days after delivering a healthy male neonate weighing 3515 g. The woman's pregnancy had been uneventful and she'd had a normal vaginal delivery without surgical procedures; the second stage of labor had not been prolonged. On presentation the woman was in cardiogenic shock; she was cold and pale with a pulse rate of 140 beats per minute, and a systolic blood pressure of 40 mm Hg that increased to 90 mm Hg after intravenous fluid. There was no cardiac murmur on auscultation. Immediate computed scanning of the thorax suggested possible dissection of the ascending aorta. Transthoracic echocardiography revealed a cardiac tamponade with massive pericardial effusion and compression of the right atrium and ventricle. Most of the effusion seemed to be an organized clot (Fig. 1). There was a dissection flap in the proximal aortic arch and blood around the pulmonary trunk. The woman was promptly transferred to the regional hospital for surgery. The dissection started in the aortic valve and extended to the brachiocephalic artery (Stanford type A) with dissection into the right coronary artery. There was a hematoma in the pericardium and around the aorta. Surgery involved excision and reimplantation of the woman's native aortic valve, excision of the diseased aorta and implantation of a Gore-Tex (W.L. Gore and Associates, Newark, DE, USA) graft, and reimplantation of the coronary arteries. The patient's recovery was uneventful. Acute aortic dissection in the ascending aorta is rare during pregnancy and the periand postpartum period, and is most often seen in patients with Marfan syndrome [1]. The condition is also described in systemic hypertension and is associated with the use of crack cocaine. The arterial wall may be altered by pregnancy [2], and thus some patients will