MANAGEMENT OF TYPE A DISSECTION IN PREGNANCY: SITE AND TEAM CAN MAKE THE DIFFERENCE

Abstract

Introduction Aortic dissection is rare in pregnancy but associated with poor maternal and neonatal outcomes. We present a case of delayed diagnosis of type A aortic dissection in pregnancy in a previously healthy woman to raise awareness and highlight the value of an integrated, multidisciplinary approach. Methods A 38-year-old, G1P0 woman was transferred to our hospital with a type A aortic dissection diagnosed at 30 weeks of pregnancy. The patient had no significant medical history and her pregnancy was uneventful. At 29 weeks gestation, however, she developed central chest pain. Her local hospital excluded a diagnosis of pulmonary embolism and discharged her home. She represented 3 days later with shortness of breath and orthopnoea. On the second day of this admission, Type A aortic dissection was diagnosed on computed tomography of the chest. She was transferred to our hospital for access to multiple specialist services including cardiothoracic surgery and high-risk obstetrics, neonatal and adult critical care. On arrival, an ad hoc MDT convened in the emergency department by a senior team of cardiothoracic surgeons, obstetricians, anaesthetists and neonatologists agreed immediate intervention was required. She went directly to theatres for delivery of the baby and dissection repair. Awake establishment of invasive blood pressure monitoring was followed by an opiate-based cardiostable induction of anaesthesia and intubation in a head-up position. The caesarian section was uneventful and exceptional measures to minimise blood loss were not required. The ascending aorta and hemi-arch were repaired on cardio-pulmonary by-pass with circulatory arrest time of 19 minutes without intraoperative complications. The baby was electively intubated and transferred to neonatal ICU in stable condition. Mother and baby were both extubated the following day and discharged home after a week. Discussion Acute aortic dissection should always be included in the differential of acute chest pain in pregnant women. It most commonly occurs during the third trimester or the early postpartum period and it can sometimes present in women with no previous history of aortopathy. High clinical suspicion, careful history taking and examination, CT, MRI or echocardiography can establish the diagnosis. Optimum management to ensure the survival of both mother and fetus varies with gestational age and planning to ensure this requires a complex balance of expertise between specialities. In the third trimester, emergency delivery followed by surgical aortic repair probably offers the best survival chances for both. Institutions which offer senior input from multiple specialities are crucial for the timely management of these complex cases. This need for urgent intervention from outside cardiothoracic surgery in cases with multiple issues must be considered when regional care models for the management of aortic dissection cases are being designed.