///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-05:00

In Hindsight:What We can Learn From "History"

Abstract Number: 72
Abstract Type: Case Report/Case Series

Andrew J. Goins D.O.1 ; Ira S. Lehrer D.O.2; Philip EF Roman MD, MPH3; Punita Sharma MD4; Lale Odekon MD, PhD5

Introduction: Acute aortic dissection (AD) is a rare complication of pregnancy. Risk factors for AD include the vascular changes of pregnancy, chronic hypertension (HTN), pre-eclampsia (PEC), trauma, cocaine abuse, Marfans Syndrome (MS)(1) and Loeys-Dietz Syndrome (LDS). We present a patient with a significant family history of MS and AD who, after a pregnancy complicated with PEC, presented post-partum with AD.

Case: The patient, G1P0, is a 24-year-old Caucasian with a history of MVP, PTSD, and substance abuse. Her mother died at age 27 after surgical repair of an AD. A maternal aunt had MS and a history of AD. The patient denied having MS. She presented at 30 3/7 weeks with severe PEC. After labor was induced and an epidural placed, she underwent an urgent C/S for NRFHR. A female infant with APGARs 6 & 7 was delivered. The patient was discharged after a smooth post-partum course. On POD #7, she returned to L&D complaining of chest pain and shortness of breath. MI was ruled out by ECG. A contrast chest CT revealed "pericardial effusion, a dilated aortic root and a Type A AD with involvement of the RCA, and extension of the dissection to renal arteries." BP and HR control were initiated with beta blockade and sedation. A right radial arterial line was inserted. A slow controlled induction was accomplished with IV fentanyl, etomidate, propofol, and succinylcholine. Tracheal intubation was confirmed, and the patient was transferred emergently to a nearby facility where valve-sparing surgical repair of AD was completed under deep hypothermic circulatory arrest. The patient was extubated on POD #1. Her post-operative course was complicated by right-sided weakness and slurred speech, which resolved. She was discharged on POD #13.The subsequent pathology report stated that the "dissection [was] at least a week old," which places the initiation of dissection at or around the time of delivery. Histologically, there was no evidence of MS, but LDS could not be excluded.

Conclusion: This case highlights the importance of timely genotyping to guide therapy, including prophylactic vascular surgery, for parturients at risk for AD(2). Had the patient presented earlier in pregnancy, she would have been beta blocked and followed with serial echocardiograms. When a dissection in early stages is detected, either a planned repair alone or a C/S followed by repair could be undertaken, depending on fetal maturity and condition. In hindsight, it is also advisable to be aggressive with diagnosis and treatment no matter when one encounters a patient with a family history of collagen vascular disease and AD. Currently, the patient is undergoing genetic studies. She is receiving losartan for HTN and presumed LDS, an inherited collagen vascular disease with a more aggressive vascular pathology than that seen in MS.

References: 1) IJOG 2008;103(1):68-69

2) NEJM 2006;355(8):788-98

SOAP 2009