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Type A Aortic Dissection Following Vaginal Delivery in the Setting of Severe Preeclampsia
Abstract Number: F-25
Abstract Type: Case Report/Case Series
Aortic dissection is a rare but devastating complication of pregnancy and delivery. The majority of pregnancy-associated aortic dissection occurs in the third trimester or peripartum(1). Heart rate, stroke volume, and cardiac output peak immediately postpartum, and have the combined effect of increased arterial wall stress and intimal shear forces. Poorly understood pregnancy-related changes in aortic wall structure may predispose to dissection, and outflow obstruction caused by uterine contraction after delivery may contribute as well. There is limited data regarding aortic dissection associated with preeclampsia, however it is well described that poorly controlled peripartum hypertension can lead to adverse sequelae.
Our patient was a previously healthy 31 y/o G1P0 diagnosed with preeclampsia without severe features at 35 wks EGA. The following day she presented with in early labor with severe-range blood pressures (BP), headache, and low urine output. Magnesium was started and an epidural was placed. During labor her BP was poorly controlled with periodic systolic BP in the 190s. Following vacuum-assisted vaginal delivery, her hypertension resolved, and she was discharged on PPD 1. That night, she had sudden onset of chest pain, left facial droop, and loss of vision in her right eye. CT scan demonstrated Type A aortic dissection with extension into the proximal innominate and left common carotid arteries, resulting in near-total occlusion of these vessels. Her aortic diameter was 4.3 cm. She was transferred to a tertiary care center, where she underwent valve-sparing aortic root and hemiarch replacement, and antegrade endovascular aortic stent placement. She has made an excellent recovery, although her course has been complicated by HTN, left vocal cord paralysis, and persistent left-sided neurologic deficits.
Although rare, Type A aortic dissection during pregnancy is associated with high rates of morbidity and mortality for both mother and fetus. Risk factors include Marfan syndrome, Ehlers-Danlos syndrome, and bicuspid aortic valve. Average aortic diameter at the time of dissection is 4.8cm(1). Current recommendations for parturients with risk factors, including aortic root diameter >4cm, are for strict BP control, serial echocardiograms, and cesarean delivery under regional anesthesia(1). In this case, prompt diagnosis and rapid surgical intervention led to an excellent outcome in what is often a fatal condition.
1. Ann Thorac Surg 2003;76:309-14.