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Anesthetic Management of a Parturient with Type A Aortic Dissection During 2nd Trimester
Abstract Number: T-38
Abstract Type: Case Report/Case Series
Introduction: Aortic dissection in pregnancy is life threatening for both mother and fetus. The hormonal and hemodynamic changes of pregnancy contribute to the increased risk of aortic dissection and rupture.
Case Description: A 29F G2P1 at 26w0d gestation presented to an outside institution with right shoulder, chest and abdominal pain. Abdominal CT demonstrated an abdominal aortic aneurysm with intimal dissection involving the mesenteric vessels extending to the iliac arteries bilaterally. She was then transferred to our hospital and received a transthoracic echo and cardiac MRI. These revealed a Type A aortic dissection beginning at the Sinuses of Valsalva, inclusive of the aortic arch involving all cranial vessels.
Members of a multidisciplinary care team involving Maternal Fetal Medicine, Pediatrics, OB Anesthesia, Cardiac Anesthesia and Cardiac Surgery developed a plan to address the safe delivery of the fetus while maintaining the health and safety of the mother. The decision was made to proceed to sequential cesarean section delivery immediately followed by repair of the Type A dissection at 27w0d gestation.
After the standard monitors were placed and left uterine displacement was accomplished, an awake radial arterial line was placed and a general endotracheal anesthetic was induced. Central venous access was obtained in the right internal jugular vein. C-section delivery was performed using a low vertical midline incision. A viable male infant was delivered with APGARS of 2 and 2 at 1 and 5 minutes. The patient then underwent replacement of the ascending aorta and lesser curve of arch, repair of coarctation of the aorta, reconstruction of dissected head vessels, and re-suspension of the native aortic valve. Total time on cardiopulmonary bypass was 153 minutes.
The patient was extubated 4 hours post-operatively and discharged home on POD 8. The infant was discharged home following a 3 month stay in the NICU. Genetic workup revealed a gene mutation of MYH11, which is associated with Familial Thoracic Aortic Aneurysms/Dissections and/or PDA.
Discussion: This case demonstrates aortic pathology due to an undiagnosed connective tissue disorder in a woman with an uncomplicated 1st pregnancy. Connective tissue disorders also raise the risk of uterine rupture and post-partum hemorrhage. A multidisciplinary approach is key to optimize maternal and fetal outcomes.