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Cesarean Delivery in a Patient with a Type B Thoracic Dissection
Abstract Number: SAT-76
Abstract Type: Case Report/Case Series
INTRODUCTION: Pregnancy-associated aortic dissections are rare and occur most often in the ascending thoracic aorta (Type A).1 Type B dissections occur less commonly and little is known about peripartum management. We present a patient with chronic Type B aortic dissection who underwent CD and offer recommendations.
CASE: A 37 yo G1P0 woman at 37 wks had presented in 2011 with acute chest and back pain in the setting of poorly controlled hypertension and was diagnosed with Type B aortic dissection. She had no history of connective tissue disorders but had family members with aortic dissection. On yearly follow up for chronic dissection CTA showed aortic arch diameter 5.7-cm and dissection from just past the L common carotid artery nearly to the superior mesenteric artery. An intrauterine pregnancy was incidentally noted so surgical intervention was delayed and the patient received aggressive antihypertensive therapy (spironolactone, labetalol, amlodipine). Cardiologists and vascular surgeons recommended CD so to avoid Valsalva maneuvers and allow for better BP control, and postpartum open repair due to the dissection’s proximity to the carotid artery. Two large-bore IV lines and a radial arterial line were placed, and an epidural was placed and slowly loaded with 20-mL 2% lidocaine/epinephrine/bicarbonate. After delivery oxytocin was infused at 300 mU/min. Intraoperative SBPs ranged from 85-150. The patient received 2L crystalloid and did not require vasopressors or anti-hypertensives. Epidural morphine and IV ketorolac were given for postoperative analgesia. Antihypertensive therapy was continued throughout the perioperative period. The patient spent POD0 in the SICU for careful BP monitoring before transferring to the postpartum unit where she had an uncomplicated course.
DISCUSSION: Aortic dissection in the parturient is rare occurring in 1.23 in 100,000 pregnancies.2 Type B dissections are less common than Type A, possibly because they are less often symptomatic and under-diagnosed.3 Hormonal changes accompanying pregnancy and intrapartum fluid shifts and hemodynamic changes may extend dissection, and hypertensive disorders of pregnancy may increase the risk further.1 Surgical repair is recommended for Type A dissections, even during pregnancy, especially in those with Marfan’s syndrome. Recommendations for the more rare Type B dissections during pregnancy are lacking. Outside of pregnancy, conservative treatment is often recommended for Type B dissections uncomplicated by rupture or ischemia.3 The primary aim of both antepartum and intrapartum management is avoidance of large fluid shifts and hypertension, including that due to anxiety or pain. We therefore chose invasive BP monitoring and slow titration of epidural anesthesia in order to avoid acute BP changes that could worsen dissection, and close postpartum BP monitoring and treatment.
1. Immer: Ann Thorac Surg 2003;76:309
2. Banerjee: BMJ 2015;5:e008318
3. Rajagopalan: IJOA 2014