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Aortic Stenosis with Worsening Aortic Root Dilation and Severe Range Blood Pressures Requiring Urgent Cesarean Delivery
Abstract Number: RF2AB-206
Abstract Type: Case Report Case Series
Parturients with an aortic root enlargement greater than 4 cm have an increased risk of aortic dissection.1 Risk factors for aortic dissection include chronic hypertension, bicuspid aortic valve, and connective tissue disorders.2 Pregnancy itself is associated with a 25-fold increased risk of aortic dissection in young women.2 We report a case of a parturient with significant aortic disease who underwent an urgent cesarean delivery under neuraxial anesthesia for progressive aortic root dilation in the setting of severe preeclampsia.
A 32-year old G3P2 female at 26 and 4/7 weeks gestation presented to our labor and delivery unit as a transfer for management of preeclampsia with severe features and progressive aortic root dilation. She had a significant history of chronic aortic root dilation, unicuspid aortic valve with moderate aortic stenosis, asthma, and systemic lupus erythematosus. A 2D echocardiogram performed prior to transfer showed an aortic root dilation to 4.7 cm from her baseline of 4.4 cm, which had been stable since 2012. Upon presentation, patient had severe range blood pressures despite increasing doses of intravenous labetalol, prompting arterial line placement and initiation of a nicardipine infusion. Although fetal heart rate tracings remained reassuring, the decision was made to pursue urgent primary low-transverse cesarean delivery given uncontrolled blood pressures with evidence of worsening aortic root dilation. The patient underwent an uncomplicated cesarean delivery under dural-puncture epidural anesthesia, incrementally dosed with 15mL of 2% lidocaine with 1:200,000 epinephrine and sodium bicarbonate and 100mcg fentanyl. A low dose phenylephrine infusion was used to maintain systolic blood pressures between 120-140 mmHg. Epidural infusion was maintained for post-operative pain control. On post-operative day one, a thoracic aorta CT angiogram showed further progression of her aortic root to 5.2 cm. She ultimately underwent a Bentall procedure at ten weeks postpartum.
The majority of dissections during pregnancy occur during the third trimester or peripartum.2 Marked hypertension should be prevented in patients at risk for aortic dissections; however, our patient had a competing hemodynamic goal of maintaining adequate preload due to her history of aortic stenosis. A dural-puncture epidural was deemed the safest anesthetic plan to achieve these hemodynamic parameters.