Acute Aortic Dissection: a possible high risk scenario of peripartum

Background: Aortic dissection (AoD) during pregnancy is rare and life-threatening for both mother and fetus.(1) According to the International Registry of Acute Aortic Dissections, being in the peripartum period of pregnancy confers a risk for AoD of 0,2%.(2) Aortic dissections often develop among individuals with connective-tissue disorders associated with abnormalities of the aortic wall, such as those present in familial thoracic aortic aneurysm/dissection, Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, and bicuspid aortic valve disease or Turner syndrome.(3) Type A aortic dissection is the presence of dissection proximal to the left subclavian artery (Stanford classification). Aortic dissection is considered a surgical emergency and if untreated the mortality rate is extremely high. 

Case Report: We present a case of a 42 year old puerpera with acute aortic dissection type A with no significant past medical history. She was submitted to a c-section at 34 weeks per non tranquilizer CTG. 24 hours after the surgery she initiated an episode of dyspnea, refractory hypoxemia and bilateral crepitations. She denied chest pain. The patient was promptly intubated, ventilated and transferred to the intensive care unit. A thoracic CT scan confirmed a Type-A dissection involving ascending aorta. The patient went to the operating room for emergent surgical intervention. Repair of aortic dissection was carried and the ascending aorta was replaced by a tubular prosthesis. Postoperative course remained benign and patient recovered fully. 

Discussion: It has been reported that pain is the most common symptom or complaint at the onset of Aod. Although the patient´s symptoms were not suggestive of aortic dissection the diagnosis was made in the least possible time. The echocardiography and CT scan were determinant to make a differential diagnosis from acute pulmonary embolism.
 
References:(1)Immer FF, Bansi AG, Immer-Bassi AS.Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg. 2003; 76: 309-314;(2)Isselbacher EM. Epidemiology of thoracic aortic aneurysms. Aortic Dissection and related syndromes. New York: Springer; 2007:1-15 (3) Braverman AC.Acute aortic dissection:clinican update.Circulation.2010;122:184-188

Learning points: Pregnancy is an independent risk factor for aortic dissection. Although the clinical manifestations of acute aortic dissection are well described the diagnosis is often overlooked in pregnancy.

Acute aortic dissection: a possible high risk scenario of peripartum