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\begin{document}

\title{Surgical Management of a Type A Aortic Dissection in a Pregnant Patient}



\author[1]{Julian Gordon}%
\author[1]{Michael  Larkins }%
\author[1]{Melisa Pasli}%
\author[2]{Sunny Cai}%
\author[3]{Adam Celio}%
\author[3]{Michael Bates}%
\affil[1]{Brody School of Medicine at East Carolina University}%
\affil[2]{East Carolina Anesthesia Associates}%
\affil[3]{East Carolina University}%


\vspace{-1em}



  
  \date{May 28, 2024}


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\textbf{Word Count:} 1,075

\textbf{Key Clinical Message:} Despite emphasis for emergent surgical
treatment of Stanford Type A aortic dissections, pregnant patients that
are clinically stable may safely receive a staged approach instead, with
delivery followed by delayed dissection repair.

\textbf{Keywords:} Cardiothoracic Surgery, Obstetrics/Gynecology,
Anesthesia, Cardiovascular Disorders

\textbf{INTRODUCTION}

Aortic dissection (AD) is a rare but life-threatening event in which a
tear in the intima of the aorta allows circulating blood to enter
between the layers of the vessel.\textsuperscript{1} Stanford Type A
AD's involve the aorta proximal to the origin of the left subclavian
artery and classically present with pathognomonic `tearing' chest pain,
though some cases may present more insidiously.\textsuperscript{2} These
dissections are associated with a 1-2\% increased mortality rate per
hour, leaving fastidious diagnosis through either computed tomography
angiography (CTA) or echocardiography a critical component to
survival.\textsuperscript{1,3} Treatment consists of pain control, beta
blockade for heart rate, blood pressure management, and typically
emergent surgery.\textsuperscript{1}

While hypertension and connective tissue disorders are well-recognized
risk factors for AD, other risk factors, such as pregnancy, may not be
thoroughly understood. Nonetheless, child-bearing remains a critical
consideration, as approximately 50\% of the dissections seen in women
under 40 years of age actually occur during
pregnancy.\textsuperscript{1,4} Both diagnosis and management of AD vary
in the pregnant population as well, with altered maternal physiology and
concern for fetal well-being necessitating special consideration from
clinicians. Although an abundance of literature exists pertaining to
AD's in the non-pregnant population, data is inadequate regarding how
this life-threatening condition should be clinically approached in
pregnant patients. We sought to present a rare case of an AD in a
third-trimester pregnant patient.

\textbf{CASE DESCRIPTION}

A 37-year-old G8P5 African American female at 31 weeks' gestation and
with a past medical history significant for hypertension, gastric bypass
surgery, gastro-esophageal reflux disease, and gestational diabetes
mellitus presented emergently to an outside hospital with abdominal pain
radiating to the neck with right arm numbness and weakness, as well as
diarrhea, nausea, and emesis. Workup revealed an unremarkable
electrocardiogram, normal troponins, and unremarkable chest x-ray.
Hypotension 70/46 mmHg was noted, and the patient was admitted with a
diagnosis of gastroenteritis with concern for sepsis. Two days later, in
conjunction with persisting abdominal pain, the patient was found to
have significantly lower blood pressures in the right upper extremity
(65/48mmHg) compared to the left upper extremity (122/58mmHg). CT
Angiogram revealed a Stanford Type A AD involving the ascending aorta,
aortic arch, descending thoracic aorta, and abdominal aorta with a
dissection flap just below the origin of the superior mesenteric artery
(\textbf{Figure 1 and 2} ).

The patient was transferred to our institution where a multidisciplinary
team of obstetricians, cardiac surgeons, and anesthesiologists decided
to use a staged approach due to her clinical stability. The patient
underwent an emergent cesarean section under general anesthesia.
Concurrently, transesophageal echocardiography (TEE) was performed and
showed preserved left ventricular systolic function (ejection fraction
60\%), mild aortic regurgitation, and moderate mitral and tricuspid
regurgitation. Importantly, the TEE indicated no pericardial effusion.
The newborn was healthy and transferred to the NICU as a precaution. The
patient was extubated and recovered from the cesarean delivery and 3
days later, the patient underwent a hemiarch replacement to repair the
type A dissection. The patient was extubated the following day, soon
weaned from vasoactive medications and had an uneventful recovery. She
was discharged home on post-operation day 12. Written informed consent
was obtained from the patient for their anonymized information to be
published in this article.

\textbf{DISCUSSION}

Classically, AD's present with widened pulse pressure, unequal blood
pressures in upper extremities, and pathognomonic `tearing' chest pain
radiating to the back.\textsuperscript{1} However, recent literature has
suggested these easily recognizable findings may not be as common, with
one study finding only 50.6\% of dissections to present with pain
described as ``tearing or ripping'' and just 28.3\% with radiating
pain.\textsuperscript{5} Conversely, some cases present with vague
symptoms, such as diarrhea and vomiting, which may easily be confounded
with general malaises of pregnancy, as was the case with our patient
initially.\textsuperscript{6} Individualizing risk factors in ambiguous
settings such as these may make diagnoses more definitive. Our patient
not only had chronic hypertension - a common risk factor for AD - but
was also pregnant, which increased the likelihood of dissection from
1.24 per million in non-pregnant women to 14.5 per million in pregnant
women due to the hyperdynamic state and hormonal effects on vasculature
associated with pregnancy.\textsuperscript{4,7}

One of the challenges in diagnosing AD during pregnancy is imaging.
While the gold standard for AD diagnosis has traditionally been CTA,
both radiographs and CT scans are discouraged in pregnancy due to the
potentially harmful effects of radiation to the
fetus.\textsuperscript{8} In addition, contrast dyes utilized for
angiography have been well-associated with nephropathy, potentially
exacerbating the already-comprised state of the kidneys due to
physiological changes of pregnancy.\textsuperscript{9,10} Although the
dose of radiation delivered by CTA is below the limit for fetal harm,
thus leaving the American College of Obstetrics and Gynecology in favor
of utilizing CT imaging in pregnant patients that require
imaging.\textsuperscript{11} Other imaging alternatives, such as
magnetic resonance imaging, can be utilized in pregnant patients with
varying diagnostic accuracy and availability.\textsuperscript{8}

Surgical planning for AD in pregnant patients is challenging,
necessitating effective communication between the patient,
anesthesiologists, obstetricians, and cardiac surgeons. Factors that
impact clinical decision making include the onset and presentation of AD
symptoms, hemodynamic stability, and fetal
viability.\textsuperscript{12} Additionally, surgical repair is
generally poorly tolerated with fetal loss upwards of 30\% due to a
complex response to stress and cardiopulmonary
bypass.\textsuperscript{13} Although there are no official guidelines
regarding the management of AD in pregnancy, some have proposed
tailoring treatment based on gestational
age.\textsuperscript{4}Additional literature has developed this strategy
further by suggesting emergent cesarean section with sternotomy standby
followed by surgical repair of the aorta within a few
days.\textsuperscript{14} In our patient's case, the clinical team
decided to have the patient undergo cesarean section first, in case of
any hemodynamic instability that may have developed during the
procedure.

We present a case of successful surgical treatment of an AD in a
pregnant patient after an initial delay in diagnosis treated with a
staged approach of delivery followed by delayed dissection repair. AD's
represent a potentially catastrophic complication of pregnancy. Although
AD's are thought to have the hallmark easily identifiable tearing chest
pain, atypical presentations may delay accurate diagnosis and clinical
management. Increased clinical suspicion for AD is warranted in patients
with corresponding risk factors, especially pregnancy. Treatment aims to
mitigate the risk of both fetal and maternal demise, and typically
includes emergent cesarean section and AD defect repair, though
consensus regarding the timing of repair is currently lacking. While AD
in the general population is well studied, future studies should aim to
better describe how AD may present during pregnancy and how management
differs in the gravid patient from that of non-pregnant patients.

\textbf{Funding:}

This research received no specific grant from any funding agency in the
public, commercial, or not-for-profit sectors.

\textbf{Declaration of Conflicting Interests:}

The Authors declare that there is no conflict of interest.



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