Introduction
Type A acute aortic dissection (TAAD) in pregnancy is a rare but
potentially lethal event for both mother and foetus. TAAD cases have
been reported on extensively in literature from 1944, and yet remains a
considerable unknown in the best ways of management1.
This is due to the low incidences of cases and limited experiences in
managing these women. The International Registry of Aortic Disease
enrolled pregnant women from 1998 to 2019, and found only 29 cases
across 17 different sites in 20 years2. Similarly,
Kamel et al. performed a cohort-crossover analysis on emergency
department visits across several states of the US, identifying 36 cases
of AAD during pregnancy in 6 566 826 pregnancies; an absolute risk of
5.5 per million cases3. Regardless of the rarity of
the incidence of the disease, the mortality is high enough (21 – 53%)
for it to be notable4. Maternal mortality rates
increase by 1-3% per hour and exceed 80% during the first month if
left untreated5.
The highest incidence of TAAD is in the third trimester (50%) and the
early postpartum period (33%)6. This suggests a link
between the integrity of the aortic wall and the cardiocirculatory
changes in late pregnancy7,8. Oestrogen and
progesterone cause structural changes in the intima and
media9. Increased systemic vascular resistance in
pregnancy increases afterload and reduces the preload, causing
endothelial injury and risk of AD10. Marfan Syndrome
(MFS) and other connective tissue disorders are also important
predisposing factors for aortic dissection in
pregnancy11.
Many women present acutely with sudden-onset, severe chest pain and
haemodynamic instability7,12,13. Although more subtle
presentations can easily be mistaken for common pregnancy complaints,
such as uncontrolled hypertension, gastro-oesophageal reflux and
neurological deficits14. Misdiagnoses of acute
myocardial infarction, pulmonary embolism, pre-eclampsia or pancreatitis
can have detrimental effect to initiation of
treatment12. As such, clinicians should have a low
threshold of suspicion; any pregnant female with acute chest pain should
be considered as possible AD and investigated
urgently14. Any pregnant woman with aortopathy should
have full imaging of her aorta as soon as possible15.