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.