DISCUSSION
Classically, AD’s present with widened pulse pressure, unequal blood pressures in upper extremities, and pathognomonic ‘tearing’ chest pain radiating to the back.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.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.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.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.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.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.11 Other imaging alternatives, such as magnetic resonance imaging, can be utilized in pregnant patients with varying diagnostic accuracy and availability.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.12 Additionally, surgical repair is generally poorly tolerated with fetal loss upwards of 30% due to a complex response to stress and cardiopulmonary bypass.13 Although there are no official guidelines regarding the management of AD in pregnancy, some have proposed tailoring treatment based on gestational age.4Additional 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.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.